What is the recommended management for pneumonia in children and adults?

Management of Pneumonia in Children and Adults

The management of pneumonia requires a structured approach based on age, severity assessment, and appropriate antimicrobial therapy, with hospitalization decisions guided by specific clinical criteria including respiratory distress and hypoxemia. 1

Initial Assessment and Triage

• Pulse oximetry should be performed in all children with suspected pneumonia to assess for hypoxemia, which guides decisions regarding site of care and further diagnostic testing 1
• Children with moderate to severe pneumonia, defined by respiratory distress and hypoxemia (SpO2 <90% at sea level), should be hospitalized for management 1
• Infants less than 3-6 months of age with suspected bacterial pneumonia should be hospitalized due to higher risk of complications 1
• Admission to ICU is indicated for children with:
  • Need for invasive mechanical ventilation 1
  • Need for non-invasive positive pressure ventilation 1
  • Impending respiratory failure 1
  • Sustained tachycardia, inadequate blood pressure, or need for pharmacologic support 1
  • Hypoxemia requiring FiO2 ≥0.50 with pulse oximetry <92% 1
  • Altered mental status due to pneumonia 1

Diagnostic Approach

Outpatient Setting

• Routine chest radiographs are not necessary for confirmation of suspected CAP in patients well enough for outpatient management 1
• Blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP managed as outpatients 1

Inpatient Setting

• Chest radiographs (posteroanterior and lateral) should be obtained in all hospitalized patients to document infiltrates and identify complications 1
• Blood cultures should be obtained in children requiring hospitalization for presumed bacterial CAP, particularly those with complicated pneumonia 1
• For mechanically ventilated patients, tracheal aspirates should be collected for Gram stain, culture, and testing for viral pathogens at the time of intubation 1

Antimicrobial Therapy

Children - Outpatient Management

• Antimicrobial therapy is not routinely required for preschool-aged children with CAP, as viral pathogens are responsible for the majority of cases 1
• For bacterial pneumonia in previously healthy, immunized infants and preschool children:
  • Amoxicillin should be used as first-line therapy (10 mg/kg/day on Day 1, followed by 5 mg/kg/day on Days 2-5) 1
  • For children ≥2 years with pharyngitis/tonsillitis, azithromycin 12 mg/kg once daily for 5 days is recommended 2

Adults - Outpatient Management

• For adults with mild community-acquired pneumonia:
  • Azithromycin 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2-5 2, 3
  • Alternative regimen: Azithromycin 500 mg daily for 3 days 2

Hospitalized Patients

• For hospitalized patients without risk factors for resistant bacteria:
  • β-lactam/macrolide combination therapy (e.g., ceftriaxone combined with azithromycin) for a minimum of 3 days 3
• Systemic corticosteroids within 24 hours of development of severe CAP may reduce 28-day mortality in adults 3

Oxygen Therapy and Respiratory Support

• Oxygen therapy should be provided to maintain SpO2 >90% in children with pneumonia and hypoxemia 1, 4
• Non-invasive ventilation can reduce the risk of death in ICU, need for endotracheal intubation, complications, and shorten ICU length of stay in appropriate patients 4
• For patients with severe pneumonia requiring mechanical ventilation, consider ICU admission with continuous cardiorespiratory monitoring 1

Monitoring and Follow-up

• Repeated chest radiographs are not routinely required in children who recover uneventfully 1
• Follow-up chest radiographs should be obtained in patients who:
  • Fail to demonstrate clinical improvement or have progressive symptoms within 48-72 hours after starting antibiotics 1
  • Have complicated pneumonia with worsening respiratory distress or clinical instability 1
  • Have persistent fever not responding to therapy over 48-72 hours 1
• Repeated chest radiographs 4-6 weeks after diagnosis should be obtained in patients with recurrent pneumonia involving the same lobe or lobar collapse with suspicion of anatomic anomaly 1

Special Considerations

• Acute-phase reactants may be used in conjunction with clinical findings to assess response to therapy in patients with more serious disease 1
• Severity assessment scores should not be used as the sole criteria for ICU admission but should be used in context with other clinical, laboratory, and radiologic findings 1
• Moderate hypoxemia (oxygen saturation ≤96%) and increased work of breathing (grunting, flaring, retractions) are signs most associated with pneumonia diagnosis in children 5

Common Pitfalls to Avoid

• Overuse of antibiotics in viral pneumonia, especially in preschool-aged children 1
• Relying solely on auscultatory findings for diagnosis, as these are not strongly associated with pneumonia 5
• Routine daily chest radiography in children with pneumonia complicated by parapneumonic effusion after chest tube placement if they remain clinically stable 1
• Failure to recognize hypoxemia, which is a critical indicator for hospitalization and more aggressive management 1, 6