In a 7-year-old boy with fever, cough, localized left lower lobe consolidation on physical examination, oxygen saturation 94% on room air, and ability to drink fluids, what is the most appropriate management?

Management of 7-Year-Old with Community-Acquired Pneumonia

Discharge this child on oral amoxicillin with clear return precautions and 48-hour follow-up instructions. 1, 2

Why Outpatient Management is Appropriate

This child does NOT meet hospitalization criteria based on multiple guideline thresholds:

• Oxygen saturation of 94% is above the <92% threshold that mandates hospital admission in children with pneumonia 1, 2
• Ability to drink fluids indicates adequate hydration and supports safe outpatient care 2
• At 7 years old, the child is well beyond the high-risk infant age group (<3-6 months) that requires hospitalization 1
• No documented severe respiratory distress (grunting, marked retractions, altered mental status) is present 1, 2

The British Thoracic Society explicitly states that oxygen saturation <92% is an absolute criterion for admission in older children; a saturation of 94% therefore does not mandate admission. 1

First-Line Antibiotic Selection

Oral amoxicillin is the definitive first-line treatment for community-acquired pneumonia in this age group:

• Amoxicillin remains the preferred agent because Streptococcus pneumoniae is the predominant bacterial pathogen across all pediatric age groups, and amoxicillin provides high efficacy, good tolerability, and low cost 1, 2, 3
• Recommended dose: 45 mg/kg/day divided every 12 hours (or 40 mg/kg/day divided every 8 hours) for lower respiratory tract infection 3
• Duration: 5-7 days is appropriate for uncomplicated pneumonia 4, 5

Why NOT Macrolides as First-Line?

Macrolides are reserved for children ≥5 years only when atypical organisms (Mycoplasma or Chlamydia) are specifically suspected; they are not first-line for typical lobar pneumonia with consolidation. 1, 2 This child has clinical and physical examination findings consistent with typical bacterial pneumonia (fever, cough, localized consolidation).

Why NOT Admit for IV Antibiotics?

Admission for IV antibiotics constitutes overtreatment in this clinical scenario:

• IV antibiotics are indicated only when oral intake is unreliable (persistent vomiting) or when severe clinical features are present (SpO₂ <92%, marked respiratory distress, inability to feed) 1, 2
• In a hemodynamically stable child without hypoxia or severe distress, admission for IV therapy is not supported by guidelines 1, 2
• Recent evidence demonstrates that oral amoxicillin is equally effective for children with mild-to-moderate CAP 4, 5

Critical Discharge Instructions

Families must receive specific guidance on when to return immediately 1, 2:

• Return immediately for: increased work of breathing, inability to drink, worsening fever despite antibiotics, lethargy or altered consciousness, cyanosis
• Mandatory follow-up within 48 hours if clinical improvement is not evident after starting oral therapy 1, 2
• Education on fever management with antipyretics (acetaminophen or ibuprofen) and maintaining adequate hydration 1
• Complete the full antibiotic course for minimum 5-7 days 4, 5

Common Pitfalls to Avoid

• Do not routinely obtain chest radiography for mild uncomplicated cases when clinical diagnosis is clear 1
• Do not prescribe macrolides as first-line unless there is specific suspicion for atypical pathogens 1, 2
• Do not admit based solely on radiographic findings (consolidation) if clinical parameters are reassuring and family can provide appropriate observation 1, 2
• Do not use broad-spectrum antibiotics (co-amoxiclav, cephalosporins) as first-line in uncomplicated cases 1

Answer: B. Discharge on oral amoxicillin with clear instructions