What are the guidelines for treating community-acquired pneumonia (CAP) in children?

Guidelines for Treating Community-Acquired Pneumonia (CAP) in Children

The first-line treatment for community-acquired pneumonia in children is amoxicillin for mild to moderate cases, with hospitalization and parenteral therapy indicated for severe cases based on specific clinical criteria. 1

Assessment and Diagnosis

Clinical Evaluation

• Key diagnostic features:
  • Fever and tachypnea are cardinal features 1, 2
  • Respiratory distress (retractions, nasal flaring, grunting)
  • Decreased oxygen saturation (<92% at sea level)
  • Altered mental status
  • Poor feeding or dehydration

Diagnostic Testing

• Pulse oximetry: Should be performed in all children with suspected CAP 2
• Chest radiographs: Not routinely needed for outpatient management but indicated for:
  • Hypoxemia or significant respiratory distress 1, 2
  • Failed initial antibiotic therapy
  • Suspected complications (parapneumonic effusions, necrotizing pneumonia) 1
• Blood cultures: Not routinely recommended for outpatients but should be obtained in:
  • Children requiring hospitalization for presumed bacterial CAP
  • Children with complicated pneumonia 1
• Biomarkers: CRP, ESR, or procalcitonin are not routinely recommended for outpatient management and cannot reliably distinguish between viral and bacterial causes 1, 2

Hospitalization Criteria

Indications for Hospitalization

1. Moderate to severe CAP with:
   • Hypoxemia (SpO2 <90% at sea level)
   • Significant respiratory distress 1
2. Infants <3-6 months of age with suspected bacterial CAP 1
3. CAP caused by virulent pathogens (e.g., CA-MRSA) 1
4. Inability to maintain oral intake or unreliable home situation 1

ICU Admission Criteria

• Requires invasive ventilation or noninvasive positive pressure ventilation
• Impending respiratory failure
• Sustained tachycardia, inadequate blood pressure, or need for pharmacologic support
• Pulse oximetry <92% on FiO2 ≥0.50
• Altered mental status due to pneumonia 1

Treatment Recommendations

Outpatient Management (Mild-Moderate CAP)

First-line therapy:

• Amoxicillin for children ≥3 months of age who are fully immunized against Haemophilus influenzae type b 1, 3
  • Dosage: 90 mg/kg/day divided in three doses (can consider twice daily to improve compliance) 3
  • Duration: 5 days 3

Alternative therapies:

• Amoxicillin-clavulanate or second/third-generation cephalosporins for unimmunized or incompletely immunized children 3
• Macrolides (azithromycin, clarithromycin) should be added for:
  • Children >5 years with persistent symptoms after 48 hours of amoxicillin 3
  • Suspected atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae) 4

Azithromycin dosing for CAP in children:

• 10 mg/kg on day 1, followed by 5 mg/kg on days 2-5 5

Inpatient Management (Severe CAP)

First-line therapy:

• Ampicillin or cefuroxime IV for hospitalized patients requiring parenteral therapy 1, 4
• Add macrolides if Mycoplasma or Chlamydophila infection is suspected 4

For complicated pneumonia:

• Consider broader coverage for resistant organisms
• Duration typically 2-4 weeks, depending on clinical response and drainage adequacy 1

Management of Parapneumonic Effusions

Treatment algorithm based on effusion size:

• Small effusion: Antibiotics alone, no drainage needed
• Moderate effusion:
  • Low respiratory compromise: IV antibiotics, obtain ultrasound, consider thoracentesis
  • High respiratory compromise: Follow algorithm for large effusions
• Large effusion: Drainage options include:
  1. Chest tube alone
  2. Chest tube with fibrinolytics (preferred initial approach)
  3. Video-assisted thoracoscopic surgery (VATS) if not responding 1

Follow-up and Monitoring

• Clinical reassessment at 48-72 hours after initiating therapy 1, 3
• Repeated chest radiographs not routinely required in children who recover uneventfully 1
• Obtain follow-up radiographs for:
  • Failure to improve clinically
  • Progressive symptoms or clinical deterioration 1

Prevention

• Immunization against bacterial pathogens:
  • Pneumococcal conjugate vaccine
  • Haemophilus influenzae type b vaccine
  • Pertussis vaccine 1
• Annual influenza vaccination for all children ≥6 months 1
• RSV-specific monoclonal antibody for high-risk infants 1

Common Pitfalls to Avoid

• Overuse of chest radiographs in mild outpatient cases
• Unnecessary blood tests for outpatient management
• Failure to perform pulse oximetry in all children with suspected pneumonia
• Overuse of broad-spectrum antibiotics when narrow-spectrum would suffice
• Inadequate follow-up within 48-72 hours to assess treatment response