Management of Community-Acquired Pneumonia (CAP) in Children
Site of Care Decision
Children with moderate to severe CAP—defined by respiratory distress, hypoxemia (SpO₂ <90-92% at sea level), age <3-6 months, or suspected high-virulence pathogens like CA-MRSA—should be hospitalized. 1, 2
Hospitalization Criteria:
- Infants <3-6 months of age with suspected bacterial CAP 1
- Respiratory distress indicators: respiratory rate >70 breaths/min (infants), retractions, dyspnea, nasal flaring, grunting 1, 2
- Hypoxemia: SpO₂ <90-92% on room air 1, 2
- Suspected CA-MRSA or other high-virulence pathogens 1
- Social concerns: inability to ensure careful observation, compliance with therapy, or follow-up 1
ICU Admission Criteria:
Children meeting any of the following require ICU or continuous cardiorespiratory monitoring 1:
- Invasive mechanical ventilation needed 1
- Noninvasive positive pressure ventilation (CPAP/BiPAP) required 1
- SpO₂ <92% on FiO₂ ≥0.50 1
- Impending respiratory failure or altered mental status 1
- Hemodynamic instability requiring vasopressor support 1
Diagnostic Evaluation
Outpatient Setting:
- Pulse oximetry should be performed in all children with suspected pneumonia 1, 2
- Chest radiography is NOT routinely required for children well enough for outpatient management 1
- Blood cultures should NOT be obtained in nontoxic, fully immunized children managed as outpatients 1
- Complete blood count and acute-phase reactants (CRP, ESR) are not routinely necessary for outpatient cases 1
Inpatient Setting:
- Chest radiography (posteroanterior and lateral) should be obtained in all hospitalized children 1, 2
- Blood cultures should be obtained prior to antibiotic administration 1, 2
- Complete blood count may provide useful information in severe disease 1
- Procalcitonin cannot be used alone to distinguish viral from bacterial CAP 1
Antibiotic Selection
Outpatient Management:
For preschool-aged children (<5 years), high-dose amoxicillin 90 mg/kg/day divided twice daily is first-line therapy. 1, 2, 3
- Preschool children (<5 years): Amoxicillin 90 mg/kg/day divided BID (maximum 4 grams/day) 1, 2, 3
- School-aged children and adolescents (≥5 years): Amoxicillin 90 mg/kg/day divided BID PLUS consider adding a macrolide (azithromycin 10 mg/kg day 1, then 5 mg/kg days 2-5) if atypical pathogens suspected 1, 4
- Macrolide monotherapy should be prescribed for children with findings compatible with atypical pneumonia (M. pneumoniae) 1
Important caveat: Antimicrobial therapy is not routinely required for preschool-aged children with CAP, as viral pathogens cause the majority of cases 1. However, when bacterial infection is suspected based on clinical presentation, amoxicillin should be used 1, 5.
Alternative Agents for Penicillin Allergy:
- Non-type I hypersensitivity: Cephalosporins (cefdinir, cefuroxime, cefpodoxime) 1
- Type I hypersensitivity: Macrolides (azithromycin, clarithromycin) or levofloxacin 1
Inpatient Management:
For hospitalized children, intravenous ampicillin or penicillin G is first-line for fully immunized children in areas with minimal penicillin resistance. 2
- Fully immunized, minimal resistance: IV ampicillin 150-200 mg/kg/day divided q6h OR penicillin G 200,000-250,000 units/kg/day divided q4-6h 2
- Incompletely immunized or significant resistance: IV ceftriaxone 50-100 mg/kg/day once daily OR cefotaxime 150 mg/kg/day divided q8h 2
- Suspected CA-MRSA: Add vancomycin 40-60 mg/kg/day divided q6-8h OR clindamycin 30-40 mg/kg/day divided q6-8h 2, 6
Transition to Oral Therapy:
Switch from IV to oral antibiotics when the child is afebrile for 24 hours, shows improved respiratory rate and work of breathing, and tolerates oral intake without vomiting, typically within 48-72 hours. 2
Treatment Duration
The standard treatment duration for uncomplicated CAP is 5-7 days. 2, 5, 7
- Uncomplicated CAP: 5 days of therapy is sufficient based on recent high-quality evidence 7
- Complicated CAP or slow response: Extend to 7-10 days 2
- Clinical improvement should occur within 48-72 hours of initiating therapy, including fever resolution, improved respiratory rate, and reduced work of breathing 2, 3
The SAFER trial demonstrated that 5 days of high-dose amoxicillin was noninferior to 10 days for clinical cure in children with CAP not requiring hospitalization 7. This supports shorter courses in accordance with antimicrobial stewardship principles 7.
Monitoring and Follow-Up
Re-evaluation Protocol:
Children who fail to demonstrate clinical improvement or have progressive symptoms within 48-72 hours require repeat chest radiography and reassessment for complications. 1, 2
Investigate for:
- Inadequate antibiotic dosing or inappropriate drug selection 2
- Complications: parapneumonic effusion, empyema, necrotizing pneumonia, pneumothorax 1
- Resistant organisms or alternative diagnoses 2
- Host factors: immunodeficiency, anatomic abnormalities 2
Routine Follow-Up Imaging:
- Repeat chest radiographs are NOT routinely required in children who recover uneventfully 1
- Follow-up radiographs at 4-6 weeks should be obtained for recurrent pneumonia involving the same lobe or lobar collapse suggesting anatomic anomaly 1
Supportive Care
- Oxygen therapy to maintain SpO₂ >92% 2
- Adequate hydration and monitoring for dehydration 2
- Antipyretics and analgesics for comfort 2
- Minimal handling in severely ill children to reduce metabolic demands 2
Special Considerations
Recurrent Pneumonia:
Children with recurrent CAP require investigation after acute illness resolves 2:
- Verify immunization status 2
- Consider immune function evaluation 2
- Assess for anatomic abnormalities (bronchoscopy, CT chest) 2
- Evaluate environmental factors (secondhand smoke, aspiration risk) 2
Influenza Coinfection:
Testing for influenza can modify clinical decision-making, as antibacterial therapy may not be required in the absence of bacterial coinfection 1.