What are the treatment guidelines for pediatric community-acquired pneumonia (CAP)?

Pediatric Community-Acquired Pneumonia Treatment Guidelines

For pediatric community-acquired pneumonia (CAP), amoxicillin should be used as first-line outpatient therapy at a dose of 90 mg/kg/day in two divided doses for 5-7 days for most children older than 3 months of age. 1

Outpatient Management

• Amoxicillin is the first-line antibiotic for outpatient treatment at 90 mg/kg/day divided twice daily (maximum 4g/day) for 5-7 days 1
• Children eligible for outpatient management must be well-appearing, able to maintain hydration, have oxygen saturation >90% on room air, and have reliable caregivers 1
• Blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP managed in the outpatient setting 2
• Routine chest radiographs are not necessary for confirmation of suspected CAP in patients well enough for outpatient treatment 2
• For children with suspected Mycoplasma pneumoniae infection (typically school-aged children), a macrolide such as azithromycin may be used 2, 3

Hospitalization Criteria

• Moderate to severe respiratory distress (increased work of breathing, grunting, nasal flaring) requires hospitalization 1
• Oxygen saturation <90% on room air is an indication for hospitalization 1
• Inability to maintain oral hydration requires hospitalization 1
• Failed outpatient therapy is an indication for hospitalization 1
• Children with suspected or documented CAP caused by a pathogen with increased virulence, such as community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) should be hospitalized 2
• Children for whom there is concern about careful observation at home or who are unable to comply with therapy or unable to be followed up should be hospitalized 2

ICU Admission Criteria

• Children requiring invasive mechanical ventilation via endotracheal tube 2
• Children requiring noninvasive positive pressure ventilation 2
• Children with impending respiratory failure 2
• Children with sustained tachycardia, inadequate blood pressure, or need for pharmacologic support of blood pressure or perfusion 2
• Children with pulse oximetry <92% on inspired oxygen of ≥0.50 2
• Children with altered mental status due to hypercarbia or hypoxemia 2

Inpatient Management

• Blood cultures should be obtained in children requiring hospitalization for presumed bacterial CAP that is moderate to severe, particularly those with complicated pneumonia 2
• Chest radiographs (posteroanterior and lateral) should be obtained in all hospitalized patients to document infiltrates and identify complications 2
• For fully immunized hospitalized children, ampicillin or penicillin G can be used as first-line therapy 1
• For children not fully immunized or in areas with high pneumococcal resistance, ceftriaxone or cefotaxime can be used 1
• If MRSA is suspected, vancomycin or clindamycin should be added to the regimen 1

Management of Complicated Pneumonia

• Small parapneumonic effusions (<10mm rim) can be managed with antibiotics alone without drainage 4
• For moderate to large effusions, management options include chest tube placement alone, chest tube with fibrinolytic therapy, or video-assisted thoracoscopic surgery (VATS) 4
• VATS should be performed when there is persistence of moderate-large effusions and ongoing respiratory compromise despite 2-3 days of chest tube management with fibrinolytic therapy 4
• A chest tube can be removed when pleural fluid drainage is <1 mL/kg/24h and there is no intrathoracic air leak 2
• In culture-negative parapneumonic effusions, antibiotic selection should be based on the treatment recommendations for hospitalized CAP patients 2
• Duration of antibiotic treatment for complicated pneumonia depends on the adequacy of drainage and clinical response, typically 2-4 weeks 2

Monitoring and Follow-up

• Clinical improvement should be seen within 48-72 hours of starting appropriate antibiotics 1
• Children who are not responding to initial therapy after 48-72 hours should be reassessed with:
  • Clinical and laboratory assessment of current severity 2
  • Imaging evaluation to assess progression of pneumonia or parapneumonic process 2
  • Further investigation for persistent pathogens, development of resistance, or secondary infection 2
• Follow-up chest radiographs are not routinely required in children who recover uneventfully 2

Discharge Criteria

• Documented overall clinical improvement, including level of activity, appetite, and decreased fever for at least 12-24 hours 4
• Consistent pulse oximetry measurements >90% in room air for at least 12-24 hours 4
• Ability to tolerate oral antibiotics if transitioning to outpatient therapy 4

Common Pitfalls to Avoid

• Unnecessary use of broad-spectrum antibiotics for uncomplicated CAP in fully immunized children 5
• Failure to reassess after 48-72 hours if no clinical improvement 1
• Unnecessary follow-up chest radiographs in children who are clinically improving 2
• Overlooking the possibility of complications in children with persistent fever or respiratory symptoms despite appropriate antibiotic therapy 6