Author: William J Barson, MD

Section Editors: Morven S Edwards, MD, George B Mallory, MD

Deputy Editor: Mary M Torchia, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2016. | This topic last updated: Dec 02, 2016.

INTRODUCTION — Community-acquired pneumonia (CAP) is defined as an acute infection of the

pulmonary parenchyma in a patient who has acquired the infection in the community, as distinguished
from hospital-acquired (nosocomial) pneumonia. CAP is a common and potentially serious illness with
considerable morbidity.

The inpatient treatment of CAP and hospital-acquired pneumonia in children will be reviewed here. The
outpatient treatment of CAP is discussed separately, as are the epidemiology, etiology, clinical features,
and diagnosis. (See "Community-acquired pneumonia in children: Outpatient treatment" and
"Pneumonia in children: Epidemiology, pathogenesis, and etiology" and "Community-acquired
pneumonia in children: Clinical features and diagnosis".)

The recommendations provided below are largely consistent with practice guidelines provided by The
Pediatric Infectious Diseases Society/Infectious Diseases Society of America and the British Thoracic
Society [1,2].

HOSPITALIZATION

Indications — The decision to hospitalize a child with community-acquired pneumonia (CAP) is

individualized based upon age, underlying medical problems, and clinical factors including severity of
illness (table 1) [1-3]. Hospitalization generally is warranted for infants younger than three to six months
of age, unless a viral etiology or Chlamydia trachomatis is suspected and they are not hypoxemic and
relatively asymptomatic. Hospitalization is also warranted for a child of any age whose family cannot
provide appropriate care and assure compliance with the management plan. Additional indications for
hospitalization include [1,2]:

● Hypoxemia (oxygen saturation [SpO2] <90 percent in room air at sea level)

● Dehydration, or inability to maintain hydration orally; inability to feed in an infant

● Moderate to severe respiratory distress: Respiratory rate >70 breaths/minute for infants <12 months
of age and >50 breaths per minute for older children; retractions; nasal flaring; difficulty breathing;
apnea; grunting

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 ● Toxic appearance (more common in bacterial pneumonia and may suggest a more severe course)
[4]

● Underlying conditions that may predispose to a more serious course of pneumonia (eg,
cardiopulmonary disease, genetic syndromes, neurocognitive disorders), may be worsened by
pneumonia (eg, metabolic disorder) or may adversely affect response to treatment (eg,
immunocompromised host)

● Complications (eg, effusion/empyema)

● Suspicion or confirmation that CAP is due to a pathogen with increased virulence, such as
Staphylococcus aureus or group A Streptococcus

● Failure of outpatient therapy (worsening or no response in 48 to 72 hours)

Indications for intensive care — The decision to treat a child with pneumonia in an intensive care
setting is individualized, based upon clinical, laboratory, and radiologic findings. Treatment in an
intensive care setting generally is warranted for children who manifest [1,2]:

● The need for ventilatory support beyond that which can be provided outside the intensive care unit
(eg, mechanical ventilation, noninvasive positive pressure ventilation, failure to maintain oxygen
saturation [SpO2] >92 percent in FiO2 >0.5)

● Signs of impending respiratory failure (lethargy, increasing work of breathing, and/or exhaustion
with or without hypercarbia)

● Recurrent apnea or slow irregular respirations

● Cardiovascular compromise with progressive tachycardia and/or hypotension that requires or is

refractory to fluid management

Care in the intensive care unit also may be warranted for children with two or more of the following [1]:

● Respiratory rate >70 breaths/minute for infants <12 months of age and >50 breaths/minute for older
children
● Apnea
● Increased work of breathing (retractions, dyspnea, nasal flaring, grunting)
● PaO2/FiO2 ratio <250
● Multilobar infiltrates
● Altered mental status
● Hypotension
● Pleural effusion
● Comorbid condition (eg, sickle cell disease, immune deficiency, immunosuppression)
● Unexplained metabolic acidosis

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 ● Pediatric Early Warning Score >6 [5]

Infection control — CAP can be caused by a variety of microbial agents requiring a variety of infection-
control measures [6]. If possible, rapid diagnostic tests should be performed at the time of admission, to
facilitate decisions regarding appropriate precautions. (See "Community-acquired pneumonia in
children: Clinical features and diagnosis", section on 'Rapid diagnostic tests'.)

Hand washing is the single most important procedure to prevent the spread of infection. Additional
infection control measures depend upon the likely pathogen(s), as follows [6,7]:

● Respiratory syncytial and parainfluenza viruses – Gown and gloves (ie, contact precautions)

● Influenza virus, group A Streptococcus (for the first 24 hours of treatment), methicillin-susceptible S.
aureus, Bordetella pertussis (until patient has received five days of effective therapy), and
Mycoplasma pneumoniae – Mask within 3 feet (ie, droplet precautions)

● Adenovirus – Contact and droplet precautions

● Methicillin-resistant S. aureus and other multidrug resistant organisms – Special organism

precautions; contact and droplet precautions and dedicated patient equipment

These precautions are discussed separately (see "Infection prevention: Precautions for preventing
transmission of infection"). Guidelines for hand hygiene in healthcare settings can be accessed through
the Centers for Disease Control and Prevention.

SUPPORTIVE CARE — Supportive care includes ensuring adequate antipyresis, analgesia, respiratory
support, and hydration.

Antipyresis and analgesia — Children hospitalized with pneumonia usually have fever and may have
pleuritic chest pain, which can lead to shallow breathing and impaired ability to cough. Administration of
antipyretics and/or analgesics (eg, acetaminophen, ibuprofen) can be used to keep the child
comfortable; opioid analgesia is rarely necessary in children without a chest tube in place. Adequate
pain control may promote coughing, which facilitates airway clearance. Antitussives should be avoided
as none have been found to be effective in pneumonia [8]. Symptomatic treatment of cough is discussed
separately. (See "The common cold in children: Management and prevention", section on 'Cough'.)

Respiratory support — Children hospitalized with pneumonia should receive ventilatory support as
indicated by their clinical condition [1,2]. A supported sitting position may help to expand the lungs and
improve respiratory symptoms [2].

We suggest that children with oxygen saturation [SpO2] <95 percent in room air be treated with
supplemental oxygen to maintain oxygen saturation ≥95 percent while they are in respiratory distress.
Different thresholds for supplemental oxygen are suggested by other experts (eg, the British Thoracic
Society guidelines suggest supplemental oxygenation to maintain oxygenation saturation >92 percent)
[2]. Gentle bulb suction of the nares may be helpful in infants and children whose nares are blocked with

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 secretions. Minimal handling seems to reduce oxygen requirements. (See "Continuous oxygen delivery
systems for infants, children, and adults".)

In children who are severely ill, it may be necessary to monitor carbon dioxide tension via blood gas
analysis in addition to oxygen saturation (SpO2) by oximetry. Hypercarbia is an important sign of
impending respiratory failure, particularly in the young infant who is tiring but may have preserved
oxygenation.

Fluid management — Children who cannot maintain adequate fluid intake because of breathlessness,
fatigue, or risk of aspiration [9] may require intravenous fluid therapy. Nasogastric (NG) tubes should be
avoided if possible because they may compromise breathing; if necessary, the smallest NG tube
possible should be used [2]. (See "Maintenance fluid therapy in children".)

Children with pneumonia are at risk for inappropriate secretion of antidiuretic hormone (SIADH) [10,11].
Serum electrolytes, fluid balance, and urine specific gravity should be monitored if there is clinical
suspicion of SIADH [11]. Confirmation of SIADH is discussed separately. Isotonic, rather than hypotonic,
intravenous fluids should be provided if SIADH is suspected. (See "Pathophysiology and etiology of the
syndrome of inappropriate antidiuretic hormone secretion (SIADH)", section on 'Pulmonary disease' and
"Maintenance fluid therapy in children", section on 'Hospitalized children'.)

Chest physiotherapy — Chest physiotherapy is not beneficial for children with uncomplicated
community-acquired pneumonia (CAP) [2]. In randomized and observational studies in children and
adults, chest physiotherapy had no conclusive effect on length of hospital stay, duration of fever, or
radiographic resolution [12-17].

Adjunctive glucocorticoid therapy — We do not routinely provide adjunctive glucocorticoid therapy to

children hospitalized with pneumonia. Although a systematic review and meta-analysis of randomized
trials in adult patients hospitalized with CAP found that corticosteroid therapy may be beneficial in
reducing the development of acute respiratory distress syndrome, need for mechanical ventilation, and
the duration of hospitalization [18], additional studies in children are necessary. A retrospective study
evaluating adjunctive glucocorticoid therapy for children being treated for CAP in the outpatient setting
found an association between adjunctive glucocorticoid therapy and treatment failure in children without
underlying asthma [19].

EMPIRIC THERAPY

Overview — Prompt initiation of antimicrobial therapy is crucial in children with community-acquired

pneumonia (CAP). The initial treatment of children who are hospitalized with pneumonia is empiric (table
2). Factors that must be considered include the spectrum of likely pathogens, antimicrobial susceptibility,
simplicity, tolerability, palatability, safety, and cost [20].

The recommendations of most guidelines are based on in vitro susceptibilities of the most likely
pathogen or pathogens, rather than evidence of the superiority of one antibiotic over another. Clinical
response to empiric therapy and results of microbiologic studies, when available, help to determine

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 whether additional evaluation or changes in therapy are necessary [1,2]. (See "Community-acquired
pneumonia in children: Clinical features and diagnosis", section on 'Microbiology' and 'Specific therapy'
below and 'Response to therapy' below.)

There are few randomized controlled trials to guide the choice of empiric antibiotics in children with CAP.
Decisions regarding empiric therapy are complicated by the substantial overlap in the clinical
presentation of bacterial and nonbacterial pneumonias [21-23]. Treatment decisions usually are based
upon algorithms that include patient age, epidemiologic and clinical information, and diagnostic
laboratory and imaging studies (table 2) [4]. The scope of empiric therapy (ie, narrow or broad) depends
upon the severity of illness and presence of complications. Agents other than those suggested in the
table may be more appropriate if there are clinical or epidemiologic features strongly suggestive of a
specific cause (eg, mediastinal or hilar lymphadenopathy, residence in the central United States, and
exposure to caves and/or bat guano suggestive of pulmonary histoplasmosis) [24].

Consultation with a specialist in infectious disease may be helpful in children with medication allergies,
comorbid conditions, failure of outpatient therapy, or multiple-drug-resistant organisms. Consultation
with a pediatric pulmonologist may be helpful in children with recurrent pneumonia. (See "Community-
acquired pneumonia in children: Clinical features and diagnosis" and "Community-acquired pneumonia
in children: Outpatient treatment", section on 'Treatment failure'.)

Etiologic clues — Certain clinical and epidemiologic features can be used to determine the most
likely pathogen(s) to aid in decisions regarding empiric therapy. Because these features often overlap,
they cannot be used with complete confidence, but are helpful in guiding empiric therapy until results of
microbiologic tests are available (table 3). These features are discussed in greater detail separately.
(See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Clues to
etiology' and "Community-acquired pneumonia in children: Clinical features and diagnosis", section on
'Etiologic clues'.)

Neonates — The treatment of neonatal pneumonia is discussed separately. (See "Neonatal

pneumonia".)

Viral pneumonia — Most children younger than three to five years of age who are admitted to the
hospital with pneumonia have viral pneumonia (eg, respiratory syncytial virus) [25]. This is particularly
true in the absence of lobar (or lobular) infiltrate and pleural effusion [4]. Viral pneumonia does not
require antibiotic therapy, unless a mixed infection or secondary bacterial infection is suspected. (See
"Respiratory syncytial virus infection: Treatment", section on 'Overview' and "Respiratory syncytial virus
infection: Clinical features and diagnosis", section on 'Clinical manifestations'.)

No effective antivirals are available for most viral pneumonias, with a few important exceptions,
described below.

Influenza pneumonia — Initiation of antiviral treatment for influenza (eg, oseltamivir) as soon as
possible is recommended for children hospitalized with presumed influenza pneumonia; laboratory

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 confirmation should not delay initiation of antiviral therapy. The diagnosis and treatment of influenza in
children are discussed separately. (See "Seasonal influenza in children: Prevention and treatment with
antiviral drugs", section on 'Antiviral therapy' and "Seasonal influenza in children: Clinical features and
diagnosis", section on 'Diagnosis'.)

For children with influenza pneumonia in whom secondary bacterial pneumonia is suspected, empiric
antibiotic therapy should include coverage for S. aureus, including methicillin-resistant S. aureus
(MRSA). Coinfection with S. aureus may be particularly severe and rapidly fatal.

Other viral pneumonias — Acyclovir can be used in the treatment of pneumonia due to herpes
simplex virus (HSV) or varicella zoster virus (VZV). Ganciclovir be used in the treatment of pneumonia
due to cytomegalovirus (CMV). (See "Treatment of varicella (chickenpox) infection", section on
'Individuals with complications'.)

Common respiratory viruses may cause serious infections in immunocompromised children and require
consideration of antiviral therapy: ribavirin for respiratory syncytial virus (RSV) or parainfluenza and
cidofovir for adenovirus. Concomitant immunoglobulin therapy is an additional consideration:
palivizumab for RSV, CMV immune globulin for CMV, and intravenous immunoglobulin for the other viral
etiologies. (See "Respiratory syncytial virus infection: Treatment", section on 'Pharmacotherapy' and
"Diagnosis, treatment, and prevention of adenovirus infection", section on 'Treatment'.)

Uncomplicated bacterial pneumonia — Streptococcus pneumoniae is the most common bacterial

cause of pneumonia in children of all ages [4,26]. Other potential bacterial pathogens that may need to
be included in empiric therapy for hospitalized children include S. aureus, including MRSA, S. pyogenes
(group A Streptococcus), Haemophilus influenzae type b (Hib) (if unimmunized), nontypeable H.
influenzae, and Moraxella catarrhalis [2,4,26-31].

The table provides several suggested parenteral empiric antibiotic regimens for uncomplicated
bacterial pneumonia in hospitalized children when S. aureus is not a consideration (table 2) [4,32,33].
The treatment of complicated CAP and severe CAP (particularly when S. aureus is a consideration) are
discussed below. (See 'Complicated CAP' below and 'Severe CAP requiring ICU admission' below.)

Ampicillin or penicillin G generally provides adequate coverage for the fully immunized child (table 4) in
communities without substantial prevalence of penicillin-resistant S. pneumoniae [1,34,35]. We suggest
a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) for children younger than 12 months and
those who are not fully immunized because third-generation cephalosporins provide coverage for the
beta-lactamase producing pathogens (eg, H. influenzae and M. catarrhalis) that may occur in these
children. We also suggest third-generation cephalosporins for children with more severe illness (table 1)
because third-generation cephalosporins provide coverage for a broader range of pathogens, including
penicillin-resistant S. pneumoniae, than ampicillin [1,36,37]. The fifth-generation parenteral
cephalosporin, ceftaroline, is approved by the US Food and Drug Administration (FDA) for treatment of
community-acquired bacterial pneumonia due to S. pneumoniae, methicillin-susceptible S. aureus
(MSSA), and H. influenzae in children ≥2 months of age. Although ceftaroline exhibits in vitro activity

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 against MRSA, clinical experience is insufficient to suggest its use when MRSA is a consideration. In a
randomized trial in children between 2 months and <18 years who were hospitalized with CAP,
ceftaroline and ceftriaxone had similar cure rates [38]. Three children with S. aureus infection (two with
MSSA recovered from sputum and one with MRSA recovered from blood) were successfully treated with
ceftaroline. However, patients considered at risk for MRSA infection or those with sputum demonstrating
a predominance of gram-positive cocci in clusters were excluded from the trial, precluding conclusions
about efficacy in this population.

A macrolide may be added (table 2) if M. pneumoniae, C. pneumoniae, or legionellosis is suspected.

(See 'Atypical pneumonia' below.)

We suggest that children who require hospitalization for treatment of CAP be treated initially with
parenteral antibiotics. However, oral amoxicillin may be an alternative for infants and children fully
immunized against Hib and S. pneumoniae with uncomplicated pneumonia that is not thought to be due
to S. aureus. In a multicenter randomized trial, treatment with amoxicillin was equivalent to treatment
with penicillin G in children with CAP who required hospital admission but did not have wheezing,
hypotension, chronic pulmonary conditions (other than asthma), immunodeficiency, pleural effusion
requiring drainage, or oxygen saturations <85 percent in room air [39]. The British Thoracic Society
guidelines suggest that oral antibiotics are safe and effective even for children with severe pneumonia
as long as they are able to tolerate oral fluids, are not vomiting, and do not have signs of septicemia or
complicated pneumonia [2].

Atypical pneumonia — Atypical bacterial pathogens include C. trachomatis in afebrile infants, and M.
pneumoniae and C. pneumoniae in older children and adolescents. The table provides several
suggested empiric regimens for atypical bacterial pneumonia in hospitalized children (table 2) [4,32].

For children older than four years, coverage for typical bacterial pathogens (eg, ampicillin or a third-
generation cephalosporin) may be added to empiric coverage for atypical pathogens if there is strong
evidence of a bacterial cause. Strong evidence of a bacterial cause includes white blood cell count
>15,000/microL, C-reactive protein (CRP) >35 to 60 mg/L (3.5 to 6 mg/dL), chills, or no response to
outpatient therapy with a macrolide or doxycycline [4,40].

Fluoroquinolones (eg, levofloxacin, moxifloxacin) may be reasonable empiric therapy for the older child
and adolescent with suspected atypical pneumonia who could actually have pneumococcal pneumonia.
The fluoroquinolones also may be used in the older child or adolescent who has a type 1
hypersensitivity (table 5) to beta-lactam antibiotics. In addition to their excellent gram-negative
spectrum, the fluoroquinolones are active against a number of the pathogens responsible for CAP,
including beta-lactam-susceptible and nonsusceptible S. pneumoniae, M. pneumoniae (including
macrolide-resistant M. pneumoniae), and C. pneumoniae [41]. However, S. pneumoniae resistant to
levofloxacin have been identified [42].

Severe CAP

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 Severe CAP not requiring ICU admission — Children with severe community-acquired pneumonia
(CAP) that does not require admission to the intensive care unit (ICU) (table 1) may benefit from
combination empiric therapy with a macrolide and a beta-lactam antibiotic (eg, penicillin or third-
generation cephalosporin) (table 2). Combination therapy improves coverage for resistant organisms
and mixed bacterial/atypical bacterial infections. Antimicrobial therapy can be adjusted as necessary
when results of microbiologic testing become available. Invasive diagnostic testing, including
bronchoscopy with bronchoalveolar lavage, may be necessary for specific microbiologic diagnosis. (See
'Uncomplicated bacterial pneumonia' above and 'Atypical pneumonia' above and "Community-acquired
pneumonia in children: Clinical features and diagnosis", section on 'Invasive studies'.)

Severe CAP requiring ICU admission — Children who are admitted to the intensive care unit for
serious or life-threatening infections require broad-spectrum empiric coverage that addresses potential
beta-lactam resistance and community-associated methicillin-resistant S. aureus (CA-MRSA). (See
'Indications for intensive care' above.)

A suggested regimen for such children may include (table 2) [43-45]:

● Vancomycin 60 mg/kg per day intravenously (IV) in four divided doses up to a maximum of 4 g/day,
and

● A third-generation cephalosporin (cefotaxime 150 mg/kg per day IV in four divided doses up to a
maximum of 10 g/day or ceftriaxone 100 mg/kg per day IV in two divided doses up to a maximum
dose of 4 g/day), and

● Azithromycin 10 mg/kg once per day IV for two days (maximum 500 mg/day), followed by 5 mg/kg
once per day IV (maximum 250 mg/day), and possibly

● Nafcillin or oxacillin 150 mg/kg per day IV in four divided doses; maximum 12 g/day if S. aureus is
likely (methicillin-susceptible S. aureus is more rapidly killed by nafcillin than by vancomycin), and
possibly

● Antiviral therapy for influenza, if the child is hospitalized during influenza season; laboratory
confirmation of influenza should not delay initiation of antiviral therapy (see "Seasonal influenza in
children: Prevention and treatment with antiviral drugs", section on 'Antiviral therapy')

This combination is necessary because of reports of treatment failure resulting from treatment of
nonsusceptible S. pneumoniae with beta-lactams, increasing clindamycin resistance among S.
pneumoniae, and concern for MRSA [43]. Virtually all strains of MRSA are susceptible to vancomycin
[44]. (See "Methicillin-resistant Staphylococcus aureus in children: Treatment of invasive infections",
section on 'Pneumonia'.)

When treating with vancomycin, renal function and serum trough levels or dosing to achieve an area
under the curve/minimum inhibitory concentration (AUC/MIC) ratio >400 should be monitored in an
attempt to assure therapeutic efficacy and limit toxicity. In adults, vancomycin trough levels between 15

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 and 20 microgram/mL have been suggested to improve clinical outcomes for complicated infections due
to S. aureus [45-47]. Similar trough levels may not be needed in children to achieve an AUC/MIC >400
and further studies are needed to evaluate the clinical effectiveness and safety of these dosing
recommendations in children [47-52].

Linezolid is an oxazolidinone antibiotic with activity against gram-positive cocci, including beta-lactam-
resistant S. pneumoniae and MRSA. Linezolid could be substituted for vancomycin and nafcillin in the
above regimen. The dose for linezolid is 10 mg/kg per dose (maximum 600 mg); it is administered every
eight hours in children younger than 12 years and every 12 hours in children 12 years and older.

Complicated CAP — Complicated community-acquired pneumonia (CAP) (eg, parapneumonic

effusion, lung abscess) requires a broader spectrum of antibiotic coverage if etiologies other than S.
pneumoniae are being considered. The expanded spectrum should include coverage for beta-lactam-
resistant isolates and CA-MRSA. Coverage for anaerobes and gram-negative organisms also may be
necessary for children with lung abscess [53]. Antimicrobial therapy can be adjusted as necessary when
results of microbiologic testing become available. (See "Community-acquired pneumonia in children:
Clinical features and diagnosis", section on 'Complications' and "Management and prognosis of
parapneumonic effusion and empyema in children".)

Complicated CAP requires a prolonged course of antimicrobial therapy, usually initiated parenterally
[24]. Appropriate regimens may include [32]:

● Ceftriaxone 100 mg/kg IV in two divided doses up to a maximum dose of 4 g/day, OR cefotaxime
150 mg/kg per day IV in four divided doses up to a maximum of 10 g/day, PLUS clindamycin 30 to
40 mg/kg per day IV in three or four divided doses to a maximum of 1 to 2 g/day if S. aureus or
anaerobes are a consideration.

Vancomycin 40 to 60 mg/kg per day IV in three or four divided doses up to a maximum of 4 g/day is
an alternative to clindamycin if the patient is allergic to clindamycin or if clindamycin-resistant S.
aureus is prevalent in the community. The threshold prevalence of clindamycin-resistant MRSA
(constitutive plus inducible) for choosing vancomycin varies from center to center, usually ranging
from 10 to 25 percent, trying to balance the benefit of definitive therapy for the patient with the risk
of increasing vancomycin resistance in the community. Additional considerations in the decision to
choose vancomycin include the prevalence of MRSA in the community, the severity of illness, and
the turn-around time for susceptibilities. When treating with vancomycin, renal function and serum
trough levels or dosing to achieve an AUC/MIC ratio of >400 should be monitored in an attempt to
assure therapeutic efficacy and limit toxicity. In adults, vancomycin trough levels between 15 and 20
microgram/mL have been suggested to improve clinical outcomes for complicated infections due to
S. aureus [45-47]. Similar trough levels may not be needed in children to achieve an AUC/MIC
>400 and further studies are needed to evaluate the clinical effectiveness and safety of these
dosing recommendations in children [47-52]. (See "Methicillin-resistant Staphylococcus aureus in
children: Treatment of invasive infections", section on 'MRSA infections'.)

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 ● Ampicillin-sulbactam 150 to 200 mg/kg per day of the ampicillin component IV in four divided doses;
maximum 12 g/day alone may be effective if a lung abscess is thought to be secondary to an
aspiration event. (See 'Aspiration pneumonia' below.)

The duration of therapy and other considerations in the management of complicated pneumonia depend
upon the type of complication:

● Parapneumonic effusion/empyema – The treatment of parapneumonic effusion and empyema is

discussed in detail separately. (See "Management and prognosis of parapneumonic effusion and
empyema in children".)

● Necrotizing pneumonia – Treatment of necrotizing pneumonia requires a prolonged course of

antibiotic therapy. The duration is determined by the clinical response but is usually a total of four
weeks or two weeks after the patient is afebrile and has improved clinically. Interventional
procedures (eg, percutaneous drainage catheter placement) should be performed cautiously in
children with necrotizing pneumonia; such procedures increase the risk of complications, such as
the development of bronchopleural fistulae [53-56].

● Lung abscess – Treatment of lung abscess requires a prolonged course of antibiotic therapy. The
duration is determined by the clinical response, but is usually a total of four weeks or two weeks
after the patient is afebrile and has clinical improvement. The average duration of fever is four to
eight days [24]. Eighty to 90 percent of lung abscesses in children resolve with antibiotic therapy
alone and spontaneous drainage through the tracheobronchial tree, provided that bronchial
obstruction is removed [57].

In cases that fail to resolve with antibiotics alone, needle aspiration or percutaneous catheter
drainage may provide diagnostic information and therapeutic benefit without the increased risk of
complications that occurs in children with necrotizing pneumonia [53,54,58,59]. Percutaneous
drainage may be warranted in children with lung abscess whose condition fails to improve or
worsens after 72 hours of antibiotic therapy [53]. At least three weeks of IV antibiotic therapy should
be delivered before lobectomy is considered for treatment failure [60].

● Pneumatocele – Most pneumatoceles involute spontaneously [61-63]. However, on occasion,

pneumatoceles result in pneumothorax [64].

Hospital-acquired pneumonia — Empiric treatment of hospital-acquired pneumonia should include

coverage for S. aureus, Enterobacteriaceae, Pseudomonas aeruginosa, and anaerobes. Acceptable
broad spectrum regimens usually include an aminoglycoside (for gram-negative pathogens) and another
agent to address gram-positive pathogens and anaerobes (table 2):

● Aminoglycoside (usually gentamicin; amikacin if extended spectrum or Amp C beta-lactamase

producing gram-negative rods are possible etiologies) plus one of the following:

• Piperacillin-tazobactam 300 mg/kg per day IV in four divided doses up to a maximum of 12

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 g/day, or

• Meropenem 60 mg/kg per day IV in three divided doses, up to a maximum of 6 g/day if

extended-spectrum or Amp C beta-lactamase-producing gram-negative rods are possible
etiologies, or

• Ceftazidime 125 to 150 mg/kg per day in three divided doses; maximum of 6 g/day, or

• Cefepime 150 mg/kg per day in three divided doses; maximum of 4 g/day

• Clindamycin 30 to 40 mg/kg per day in three or four divided doses; maximum 3.6 g/day (for
patients with type 1 hypersensitivity (table 5) to beta-lactam antibiotics)

The combination of amikacin and meropenem should be used if extended-spectrum or Amp C beta-
lactamase-producing gram-negative rods are possible etiologies. The cephalosporin/aminoglycoside
combination lacks anaerobic coverage so should NOT be used when aspiration pneumonia is a
possibility. (See 'Aspiration pneumonia' below.)

Vancomycin should be added to the empiric regimen if MRSA is a consideration.

Aspiration pneumonia — Empiric antibiotic regimens for community-acquired aspiration pneumonia

must cover oral anaerobes. Appropriate antibiotic regimens for hospitalized children include [53]:

● Ampicillin-sulbactam 150 to 200 mg/kg per day of the ampicillin component IV in four divided doses;
maximum 12 g/day, or

● Clindamycin 30 to 40 mg/kg per day IV in three or four divided doses to a maximum of 1 to 2 g/day
if MRSA etiology is suspected.

In neurologically compromised older adolescents prone to aspiration events, empiric treatment for CAP
with a fluoroquinolone like moxifloxacin (400 mg once daily) may be reasonable. Moxifloxacin has
activity against anaerobic bacteria, as well as the usual treatable causes of CAP (S. pneumoniae, M.
pneumoniae, and C. pneumoniae).

Appropriate antibiotic regimens for children with healthcare-associated aspiration who are known to be
colonized with unusual gram-negative pathogens (eg, Klebsiella pneumoniae) include:

● Piperacillin-tazobactam 300 mg/kg per day IV in four divided doses up to a maximum of 12 g/day,
or

● Meropenem 60 mg/kg per day IV in three divided doses, up to a maximum of 6 g/day

Vancomycin should be added to the empiric regime if MRSA is a consideration.

Patients with true beta-lactam hypersensitivity (ie, type 1 hypersensitivity reaction) (table 5) can be
treated with a combination of clindamycin and an aminoglycoside.

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 Immunocompromised host — Empiric treatment for pneumonia in immunocompromised hosts also
requires broad-spectrum gram-positive and gram-negative coverage, similar to that required for hospital-
acquired pneumonia, with the addition of vancomycin if MRSA is considered, and possibly trimethoprim-
sulfamethoxazole for Pneumocystis jirovecii (formerly P. carinii). Empiric regimens may need to be
modified once results of cultures and antibiotic susceptibility testing are available. Invasive testing may
be required to obtain a satisfactory specimen in such patients (see "Community-acquired pneumonia in
children: Clinical features and diagnosis", section on 'Invasive studies'). Treatment of CAP in the
immunocompromised host should occur in consultation with an infectious disease specialist.

An aggressive approach to specific microbial diagnosis is indicated in immunocompromised hosts with

clinically significant pneumonias. For patients with an endotracheal tube in place, specific microbial
diagnosis may involve early flexible bronchoscopy for bronchoalveolar lavage with viral, fungal, and
bacterial cultures. Although the protected specimen brush technique has been utilized in some settings,
quantitative bacterial cultures are more commonly used to differentiate colonization from true lower
respiratory tract infection. (See "Flexible bronchoscopy in adults: Indications and contraindications",
section on 'Diagnostic indications' and "Clinical presentation and diagnosis of ventilator-associated
pneumonia", section on 'Diagnostic evaluation'.)

SPECIFIC THERAPY — Once results of microbiologic tests are available, antimicrobial therapy can be
directed toward the responsible pathogen or pathogens. Specific antibiotic therapy for bacterial
community-acquired pneumonia (CAP) is summarized in the table (table 6). Specific antimicrobial and/or
supportive therapy for the pathogens that commonly cause CAP in children is discussed in the topic
reviews listed below.

● S. pneumoniae (see "Pneumococcal pneumonia in children", section on 'Specific therapy')

● M. pneumoniae (see "Mycoplasma pneumoniae infection in children", section on 'Treatment')

● C. pneumoniae (see "Pneumonia caused by Chlamydia species in children")

● Methicillin-susceptible S. aureus – Methicillin-susceptible S. aureus pneumonia may be treated with

oxacillin, nafcillin, or cefazolin [1,4]

● Methicillin-resistant S. aureus (MRSA) (see "Methicillin-resistant Staphylococcus aureus in children:

Treatment of invasive infections", section on 'Definitive therapy')

● Respiratory syncytial virus (see "Respiratory syncytial virus infection: Treatment")

● Influenza (see "Seasonal influenza in children: Prevention and treatment with antiviral drugs",
section on 'Antiviral therapy')

● Parainfluenza (see "Parainfluenza viruses in children", section on 'Treatment')

● Adenovirus (see "Diagnosis, treatment, and prevention of adenovirus infection", section on

'Treatment')

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 ● Human metapneumovirus (see "Human metapneumovirus infections", section on 'Treatment')

DURATION OF TREATMENT

Parenteral therapy — There are few data to guide decisions about the duration of parenteral therapy
for community-acquired pneumonia (CAP) [2]. It is common to switch to oral therapy in patients who
have received parenteral antibiotics when the patient has become afebrile for 24 to 48 hours and is not
having emesis [65].

Total duration — There are few randomized controlled trials to guide decisions about the appropriate
duration of antimicrobial therapy for radiographically confirmed childhood pneumonia [2]. Current
practice assigns duration of therapy according to the host, causative agent, and severity.

Uncomplicated cases — The usual duration of combined parenteral and oral therapy for
uncomplicated pneumonia is 7 to 10 days [1,2]. Some authorities suggest continuing oral therapy at
least one week beyond resolution of fever; others suggest treating until the erythrocyte sedimentation
rate falls below 20 mm/hour. Some data from trials in adults suggest that a shorter course may be
equivalent to a 7- to 10-day course, but additional controlled studies are necessary before this practice
can be recommended routinely for children [53,66-68].

Complicated cases — Treatment of complications, such as necrotizing pneumonia and lung

abscess, requires a prolonged course of antibiotic therapy, usually initiated parenterally. The duration is
determined by the clinical response, but usually is either a total of four weeks or a total of two weeks
after the patient is afebrile and has improved clinically. (See 'Complicated CAP' above.)

RESPONSE TO THERAPY — The following clinical parameters can be monitored to assess response
to treatment [1,2]:

● Temperature
● Respiratory rate
● Heart rate
● Oxygen saturation (SpO2)
● Work of breathing (eg, retractions, nasal flaring, grunting)
● Chest examination (extent of abnormal or absent breath sounds; extent of dullness to percussion)
● Mental status
● Ability to maintain oral intake and hydration

The frequency of monitoring depends upon the severity of illness. In patients who are receiving oxygen
supplementation, oxygen saturation should be evaluated regularly. Evaluation for hypercarbia may be
necessary in children with severe respiratory distress, as oxygenation may be preserved.

The respiratory status of children with community-acquired pneumonia (CAP) who are appropriately
treated should improve within 48 to 72 hours [1]. However, fevers may persist for several days after

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 initiation of appropriate therapy [53].

Treatment failure — In children who fail to improve as anticipated, the following possibilities must be
considered [1,2,69,70]:

● Alternative or coincident diagnoses (eg, foreign body aspiration) (see "Community-acquired

pneumonia in children: Clinical features and diagnosis", section on 'Differential diagnosis')

● Ineffective antibiotic coverage (lack of coverage for the actual etiology or resistant organism)

● Development of complications (see "Community-acquired pneumonia in children: Clinical features

and diagnosis", section on 'Complications')

● Underlying immunodeficiency condition

The history should be reviewed with special attention to the possibility of foreign body aspiration and
geographic or environmental exposures associated with pathogens not treated by the empiric regimen
(table 7).

Changes in laboratory parameters (eg, peripheral white blood cell count, inflammatory markers [if
obtained initially]) may provide information about disease progression. Repeat radiographs or additional
imaging studies can help to assess the degree of parenchymal involvement and evaluate for
complications or anatomic abnormalities [1]. (See "Community-acquired pneumonia in children: Clinical
features and diagnosis", section on 'Complications' and "Pneumonia in children: Epidemiology,
pathogenesis, and etiology", section on 'Etiologic agents'.)

Depending upon the severity of illness, more aggressive attempts may need to be made to establish a
microbiologic diagnosis (eg, induced sputum [71], bronchoscopy with bronchoalveolar lavage,
percutaneous needle aspiration, or lung biopsy). In children with lung abscess whose condition fails to
improve or worsens after 72 hours of antibiotic therapy, needle aspiration or percutaneous catheter
drainage may provide diagnostic information and therapeutic benefit [53,54,58,59]. (See "Community-
acquired pneumonia in children: Clinical features and diagnosis", section on 'Invasive studies'.)

DISCHARGE CRITERIA — Discharge criteria for children who have been admitted to the hospital with
community-acquired pneumonia (CAP) have not been standardized, but typically include [1,53]:

● Improvement of vital signs

● Ability to maintain adequate fluid and nutrition orally
● Ability to maintain oxygen saturation ≥90 percent in room air
● Improvement in respiratory status
● Overall clinical improvement including level of activity, appetite, and decreased fever for at least 12
to 24 hours
● Stable and/or baseline mental status
● Parents' ability to administer and child's ability to comply with home antibiotic regimen

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 ● Safe and compliant home environment

Outpatient parenteral antibiotic therapy — Outpatient parenteral antimicrobial therapy (OPAT) is an

option for selected patients who require prolonged treatment (usually for complicated CAP that for some
reason cannot be treated with an oral antibiotic) and have stabilized clinically [53,72,73]. Eligibility for
OPAT requires a suitable home environment and a pharmacologic agent with a reasonable dosing
schedule [74]. Decisions regarding OPAT should involve the caregivers, an infectious disease specialist
(or clinician knowledgeable about the use of antimicrobial agents in OPAT), a hospital pharmacist, and
the primary care provider. The services of a visiting nurse may be required for home visits, education
and observation of caregiver administration, and/or obtaining blood samples for therapeutic monitoring.

FOLLOW-UP

Clinical course — Children with pneumonia should be seen by their primary care provider soon after
discharge to ensure that clinical improvement continues and antibiotic therapy is being taken as
prescribed [53]. Decisions regarding the timing of clinical follow-up should involve the child's primary
care provider and the clinical status of the child at the time of discharge.

Children who are appropriately treated for pneumonia should gradually improve with time. Cough may
persist for as long as three to four months after viral pneumonia or pertussis. Children who are
recovering from typical or atypical bacterial pneumonia may continue to cough for several weeks and
have moderate dyspnea on exertion for two to three months [75]. Symptomatic treatment of cough is
discussed separately. (See "The common cold in children: Management and prevention", section on
'Cough'.)

Radiographs — Follow-up radiographs are not necessary in asymptomatic children with uncomplicated
community-acquired pneumonia (CAP). However, in children with complicated CAP or CAP that required
intervention, follow-up radiographs help to ensure resolution [2,76]. Follow-up radiographs also may be
helpful in children with recurrent pneumonia, persistent symptoms, severe atelectasis, unusually located
infiltrates, or round pneumonia (ie, pulmonary consolidation that appears to be spherical) [2,53,77].
Conditions that must be considered if a round pneumonia fails to resolve on follow-up imaging include
congenital lung sequestration, metastatic Wilms tumor, cavitary necrosis, pleural pseudocyst, and
primary lung carcinoma [77-81]. When follow-up radiographs are indicated, they should be obtained two
to three weeks after hospital discharge [53,82].

Several studies have evaluated the utility of follow-up radiographs in cohorts of children with acute
radiologically proven CAP [83-88]. Three of the studies included clinical as well as radiologic follow-up at
three to seven weeks after initial diagnosis [83-86]. In each of these studies, follow-up radiographs were
normal or improved in asymptomatic children. Residual findings, even when present, did not result in
additional therapy.

PROGNOSIS — Most otherwise healthy children with pneumonia recover without sequelae, even if the
pneumonia is complicated [53,55,56,89]. In a multicenter cohort study, approximately 3 percent of

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 82,566 children hospitalized with pneumonia were readmitted with pneumonia within 30 days of
discharge; 8 percent were readmitted for any reason. Readmission was more common among children
younger than one year and children with chronic medical conditions [90].

Although some data suggest that nearly one-half of children who are hospitalized for viral pneumonia
have symptoms of asthma five years after hospitalization, it is not clear whether this is related to
unrecognized asthma at the time of presentation with pneumonia or a tendency to develop asthma after
community-acquired viral pneumonia [91,92].

The overall pneumonia mortality rate in developed countries is <1 per 1000 per year [25,93].
Pneumococcal pneumonia case fatality rates (not adjusted for comorbid conditions) for children in the
United States were estimated to be 4 percent in children younger than two years and 2 percent in
children 2 to 17 years before the introduction of pneumococcal conjugate vaccines [94].

The introduction of pneumococcal conjugate vaccines has resulted in a dramatic reduction (37 to 80
percent) in invasive disease and mortality rates in the countries in which they have been introduced [95].
However, pneumococcal pneumonia mortality rates have not been specifically examined. Data from the
United States Pediatric Multicenter Pneumococcal Surveillance Study Group demonstrated overall
pneumococcal mortality rates of 1 percent after the introduction of PCV7 (during 2006 to 2009) and 0
percent after the introduction of PCV13 (during 2011 to 2014) [96] In a study from eastern Gambia,
introduction of a nine-valent pneumococcal conjugate vaccine resulted in reduced all-cause mortality
(25.2 versus 30.1 per 1000 child-years, a 16 percent reduction) [97]. (See "Pneumococcal
(Streptococcus pneumoniae) conjugate vaccines in children", section on 'Efficacy and effectiveness'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The
Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at
the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and who
prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and
are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-
mail these topics to your patients. (You can also locate patient education articles on a variety of subjects
by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Pneumonia in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

● The decision to hospitalize a child with community-acquired pneumonia (CAP) must be

individualized and is based upon age, underlying medical problems, and severity of illness (table 1).
(See 'Indications' above.)

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 ● CAP can be caused by a variety of microbial agents requiring a variety of infection-control
measures. (See 'Infection control' above.)

● Supportive care for children hospitalized with pneumonia includes provision of adequate respiratory
support, hydration, antipyresis, and analgesia. (See 'Supportive care' above.)

● Children with CAP who are hospitalized are treated empirically until information from the
microbiologic evaluation is available to direct therapy toward a specific pathogen. Decisions
regarding empiric antimicrobial therapy for CAP in children are usually based upon age unless
there are other overriding epidemiologic or clinical factors to suggest a specific etiologic agent
(table 2). (See 'Overview' above and "Pneumonia in children: Epidemiology, pathogenesis, and
etiology", section on 'Etiologic agents'.)

● We recommend that empiric antibiotic therapy for presumed bacterial pneumonia in hospitalized
children include coverage for Streptococcus pneumoniae (table 2) (Grade 1B). (See
'Uncomplicated bacterial pneumonia' above.)

● Extended empiric coverage may be indicated for children with complicated or severe pneumonia,
particularly those who require admission to an intensive care unit (table 2). (See 'Complicated CAP'
above and 'Severe CAP requiring ICU admission' above.)

● When results of microbiologic tests are available, antibiotic therapy can be directed toward the
specific pathogen recovered (table 6). (See 'Specific therapy' above.)

● Oral therapy typically is initiated when the patient has been afebrile for 24 to 48 hours and can
tolerate oral intake. The total duration of antibiotic therapy is usually 7 to 10 days for uncomplicated
CAP and up to four weeks in complicated CAP. (See 'Duration of treatment' above.)

● The respiratory status of children receiving appropriate therapy for CAP should improve within 48 to
72 hours. Children who fail to improve as anticipated may be receiving inadequate antibiotic
therapy, have developed complications, or have an alternative or coincident diagnosis. (See
'Treatment failure' above.)

● Children recovering from CAP may continue to have cough for several weeks to four months,
depending upon the etiology. Those recovering from typical or atypical bacterial pneumonia may
have moderate dyspnea on exertion for two to three months. (See 'Clinical course' above.)

● Follow-up radiographs are not necessary in asymptomatic children with uncomplicated CAP.
However, in children with complicated CAP or CAP that required intervention, follow-up radiographs
help to ensure resolution. Follow-up radiographs two to three weeks after completion of therapy
may be helpful in children with recurrent pneumonia, persistent symptoms, severe atelectasis,
round pneumonia, or unusually located infiltrates. (See 'Radiographs' above.)

● Most otherwise healthy children who develop pneumonia recover without any long-term sequelae.

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 (See 'Prognosis' above.)

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