What are the guidelines for managing community-acquired pneumonia (CAP) in adults and children?

Community-Acquired Pneumonia (CAP) Management Guidelines

Pediatric CAP (Children >3 months)

Site of Care Decision

Children with moderate to severe CAP—defined by respiratory distress, hypoxemia (SpO₂ <90% at sea level), or increased work of breathing—should be hospitalized for skilled nursing care and monitoring. 1

• Infants <3-6 months with suspected bacterial CAP benefit from hospitalization 1
• Children with suspected community-associated MRSA should be hospitalized 1
• Consider hospitalization if concerns exist about home observation, compliance with therapy, or follow-up 1

ICU Admission Criteria for Children

A child requires ICU admission if they need invasive mechanical ventilation, have SpO₂ <92% on FiO₂ ≥0.50, or demonstrate impending respiratory failure. 1

Additional ICU criteria include: 1

• Need for noninvasive positive pressure ventilation (CPAP/BiPAP)
• Sustained tachycardia, inadequate blood pressure, or need for vasopressor support
• Altered mental status from hypercarbia or hypoxemia
• Severity scores should supplement, not replace, clinical judgment 1

Diagnostic Testing in Children

Routine chest radiographs are not necessary for outpatient pediatric CAP but should be obtained for hospitalized children and those with hypoxemia or respiratory distress. 1

Blood cultures: 1

• Not routinely needed for nontoxic, fully immunized outpatients
• Obtain for hospitalized children with moderate-to-severe CAP
• Obtain for children failing initial therapy or showing clinical deterioration

Laboratory testing: 1

• Pulse oximetry mandatory for all children with suspected hypoxemia
• Complete blood count not routinely needed for outpatients but useful in severe disease
• Acute-phase reactants (CRP, ESR, procalcitonin) cannot distinguish viral from bacterial CAP alone
• Testing for respiratory viruses (especially influenza) can modify management by avoiding unnecessary antibiotics 1

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Adult CAP

Severity Assessment and Site of Care

Use validated tools like the Pneumonia PORT severity index or CURB-65 to determine appropriate outpatient management; patients in PORT risk classes I-II or CURB-65 scores 0-1 are generally appropriate for outpatient treatment. 2

Antibiotic Therapy for Outpatient Adults

For healthy adults without comorbidities, amoxicillin 1g three times daily is the first-line recommendation. 2

Alternative for healthy adults: 2

• Doxycycline 100mg twice daily (conditional recommendation)

For adults with comorbidities, use combination therapy with amoxicillin/clavulanate plus a macrolide or doxycycline. 2

Alternative for comorbidities: 2

• Respiratory fluoroquinolone monotherapy (levofloxacin, moxifloxacin, or gemifloxacin)

Antibiotic Therapy for Hospitalized Adults (Non-Severe)

Most hospitalized patients with non-severe CAP should receive combined oral therapy with amoxicillin and a macrolide (erythromycin or clarithromycin). 1

When oral therapy is contraindicated: 1

• Intravenous ampicillin or benzylpenicillin plus erythromycin or clarithromycin

Fluoroquinolones with pneumococcal activity (levofloxacin) are alternatives for: 1

• Penicillin or macrolide intolerance
• Local concerns about Clostridium difficile diarrhea

Antibiotic Therapy for Severe CAP

Patients with severe pneumonia require immediate parenteral antibiotics: intravenous β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone) combined with a macrolide (clarithromycin or erythromycin). 1

Recent evidence supports: 3

• Ceftriaxone combined with azithromycin for hospitalized patients without resistant bacteria risk factors
• Minimum 3 days of therapy for hospitalized patients

Alternative for β-lactam/macrolide intolerance: 1

• Fluoroquinolone with enhanced pneumococcal activity plus intravenous benzylpenicillin

Duration of Therapy

Treat for a minimum of 5 days, ensuring the patient is afebrile for 48-72 hours before discontinuing antibiotics. 2

Extended duration (14-21 days) for: 1

• Legionella pneumonia
• Staphylococcal pneumonia
• Gram-negative enteric bacilli pneumonia

Diagnostic Testing in Adults

Blood cultures should be obtained before antibiotic therapy in all hospitalized patients with CAP. 1

Additional testing: 1

• Chest radiograph to confirm diagnosis and assess extent
• Pulse oximetry or arterial blood gases within 24 hours of admission
• Legionella urinary antigen testing when epidemiologically indicated

Management of Treatment Failure

For patients failing to improve, conduct a careful review of clinical history, examination, prescription chart, and investigation results by an experienced clinician. 1

Further investigations should include: 1

• Repeat chest radiograph
• CRP and white cell count
• Additional microbiological specimens

Antibiotic modification for treatment failure: 1

• Non-severe CAP on amoxicillin monotherapy: add or substitute a macrolide
• Non-severe CAP on combination therapy: change to fluoroquinolone with pneumococcal coverage
• Severe CAP not responding: consider adding rifampicin

Follow-up

Clinical review at approximately 6 weeks with follow-up chest radiograph for patients with persistent symptoms, physical signs, or those at higher risk of underlying malignancy (smokers and those >50 years). 2

Repeat chest radiographs in children: 1

• Not routinely required for uncomplicated recovery
• Obtain for children failing to improve within 48-72 hours

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Critical Pitfalls to Avoid

Do not underestimate severity of illness, which leads to inappropriate outpatient management and delayed ICU admission with worse outcomes. 2, 4

Additional pitfalls: 2

• Avoid macrolide monotherapy in areas with high pneumococcal resistance
• Avoid inadequate duration of therapy (<5 days)
• Avoid overuse of fluoroquinolones as first-line agents; reserve for specific situations 1, 2
• Do not use severity scores as sole criteria for ICU admission 1