What are the community-acquired pneumonia (CAP) clinical practice guidelines (CPG) for a previously healthy pediatric patient in a specific location?

Pediatric Community-Acquired Pneumonia Clinical Practice Guidelines

Initial Assessment and Site of Care Decision

For previously healthy pediatric patients with community-acquired pneumonia, use pulse oximetry universally to guide site of care decisions, obtain chest radiographs only for hospitalized children or those with hypoxemia/respiratory distress, and initiate amoxicillin as first-line therapy for outpatients. 1

Hospitalization Criteria

Admit children who meet any of the following criteria:

• Infants <3-6 months of age with suspected bacterial CAP 2, 3
• Moderate to severe disease requiring skilled nursing care and monitoring 2
• Suspected community-associated MRSA infection 1, 2
• Concerns about home observation, compliance with therapy, or ability to follow-up 1, 2
• Hypoxemia or significant respiratory distress 1

ICU Admission Criteria

Transfer to ICU or continuous cardiorespiratory monitoring unit if:

Major criteria (any one requires ICU):

• Invasive mechanical ventilation needed 1, 2
• SpO₂ <92% on FiO₂ ≥0.50 1, 2
• Fluid-refractory shock 1
• Acute need for noninvasive positive pressure ventilation (CPAP/BiPAP) 1, 2

Minor criteria (≥2 require ICU consideration):

• Impending respiratory failure 1, 2
• Sustained tachycardia, inadequate blood pressure, or need for vasopressor support 1, 2
• Altered mental status due to hypercarbia or hypoxemia 1, 2
• Respiratory rate exceeding WHO age-based thresholds 1
• Multilobar infiltrates 1

Diagnostic Approach

Pulse Oximetry

Perform pulse oximetry in ALL children with suspected pneumonia and hypoxemia to guide site of care and further diagnostic decisions. 1, 2

Chest Radiography

Outpatient setting:

• Do NOT routinely obtain chest radiographs for children well enough for outpatient management 1, 2
• Obtain posteroanterior and lateral chest radiographs if hypoxemia, significant respiratory distress, or failed initial antibiotic therapy 1

Inpatient setting:

• Obtain posteroanterior and lateral chest radiographs in ALL hospitalized children to document infiltrates and identify complications 1, 2

Blood Cultures

Outpatient setting:

• Do NOT routinely obtain blood cultures in nontoxic, fully immunized children 1, 2
• Obtain blood cultures if clinical deterioration or failure to improve after initial therapy 1

Inpatient setting:

• Obtain blood cultures in all children requiring hospitalization for moderate-to-severe bacterial CAP, particularly with complicated pneumonia 1, 2, 3

Laboratory Testing

Complete blood count:

• Not routinely necessary for outpatient management 1
• Obtain for severe pneumonia requiring hospitalization, interpreted with clinical context 1

Acute-phase reactants (CRP, ESR, procalcitonin):

• Cannot be used as sole determinant to distinguish viral from bacterial CAP 1
• Not routinely measured in fully immunized outpatients 1
• May be useful in hospitalized patients to assess response to therapy 1

Viral and Atypical Testing

Influenza testing:

• Use sensitive and specific rapid tests for influenza and other respiratory viruses 1
• Antibacterial therapy is NOT necessary with positive influenza test absent clinical/laboratory/radiographic findings suggesting bacterial coinfection 1

Mycoplasma pneumoniae:

• Test children with suspicious signs/symptoms to guide antibiotic selection 1

Chlamydophila pneumoniae:

• Do NOT test as reliable diagnostic tests do not exist 1

Antibiotic Treatment

Outpatient Management (Previously Healthy Children)

First-line therapy:

• Amoxicillin 90 mg/kg/day divided into 2-3 doses (maximum 4 grams/day) for children ≥3 months who are fully immunized against Haemophilus influenzae type b and Streptococcus pneumoniae 2, 4
• Two daily doses may be considered to improve compliance 4

Alternative for unimmunized/incompletely immunized children:

• Amoxicillin-clavulanate 90 mg/kg/day (of amoxicillin component) divided twice daily 2, 4
• Second- or third-generation cephalosporins 4

For children ≥5 years with persistent symptoms after 48 hours:

• Consider adding macrolide (azithromycin or clarithromycin) to amoxicillin if clinical condition remains good 2, 4, 5

Treatment duration:

• 5 days minimum, ensuring patient is afebrile for 48-72 hours before discontinuation 2, 4
• Clinical reassessment at approximately 72 hours after starting antibiotics 4

Inpatient Management

For hospitalized children with moderate-to-severe CAP:

• Ampicillin or penicillin G as first-line parenteral therapy 2, 6
• Add vancomycin or clindamycin if CA-MRSA suspected 2, 3
• Consider adding macrolide if Mycoplasma pneumoniae or Chlamydophila pneumoniae suspected 2, 7

Transition to oral therapy:

• Amoxicillin when clinically improving and able to tolerate oral medications 2, 6

Follow-up and Monitoring

Repeat Chest Radiographs

• NOT routinely required in children recovering uneventfully 1
• Obtain repeat imaging if failure to improve, progressive symptoms, or clinical deterioration within 48-72 hours 1, 8

Discharge Criteria

Children are ready for discharge when:

• Overall clinical improvement documented (activity level, appetite) 8
• Afebrile for 12-24 hours 8
• SpO₂ >90% in room air for 12-24 hours 8
• Able to tolerate oral antibiotics 8

Critical Pitfalls to Avoid

• Do NOT underestimate severity of illness, which leads to inappropriate outpatient management and delayed ICU admission with worse outcomes 2
• Avoid macrolide monotherapy in areas with high pneumococcal resistance 2
• Do NOT use inadequate treatment duration (<5 days) 2
• Avoid overuse of fluoroquinolones as first-line agents 2
• Do NOT rely solely on CRP or acute-phase reactants to guide antibiotic decisions 1, 9
• Avoid unnecessary chest radiographs in well-appearing outpatients, as this drives overdiagnosis without improving outcomes 1, 2