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Neumonía en niños: tratamiento hospitalario

AUTOR: William J Barson, MD
EDITOR DE SECCIÓN: Morven Edwards, MD
EDITOR ADJUNTO: Diane Blake, MD

Todos los temas se actualizan a medida que hay nueva evidencia disponible y nuestro proceso de revisión por pares
se completa.

Revisión de la literatura vigente hasta: marzo de 2024.

Este tema se actualizó por última vez: 25 de abril de 2022.

INTRODUCCIÓN

La neumonía adquirida en la comunidad (NAC) se define como una infección aguda del parénquima
pulmonar en un paciente que ha adquirido la infección en la comunidad, a diferencia de la neumonía
adquirida en el hospital (nosocomial). La NAC es una enfermedad común y potencialmente grave con una
morbilidad considerable.

Aquí se revisará el tratamiento hospitalario de la NAC y la neumonía adquirida en el hospital en niños.

Nuestras recomendaciones son en gran medida consistentes con las pautas de práctica proporcionadas
por la Sociedad de Enfermedades Infecciosas Pediátricas/Sociedad de Enfermedades Infecciosas de
América y la Sociedad Torácica Británica [ 1, 2 ]. (Consulte 'Enlaces de directrices de la sociedad' a
continuación).

El tratamiento ambulatorio de la NAC; la epidemiología, etiología, características clínicas y diagnóstico de

NAC en niños; y el manejo de la neumonía relacionada con la enfermedad por coronavirus 2019 se
analizan por separado:

● (Ver "Neumonía adquirida en la comunidad en niños: tratamiento ambulatorio" .)

● (Ver "Neumonía en niños: epidemiología, patogénesis y etiología" .)
● (Ver "Neumonía adquirida en la comunidad en niños: características clínicas y diagnóstico" .)
● (Ver "COVID-19: Manejo en niños" .)

HOSPITALIZACIÓN

Indicaciones : la decisión de hospitalizar a un niño con neumonía adquirida en la comunidad (NAC) se

individualiza según la edad, los problemas médicos subyacentes y los factores clínicos, incluida la
gravedad de la enfermedad ( tabla 1 ) [ 1-3 ]. Por lo general, se justifica la hospitalización en bebés
menores de tres a seis meses de edad, a menos que se sospeche una etiología viral o Chlamydia
trachomatis y no sean hipoxémicos y sean relativamente asintomáticos. La hospitalización también está
garantizada para un niño de cualquier edad cuyos cuidadores no puedan brindar la atención adecuada y
garantizar el cumplimiento del plan de manejo. Las indicaciones adicionales de hospitalización incluyen [
1,2 ]:

● Hipoxemia (saturación de oxígeno capilar periférico [SpO 2 ] <90 por ciento en aire ambiente al nivel
del mar)

● Deshidratación o incapacidad para mantener la hidratación por vía oral; incapacidad para
alimentarse en un bebé

● 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

● 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, necrotizing process, abscess)

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

● 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
(ICU; eg, mechanical ventilation, noninvasive positive pressure ventilation, failure to maintain SpO2
>92 percent in fraction of inspired oxygen [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 ICU 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)
● Partial pressure of oxygen in arterial blood (PaO2):FiO2 ratio <250
● Multilobar infiltrates
● Altered mental status
● Hypotension
● Pleural effusion
● Comorbid condition (eg, sickle cell disease, immune deficiency, immunosuppression)
● Unexplained metabolic acidosis
● 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 'Approach to microbiologic testing'.)

Hand washing is the single most important procedure to prevent the spread of infection. Guidelines for
hand hygiene in health care settings can be accessed through the Centers for Disease Control and
Prevention.

Additional infection control measures depend upon the likely pathogen(s), as follows [6,7]:

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

● Influenza and rhinoviruses, GAS (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

Because isolation precautions are different for different pathogens, we favor simplifying the approach for
viral respiratory pathogens by placing all patients with suspected viral respiratory tract infection on both
contact and droplet precautions. These precautions are discussed separately. (See "Infection prevention:
Precautions for preventing transmission of infection".)

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
secretions. Minimal handling seems to reduce oxygen requirements. (See "Continuous oxygen delivery
systems for the acute care of 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 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 (IV) fluid therapy. Nasogastric tubes should be
avoided if possible because they may compromise breathing; if necessary, the smallest nasogastric tube
possible should be used [2]. (See "Maintenance intravenous 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, IV
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
intravenous fluid therapy in 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 two small
heterogeneous trials suggested that glucocorticoids reduce clinical failure (defined as death from any
cause, radiographic progression, or clinical instability at day 5 to 8) and time to clinical cure, additional
studies in children are necessary before glucocorticoids can be routinely recommended [18-20]. 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 [21].

Adjunctive glucocorticoids for adults with pneumonia are discussed separately. (See "Treatment of
community-acquired pneumonia in adults who require hospitalization", section on 'Adjunctive
glucocorticoids'.)

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 2A-B). Factors that must be considered include the spectrum of likely pathogens, antimicrobial
susceptibility, simplicity, tolerability, palatability, safety, and cost [22].

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

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 [23-25]. Treatment decisions usually are based
upon algorithms that include patient age, epidemiologic and clinical information, and diagnostic
laboratory and imaging studies ( table 2A-B) [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).
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 [RSV]) [26]. 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: Clinical features and diagnosis in infants and children", section
on 'Clinical manifestations' and "Respiratory syncytial virus infection: Treatment in infants and children".)

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

COVID-19 pneumonia — The management of coronavirus 2019 (COVID-19)-related pneumonia is

discussed separately. (See "COVID-19: Management in children", section on 'Management of hospitalized
children'.)

Influenza pneumonia — Initiation of antiviral treatment for influenza (eg, oseltamivir) as soon as
possible is recommended for children hospitalized with presumed influenza pneumonia; laboratory
confirmation should not delay initiation of antiviral therapy. The diagnosis and treatment of influenza in
children are discussed separately. (See "Seasonal influenza in children: Management", 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. (See "Staphylococcus aureus in
children: Overview of treatment of invasive infections", section on 'Empiric antimicrobial therapy'.)

Other viral pneumonias — Acyclovir can be used in the treatment of pneumonia due to herpes simplex
virus or varicella zoster virus. Ganciclovir can 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 RSV or parainfluenza and cidofovir for adenovirus.
Concomitant immunotherapy is an additional consideration: palivizumab for RSV, CMV immune globulin
for CMV, and intravenous immunoglobulin for the other viral etiologies. (See "Diagnosis, treatment, and
prevention of adenovirus infection", section on 'Treatment' and "Respiratory syncytial virus infection:
Treatment in infants and children".)

Uncomplicated bacterial pneumonia — Streptococcus pneumoniae is the most common bacterial cause
of pneumonia in children of all ages [4,27]. Other potential bacterial pathogens that may need to be
included in empiric therapy for hospitalized children include S. aureus, including MRSA, Streptococcus
pyogenes (group A Streptococcus), Haemophilus influenzae type b (Hib; if unimmunized), other typeable
non-b and nontypeable H. influenzae, and Moraxella catarrhalis [2,4,27-32].

The table provides several suggested parenteral empiric antibiotic regimens for uncomplicated bacterial
pneumonia in hospitalized children when S. aureus is not a consideration ( table 2A-B) [4,33,34]. 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' 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 [1,35,36].

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 [1,37,38].

When community-associated-MRSA (CA-MRSA) is considered a potential pathogen for CAP in children, we

usually add clindamycin or vancomycin (depending upon local susceptibility patterns). The fifth-
generation cephalosporin, ceftaroline, is an alternative. In the United States, ceftaroline is available for
the treatment of pediatric CAP due to S. pneumoniae, methicillin-susceptible S. aureus, and H. influenzae in
children ≥2 months of age [39]. Although ceftaroline has good in vitro activity against MRSA isolates [40]
and has been effective in the treatment of pediatric CAP in randomized trials, few children included in the
trials had documented MRSA [41,42].

A macrolide may be added ( table 2A-B) if M. pneumoniae, Chlamydia pneumoniae, or legionellosis is

suspected, although the benefits of combination therapy are uncertain. In a prospective population-based
study of 1418 children hospitalized with radiographically confirmed CAP, the addition of a macrolide to
beta-lactam antimicrobial therapy was not associated with decreased length of stay, intensive care
admission, rehospitalization, or self-reported recovery [43]. In subgroup analysis, combination therapy
was not associated with decreased length of stay in children in whom atypical bacteria were detected,
children older than five years, children admitted to the intensive care unit (ICU), or children with
wheezing. (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 [44]. 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 [45]. 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 2A-B) [4,33].

For children older than four years with suspected atypical pneumonia, 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 >35 to 60 mg/L (3.5 to 6 mg/dL), chills,
or no response to outpatient therapy with a macrolide or doxycycline [4,46].

Fluoroquinolones (eg, levofloxacin, moxifloxacin) may be reasonable empiric therapy for the older child
and adolescent with suspected atypical pneumonia who could possibly have pneumococcal pneumonia.
The fluoroquinolones also may be used in the older child or adolescent who is unable to receive beta-
lactam antibiotics (eg, history of immunoglobulin [Ig]E-mediated reaction or serious delayed reaction
( table 5)). 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 [47]. However, S. pneumoniae resistant to levofloxacin have been identified [48].

Severe CAP

Severe CAP not requiring ICU admission — Children with severe CAP who do not require admission to
the ICU ( table 1) may benefit from combination empiric therapy with a macrolide and a beta-lactam
antibiotic (eg, ampicillin or third-generation cephalosporin) ( table 2A-B). Combination therapy improves
coverage for resistant organisms and mixed bacterial/atypical bacterial infections.

If S. aureus is an etiologic consideration, options include:

 ● Adding either vancomycin or clindamycin (depending upon local susceptibility patterns) to the
combination macrolide and beta-lactam, or

● Switching from the combination macrolide and beta-lactam to ceftaroline plus azithromycin

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 ICU for serious or life-
threatening infections require broad-spectrum empiric coverage that addresses potential beta-lactam
resistance and CA-MRSA. (See 'Indications for intensive care' above.)

A suggested regimen for such children may include ( table 2A-B) [49-51]:

● Vancomycin ( table 6), and

● A third-generation cephalosporin (cefotaxime 150 mg/kg per day IV in four divided doses up to a
maximum of 8 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 to 200 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: Management", section on 'Antiviral therapy')

This combination is necessary because of reports of treatment failure resulting from treatment of
nonsusceptible S. pneumoniae with beta-lactams, clindamycin resistance among S. pneumoniae (which,
however, is becoming less prevalent), and concern for MRSA [49]. Virtually all strains of MRSA are
susceptible to vancomycin [50]. (See "Staphylococcus aureus in children: Overview of treatment of invasive
infections", section on 'MRSA infections'.)

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
and 20 microgram/mL have been suggested to improve clinical outcomes for complicated infections due
to S. aureus [51-53]. 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 [53-58].

For children in whom S. aureus is likely, linezolid could be substituted for vancomycin and nafcillin in the
above regimen. Linezolid is an oxazolidinone antibiotic with activity against gram-positive cocci, including
beta-lactam-resistant S. pneumoniae and MRSA. However, against S. aureus it is only bacteriostatic.
Linezolid is dosed according to age as follows:

● Age <12 years – 10 mg/kg per dose IV every 8 hours (maximum 600 mg/dose)
● Age ≥12 years – 600 mg every 12 hours

An alternative non-vancomycin-containing regimen for children in whom S. aureus is a consideration

consists of:

● Ceftaroline

• Age ≥2 months and <2 years – 8 mg/kg per dose IV every 8 hours
• Age ≥2 years and <18 years:
- Weight ≤33 kg – 12 mg/kg per dose IV every 8 hours
- Weight >33 kg – 400 mg/dose IV every 8 hours or 600 mg/dose IV every 12 hours
• Age ≥18 years – 600 mg/dose IV every 12 hours

● Plus 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

● 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: Management", section on 'Antiviral therapy')

Complicated CAP — Complicated CAP (eg, parapneumonic effusion, necrotizing process, 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 including
CA-MRSA. Coverage for anaerobes and gram-negative organisms also may be necessary for children with
lung abscess [59]. 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 [60].
Appropriate regimens may include [33]:

● Either ceftriaxone 100 mg/kg IV in two divided doses (maximum 4 g/day) or cefotaxime 150 mg/kg
per day IV in four divided doses (maximum 8 g/day)
 If S. aureus or anaerobes are a consideration, add clindamycin 30 to 40 mg/kg per day IV in three or
four divided doses (maximum 2.7 g/day).

Vancomycin ( table 6) 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, in an effort 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, severity of illness, renal function and/or use of other nephrotoxic agents, and
turnaround 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 [51-53]. 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 [53-58]. (See "Staphylococcus aureus in children: Overview of treatment
of invasive infections", section on 'MRSA infections'.)

● Monotherapy with ceftaroline is an alternative if S. aureus is a consideration:

• Age ≥2 months and <2 years – 8 mg/kg per dose IV every 8 hours
• Age ≥2 years and <18 years:
- Weight ≤33 kg – 12 mg/kg per dose IV every 8 hours
- Weight >33 kg – 400 mg/dose IV every 8 hours or 600 mg/dose IV every 12 hours
• Age ≥18 years – 600 mg/dose IV every 12 hours

In a multicenter randomized trial in 40 children with complicated community-acquired bacterial

pneumonia (only one had documented MRSA), clinical cure rates at the end of treatment were
similar with ceftaroline monotherapy and combination ceftriaxone and vancomycin (approximately
80 percent) [42].

● For children with lung abscess that is thought to be secondary to aspiration, ampicillin-sulbactam
150 to 200 mg/kg per day of the ampicillin component IV in four divided doses (maximum 8 g/day
for the ampicillin component) alone may be effective. (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 [59,61-63].

● Lung abscess – Treatment of lung abscess requires a prolonged course of antibiotic therapy. The
duration is determined by the clinical response and radiographic resolution of the abscess or
stabilization of a small lesion. The usual course is a total of three to four weeks or two weeks after
the patient is afebrile and has clinical improvement [60]. The average duration of fever is four to
eight days. Antibiotic therapy can be changed from the parenteral to the oral route when the child is
improving clinically and is afebrile. Eighty to 90 percent of lung abscesses in children resolve with
antibiotic therapy alone and spontaneous drainage through the tracheobronchial tree, provided that
any bronchial obstruction is removed [64].

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 [59,61,65,66]. Percutaneous
drainage may be warranted in children with lung abscess whose condition fails to improve or
worsens after 72 hours of antibiotic therapy [67]. At least three weeks of IV antibiotic therapy should
be delivered before lobectomy is considered for treatment failure [68].

● Pneumatocele – Most pneumatoceles involute spontaneously [69-71]. However, on occasion,

pneumatoceles may result in pneumothorax [72].

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:

● 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 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, or
 • Clindamycin 30 to 40 mg/kg per day in three or four divided doses; maximum 2.7 g/day (for
patients unable to receive beta-lactam antibiotics [eg, history of IgE-mediated reaction or severe
delayed hypersensitivity reaction ( table 5)])

The combination of amikacin and meropenem should be used if extended-spectrum beta-lactamase-

producing gram-negative rods are a consideration. The combination of amikacin and either meropenem
or cefepime should be used if AmpC beta-lactamase-producing gram-negative rods are a consideration.

The cephalosporin/aminoglycoside combination lacks anaerobic coverage, so it 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. An agent other than
piperacillin-tazobactam should be chosen as the second agent, if feasible, when vancomycin is added
because the combination of these two drugs has been associated with increased risk of acute kidney
injury [73,74]. Ceftaroline is an alternative to vancomycin 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 [67]:

● Ampicillin-sulbactam 150 to 200 mg/kg per day of the ampicillin component IV in four divided doses;
maximum 8 g/day of the ampicillin component, or

● Clindamycin 30 to 40 mg/kg per day IV in three or four divided doses to a maximum of 2.7 g/day if
MRSA etiology is suspected or for patients unable to receive beta-lactam antibiotics (eg, history of
IgE-mediated reaction or severe delayed hypersensitivity reaction ( table 5)).

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 health care-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 regimen if MRSA is a consideration. Meropenem may be
preferred for gram-negative coverage if vancomycin is added because the combination of vancomycin
and piperacillin-tazobactam has been associated with increased risk of acute kidney injury [73,74].
However, this risk must be weighed against the development of meropenem resistance, particularly in
closed units. Ceftaroline is an alternative to vancomycin if MRSA is a consideration.
Patients with contraindications to beta-lactam antibiotics (eg, history of IgE-mediated reaction or severe
delayed hypersensitivity reaction ( table 5)) can be treated with a combination of clindamycin and an
aminoglycoside.

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 diagnostic studies. 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 diagnostic evaluation 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 antimicrobial and/or supportive therapy for the pathogens
that commonly cause community-acquired pneumonia (CAP) in children is discussed in the topic reviews
listed below.

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

● Group A Streptococcus – Penicillin G or ampicillin are the preferred parenteral agents for pneumonia
caused by group A Streptococcus; the doses are as follows [1]:

• Penicillin G 100,000 to 250,000 units/kg per day intravenously (IV) divided in four or six doses
• Ampicillin 200 mg/kg per day IV divided in four doses

Alternative parenteral agents include cefazolin, ceftriaxone or cefotaxime, clindamycin (if

susceptible), and vancomycin (for children unable to receive beta-lactam antibiotics [eg, history of
IgE-mediated reaction or severe delayed hypersensitivity reaction ( table 5)]) [1].

Amoxicillin or penicillin V are the preferred oral agents; the doses are as follows [1]:
 • Amoxicillin 50 to 75 mg/kg per day orally divided in two doses (maximum 4 g/day)
• Penicillin V 50 to 75 mg/kg per day orally divided in three doses (maximum 2 g/day)

Alternative oral agents include cephalexin 75 to 100 mg/kg per day in three or four divided doses
(maximum 4 g/day) or clindamycin (if susceptible) 40 mg/kg per day orally divided in three doses
(maximum 1.8 g/day) [1].

● Haemophilus influenzae (typeable or nontypeable) (see "Epidemiology, clinical manifestations,

diagnosis, and treatment of Haemophilus influenzae", section on 'Directed treatment')

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

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

● Methicillin-susceptible S. aureus (MSSA) – MSSA pneumonia may be treated with oxacillin, nafcillin, or
cefazolin [1,4]

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

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

● Respiratory syncytial virus (see "Respiratory syncytial virus infection: Treatment in infants and
children")

● Influenza (see "Seasonal influenza in children: Management", 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')

● 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) [2,75]. 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 [76].

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

● Uncomplicated cases – For children hospitalized with uncomplicated pneumonia, we generally treat
with a seven-day course of combined parenteral and oral therapy, although a course of five to seven
 days may also be effective.

Although evidence from randomized trials in children is lacking, there is some evidence to support
five to seven days of therapy. In a single-center observational study in children ≥6 months of age
who were hospitalized with uncomplicated community-acquired pneumonia (CAP), rates of
treatment failure were similar among those who received antibiotic therapy for 5 to 7 days and 8 to
14 days (3 versus 6 percent, odds ratio 0.48, 95% CI 0.18-1.20) [77]. Treatment failure was defined as
a composite of unanticipated emergency department or outpatient visits, readmission, or death
within 30 days after completion of antibiotics. Randomized trials in adult patients with mild to
moderate CAP also suggest that outcomes in patients treated for less than seven days are similar to
those in patients treated longer. These trials are discussed separately. (See "Treatment of
community-acquired pneumonia in adults in the outpatient setting", section on 'Duration of
therapy'.)

● 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 three to four weeks or a total of
two weeks after the patient is afebrile and has improved clinically. Some infectious diseases
specialists use an erythrocyte sedimentation rate value of <20 mm/hour as a laboratory indicator
that the duration of therapy has been sufficient. (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
● Peripheral capillary 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
initiation of appropriate therapy [67].
Treatment failure — In children who fail to improve as anticipated, the following possibilities must be
considered [1,2,78,79]:

● 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 [80], 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 [61,65-67]. (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 [1,67]:

● 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
 ● Caregivers' ability to administer and child's ability to comply with home antibiotic regimen
● 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 [67,81,82]. Eligibility for
OPAT requires a suitable home environment and a pharmacologic agent with a reasonable dosing
schedule [83]. 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 [67]. 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 [84]. 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), including round pneumonia [85]. However, in children with
complicated CAP or CAP that required intervention, follow-up radiographs help to ensure resolution
[2,86]. Follow-up radiographs also may be helpful in children with recurrent pneumonia, persistent
symptoms, severe atelectasis, or unusually located infiltrates [2,67,87]. When follow-up radiographs are
indicated, they should be obtained two to three weeks after hospital discharge [67,88]. Other conditions
that should be considered if symptoms persist in children with round pneumonia include congenital lung
sequestration, pulmonary arteriovenous malformation, metastatic Wilms tumor, cavitary necrosis, pleural
pseudocyst, and primary lung carcinoma [85,87,89-92].

Several studies have evaluated the utility of follow-up radiographs in cohorts of children with acute
radiologically proven CAP [93-98]. Three of the studies included clinical as well as radiologic follow-up at
three to seven weeks after initial diagnosis [93-96]. In each of these studies, follow-up radiographs were
normal or improved in asymptomatic children. Residual radiographic 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 [62,63,67,99]. In a multicenter cohort study, approximately 3 percent of 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 [100].

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 [101,102].

The overall pneumonia mortality rate in developed countries is <1 per 1000 per year [26,103].
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 [104].

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 [105].
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) [106]. 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) [107]. (See "Pneumococcal vaccination in
children", section on 'Efficacy and effectiveness'.)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around the
world are provided separately. (See "Society guideline links: Pediatric pneumonia".)

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 email
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 topic (see "Patient education: Pneumonia in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Hospitalization and supportive care – 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.)

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.)

● Empiric antimicrobial therapy – 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 2A-B). (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 2A-B) (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 (ICU) ( table 2A-B). (See
'Complicated CAP' above and 'Severe CAP requiring ICU admission' above.)

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

● Switch to oral therapy – 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 seven days
for uncomplicated CAP, although a course of five to seven days may also be effective. Up to four
 weeks of antimicrobial therapy may be necessary for complicated CAP. (See 'Duration of treatment'
above.)

● Treatment failure – 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.)

● Clinical course and follow-up – 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, or
unusually located infiltrates. (See 'Radiographs' above.)

Most otherwise healthy children who develop pneumonia recover without any long-term sequelae.
(See 'Prognosis' above.)

Use of UpToDate is subject to the Terms of Use.

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Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2009;
66:82.

53. McKamy S, Hernandez E, Jahng M, et al. Incidence and risk factors influencing the development of
vancomycin nephrotoxicity in children. J Pediatr 2011; 158:422.
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55. Cies JJ, Shankar V. Nephrotoxicity in patients with vancomycin trough concentrations of 15-20 μg/ml
in a pediatric intensive care unit. Pharmacotherapy 2013; 33:392.
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invasive methicillin-resistant Staphylococcal infections. Pediatr Infect Dis J 2013; 32:1077.
57. Chhim RF, Arnold SR, Lee KR. Vancomycin Dosing Practices, Trough Concentrations, and Predicted
Area Under the Curve in Children With Suspected Invasive Staphylococcal Infections. J Pediatric Infect
Dis Soc 2013; 2:259.

58. Patel K, Crumby AS, Maples HD. Balancing vancomycin efficacy and nephrotoxicity: should we be
aiming for trough or AUC/MIC? Paediatr Drugs 2015; 17:97.
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for interventional therapy. Pediatr Radiol 1999; 29:87.
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74. Cook KM, Gillon J, Grisso AG, et al. Incidence of Nephrotoxicity Among Pediatric Patients Receiving
Vancomycin With Either Piperacillin-Tazobactam or Cefepime: A Cohort Study. J Pediatric Infect Dis
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75. Lassi ZS, Imdad A, Bhutta ZA. Short-course versus long-course intravenous therapy with the same
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79. Hyde TB, Gay K, Stephens DS, et al. Macrolide resistance among invasive Streptococcus pneumoniae
isolates. JAMA 2001; 286:1857.
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1993; 31:651.
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Pulmonol 2005; 40:223.
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307:1117.
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Acta Paediatr 2008; 97:46.
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19:188.
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pneumonia. Pediatrics 2014; 134:100.
101. Clark CE, Coote JM, Silver DA, Halpin DM. Asthma after childhood pneumonia: six year follow up
study. BMJ 2000; 320:1514.
102. Eastham KM, Hammal DM, Parker L, Spencer DA. A follow-up study of children hospitalised with
community-acquired pneumonia. Arch Dis Child 2008; 93:755.

103. Wu J, Yang S, Cao Q, et al. Pneumonia Mortality in Children Aged <5 Years in 56 Countries: A
Retrospective Analysis of Trends from 1960 to 2012. Clin Infect Dis 2017; 65:1721.
104. Feikin DR, Schuchat A, Kolczak M, et al. Mortality from invasive pneumococcal pneumonia in the era
of antibiotic resistance, 1995-1997. Am J Public Health 2000; 90:223.
105. Fitzwater SP, Chandran A, Santosham M, Johnson HL. The worldwide impact of the seven-valent
pneumococcal conjugate vaccine. Pediatr Infect Dis J 2012; 31:501.
106. Olarte L, Barson WJ, Barson RM, et al. Pneumococcal pneumonia requiring hospitalization in US childr
en in the 13-valent pneumococcal conjugate vaccine era (abstract). 9th World Congress of The World
Society for Pediatric Infectious Diseases (WSPID), Rio de Janeiro, Brazil. November 2015.
107. Cutts FT, Zaman SM, Enwere G, et al. Efficacy of nine-valent pneumococcal conjugate vaccine against
pneumonia and invasive pneumococcal disease in The Gambia: randomised, double-blind, placebo-
 controlled trial. Lancet 2005; 365:1139.
Topic 6054 Version 67.0
GRAPHICS

Severity of community-acquired pneumonia in infants and children

Clinical features of mild pneumonia Clinical features of severe pneumonia

Temperature <38.5°C (101.3°F) Temperature ≥38.5°C (101.3°F)

Mild or absent respiratory distress: Moderate to severe respiratory distress:

Increased RR, but less than the age-specific RR that RR >70 breaths/minute for infants; RR >50
defines moderate to severe respiratory distress breaths/minute for older children
Mild or absent retractions Moderate/severe suprasternal, intercostal, or
No grunting subcostal retractions (<12 months)
No nasal flaring Severe difficulty breathing (≥12 months)
No apnea Grunting
Mild shortness of breath Nasal flaring
Apnea
Significant shortness of breath

Normal color Cyanosis

Normal mental status Altered mental status

Normoxemia (oxygen saturation ≥92 percent in room air) Hypoxemia (sustained oxygen saturation <90 percent
in room air at sea level)

Normal feeding (infants); no vomiting Not feeding (infants) or signs of dehydration (older
children)

Normal heart rate Tachycardia

Capillary refill <2 seconds Capillary refill ≥2 seconds

RR: respiratory rate.

Data from:

1. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months
of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect
Dis 2011; 53:e25.
2. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children:
Update 2011. Thorax 2011; 66:ii1.

Graphic 72015 Version 4.0

Parenteral empiric antibiotics for inpatient treatment of pediatric community-acquired
pneumonia [1,2]
Age group and suspected
pathogens
1 to 6 months
Bacterial (not Chlamydia
trachomatis or Staphylococcus
aureus)
C. trachomatis
≥6 months
Uncomplicated bacterial (not
Mycoplasma pneumoniae,
Chlamydia pneumoniae, or S.
aureus)
M. pneumoniae or C. pneumoniae
Clinical syndrome (any age)
Severe pneumonia
Severe pneumonia requiring ICU
admission
Suggested parenteral empiric
Comments
agent(s)
One of the following: If CA-MRSA is suspected, ADD
Ceftriaxone one of the following:
Cefotaxime Vancomycin or clindamycin
Ceftaroline* (alternative)
Azithromycin
One of the following: Cefotaxime and ceftriaxone are
Ampicillin or penicillin G reserved for:
(preferred) Children with incomplete Hib
Cefotaxime or Streptococcus pneumoniae
Ceftriaxone immunizations, or
Communities with substantial
prevalence of penicillin-
resistant S. pneumoniae (eg,
≥25%)
One of the following:
Azithromycin
Erythromycin
Levofloxacin
Suggested empiric parenteral
Comments
agent(s)
Combination therapy with one of the Children with severe infection ma
following: benefit from broad-spectrum
Ceftriaxone therapy that addresses both
Cefotaxime typical and atypical pathogens
PLUS one of the following: If S. aureus is a consideration,
Azithromycin either:
Erythromycin ADD vancomycin or
clindamycin, OR
Doxycycline
Provide therapy with
ceftaroline* PLUS
azithromycin
Combination therapy with: If S. aureus is likely:
Vancomycin ADD nafcillin ¶ , OR
PLUS one of the following:
 Ceftriaxone SUBSTITUTE linezolid for
Cefotaxime vancomycin and nafcillin, OR
PLUS: Use ceftaroline* PLUS
Azithromycin azithromycin PLUS antiviral
treatment for influenza if the
PLUS:
child is hospitalized during
Antiviral treatment for influenza
influenza season
if the child is hospitalized
during influenza season

Complicated pneumonia (eg,
effusion/empyema, necrotizing
process, abscess Δ )
Combination therapy with one of the Potential pathogens include S.
following: pneumoniae, S. aureus, and
Ceftriaxone Streptococcus pyogenes
Cefotaxime Vancomycin is an alternative to
PLUS: clindamycin for children with
Clindamycin if S. aureus or allergy to clindamycin or high
anaerobic infection is a prevalence of clindamycin
consideration resistance in the community ◊
Monotherapy with ceftaroline is
an alternative if S. aureus is a
consideration

This table is meant for use with UpToDate content on the treatment of CAP in children. Refer to related UpToDate
content for details regarding complete Hib and S. pneumoniae immunization, criteria for severe pneumonia, and
pneumonia requiring ICU admission. Consultation with a specialist in infectious diseases for children is suggested
for children with severe hypersensitivity to beta-lactam antibiotics (eg, penicillins and cephalosporins).

CA-MRSA: community-associated methicillin-resistant S. aureus; Hib: Haemophilus influenzae type b; ICU: intensive
care unit; CAP: community-acquired pneumonia; MSSA: methicillin-susceptible S. aureus; MRSA: methicillin-resistant
S. aureus.

* Ceftaroline is a fifth-generation cephalosporin. It is available in the United States for the treatment of pediatric
CAP due to S. pneumoniae, MSSA, and H. influenzae in children ≥2 months of age. Although ceftaroline has in vitro
activity against MRSA, experience in children with documented MRSA CAP is limited.

¶ Nafcillin is added if S. aureus is likely because MSSA is more rapidly killed by nafcillin than by vancomycin.

Δ Ampicillin-sulbactam alone may be effective if lung abscess is thought to be secondary to aspiration.

◊ The threshold prevalence of clindamycin-resistant MRSA (constitutive plus inducible) for choosing vancomycin
varies from center to center, usually ranging from 10 to 25%, in an effort 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.

Data from:
1. McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
2. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months
of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect
Dis 2011; 53:e25.

Graphic 56260 Version 34.0

Doses for parenteral antibiotics for the empiric treatment of community-acquired
pneumonia in hospitalized children
Agent Regimen [1,2]
Ampicillin 150 to 200 mg/kg per day in 4
divided doses (MAX 12 g/day)
Azithromycin 10 mg/kg once per day on days 1
and 2 of therapy (MAX 500
mg/day)
5 mg/kg once per day on
subsequent days of therapy (MAX
250 mg/day)
Cefazolin 100 to 150 mg/kg per day in 3
divided doses (MAX 12 g/day)
Cefotaxime 150 mg/kg per day in 3 or 4
divided doses (MAX 8 g/day)
Ceftaroline Age ≥2 months and <2 years: 8
mg/kg every 8 hours
Age ≥2 and <18 years:
Weight ≤33 kg: 12 mg/kg
every 8 hours
Weight >33 kg: 400 mg every 8
hours or 600 mg every 12
hours
Age ≥18 years: 600 mg every 12
hours
Ceftriaxone 50 to 100 mg/kg per day in 1 or 2
divided doses (MAX 4 g/day)
Clindamycin 30 to 40 mg/kg per day in 3 or 4
divided doses (MAX 2.7 g/day)
Doxycycline 4 mg/kg per day in 2 divided
doses (MAX 200 mg/day)
Comments
Transition to oral therapy at 5
mg/kg per day as soon as
clinically appropriate
Limited data on doses >100
mg/kg per day
The 4-dose regimen should be
used for severe infection or
substantial local penicillin
resistance
Experience with ceftaroline in
children with documented MRSA
infection is limited
The 100 mg/kg per day dose
should be used only if local rates
of penicillin resistance to
Streptococcus pneumoniae are
substantial (eg, ≥25%)
The 2-dose regimen should be
used for severe infection or if loca
rates of penicillin resistance to S.
pneumoniae are substantial (eg,
≥25%)
Transition to oral therapy as soon
as clinically appropriate
 Erythromycin 20 mg/kg per day in 4 divided Parenteral erythromycin is
doses (MAX 4 g/day) associated with phlebitis,
prokinetic, and cardiotoxic effects
(rare)

Levofloxacin Age 6 months and <5 years: 16 to Fluoroquinolones may prolong

20 mg/kg per day in 2 divided
doses
Age ≥5 to 16 years: 8 to 10 mg/kg
once per day (MAX 750 mg)
QTc interval; avoid use in patients
with: [3]
Long QT syndrome
Hypokalemia or
hypomagnesemia
Organic heart disease (eg,
congestive heart failure;
requiring a class Ia
antiarrhythmic drug*,
particularly quinidine)
Concurrent use of other
medications that prolong the
QTc interval

Linezolid Age <12 years: 10 mg/kg every 8

hours (MAX 600 mg/dose)
Age ≥12 years: 600 mg every 12
hours

Nafcillin 150 to 200 mg/kg per day in 4 or 6

divided doses (MAX 12 g/day)

Penicillin G For therapy: 200,000 to 250,000

units/kg per day in 4 or 6 divided
doses (MAX 24 million units/day)

Vancomycin 40 to 60 mg/kg per day in 3 or 4

divided doses (MAX 4 g/day) ¶

This table is meant for use with UpToDate content on the treatment of community-acquired pneumonia in children.
Refer to related UpToDate content for details about choice of therapy. Consultation with a specialist in pediatric
infectious diseases is suggested for children with severe hypersensitivity to beta-lactam antibiotics (eg, penicillins
and cephalosporins). The recommended doses are for children with normal renal function.

MAX: maximum dose; MRSA: methicillin-resistant Staphylococcus aureus.

* Class Ia antiarrhythmic drugs include quinidine, ajmaline, disopyramide, and procainamide.

¶ Alternative dosing is suggested for clinicians/institutions who follow AUC-guided therapeutic monitoring for
vancomycin for serious MRSA infections as suggested by consensus guidelines [4] ; this strategy requires input from
a clinical pharmacist, who will provide recommendations for initial dosing. Refer to UpToDate content on invasive
staphylococcal infections in children for details of trough-guided and AUC-guided vancomycin dosing.

References:
 1. American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2021-2024 Report of the Committee on Infectious
Diseases, 32 nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.876.
2. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months
of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect
Dis 2011; 53:e25.
3. American Academy of Pediatrics. Fluoroquinolones. In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32 nd ed,
Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.864.
4. Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A
revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America,
the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2020; 77:835.

Graphic 127763 Version 4.0

Clinical and radiographic clues to the etiology of pneumonia in children*

Etiology Clinical features Radiographic features

Bacteria Children of all ages Alveolar infiltrates

(most commonly Abrupt onset Segmental consolidation
Streptococcus
Ill-appearance Lobar consolidation
pneumoniae)
Chills "Round" pneumonia
Moderate to severe respiratory distress Complications:
Focal auscultatory findings Pleural effusion/empyema
Localized chest pain Lung abscess
WBC count >15,000/microL (if obtained) Necrotizing pneumonia
Elevated acute phase reactants (if Pneumatocele
obtained)

Atypical bacterial Children of all ages (most common in M. pneumoniae:

(Mycoplasma children >5 years) Lobar or segmental consolidation
pneumoniae, Abrupt onset with constitutional findings (37%)
Chlamydia (malaise, myalgia, headache, rash, Parahilar or peribronchial infiltrates
pneumoniae) conjunctivitis, photophobia, sore throat) (27%)
Gradually worsening nonproductive Localized reticulonodular infiltrates
cough (21%)
Wheezing Patchy infiltrates (15%)
Extrapulmonary manifestations or
complications (eg, polymorphous
mucocutaneous eruptions, hemolytic
anemia, hepatitis, pancreatitis,
myopericarditis, aseptic meningitis)

Viral Usually children <5 years Interstitial infiltrates

Gradual onset Associated bronchiolitis:
Preceding upper airway symptoms Patchy atelectasis
Nontoxic appearing Peribronchial infiltrations with air
Diffuse, bilateral auscultatory findings bronchograms
Wheezing Hyperinflation with flattening of the
May have associated rash (eg, measles, diaphragms
varicella)

Afebrile pneumonia Usually in infants 2 weeks to 4 months Hyperinflation with interstitial infiltrates
of infancy Insidious onset
(most commonly
Tachypnea, diffuse crackles
Chlamydia
Rhinorrhea
trachomatis)
Staccato cough pattern
Peripheral eosinophilia (if CBC obtained)

Fungal Appropriate geographic or environmental Mediastinal or hilar adenopathy

exposure
 Mycobacterium Children of any age Mediastinal or hilar adenopathy
tuberculosis Chronic cough
Constitutional symptoms
Exposure history

WBC: white blood cell; CBC: complete blood count.

* The clinical features frequently overlap and cannot reliably distinguish between bacterial, atypical bacterial, and
viral etiologies; up to one-half of community-acquired pneumonias in children may be mixed bacterial/viral
infections. Chest radiography generally is not helpful in determining the potential causative agent of pneumonia.
Nonetheless, these features may facilitate decisions regarding empiric therapy.

Data from:
1. Bartlett JG, Mundy LM. Community-acquired pneumonia. N Engl J Med 1995; 333:1618.
2. Boyer KM. Nonbacterial pneumonia. In: Textbook of Pediatric Infectious Diseases, 6 th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ,
Kaplan SL (Eds), Saunders, Philadelphia 2009. p.289.
3. Broughton RA. Infections due to Mycoplasma pneumoniae in childhood. Pediatr Infect Dis 1986; 5:71.
4. McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
5. Cho YJ, Han MS, Kim WS, et al. Correlation between chest radiographic findings and clinical features in hospitalized children with
Mycoplasma pneumoniae pneumonia. PLoS One 2019; 14:e0219463.
6. Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health 1990; 26:209.

Graphic 52021 Version 14.0

Suggested criteria for full Haemophilus influenza type b and Streptococcus pneumoniae
immunization status when considering empiric antibiotics for community-acquired
pneumonia in children

Current age* Criteria for full immunization ¶

Haemophilus influenzae type b

12 to 15 months ≥2 doses of Hib conjugate vaccine, with at least one dose

at ≥12 months of age

15 months to 5 years ≥2 doses of Hib conjugate vaccine, with at least one dose
at ≥12 months of age, or

≥1 dose of Hib conjugate vaccine at ≥15 months of age

≥5 years, not high risk Δ Hib immunization not necessary

Streptococcus pneumoniae

12 to 24 months ≥3 doses of PCV at <16 months, with ≥1 dose at ≥12

months, or

2 doses of PCV, both at ≥12 months

24 months through 5 years ≥3 doses of PCV at <16 months, with ≥1 dose at ≥12
months, or

2 doses of PCV, both at ≥12 months, or

≥1 dose of PCV at ≥24 months

>5 years, not high risk ◊ PCV immunization not necessary

Hib: H. influenzae type b; PCV: pneumococcal conjugate vaccine.

* Children younger than 12 months are incompletely immunized against Hib and S. pneumoniae.

¶ Immunizations must be completed at least two weeks before pneumonia diagnosis.

Δ Children at high risk for invasive Hib disease include chemotherapy recipients and those with anatomic or
functional asplenia (including sickle cell disease), HIV infection, immunoglobulin deficiency, or early component
complement deficiency. Please refer to the UpToDate topic on prevention of H. influenzae infection for a discussion
of full Hib immunization in children at high risk for invasive Hib disease.

◊ Children at high risk for invasive S. pneumoniae disease include those with chronic heart disease (particularly
cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma if treated with high-
dose oral corticosteroid therapy); diabetes mellitus; cerebrospinal fluid leak; cochlear implant; sickle cell disease and
other hemoglobinopathies; anatomic or functional asplenia; HIV infection; chronic renal failure; nephrotic
syndrome; diseases associated with treatment with immunosuppressive drugs or radiation therapy, including
malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; solid organ transplantation; or congenital
immunodeficiency. Please refer to the UpToDate topics on PCVs and pneumococcal polysaccharide vaccines for a
discussion of full S. pneumoniae immunization in children at high risk for invasive S. pneumoniae disease.

Graphic 95852 Version 6.0

Type of drug reactions

Type of reaction Common features

Non-allergic reaction Adverse effects (eg, diarrhea, vomiting, yeast vaginitis)

Family history of penicillin allergy but no personal history

Mild non-IgE-mediated reaction Maculopapular rash (with or without itching)

Medical record lists penicillin allergy but patient unaware of reaction

IgE-mediated reaction Anaphylaxis

Angioedema
Wheezing
Laryngeal edema
Hypotension
Hives/urticaria

Serious delayed reactions Toxic epidermal necrolysis (TEN)

Stevens-Johnson syndrome (SJS)
Drug reaction with eosinophilia and systemic symptoms/drug-induced
hypersensitivity syndrome (DRESS/DiHS)
Other exfoliating dermatoses/erythroderma
Serum sickness-like reactions
Drug-induced cytopenias
Drug-induced renal, hepatic, or other specific organ damage

IgE: immunoglobulin E.

Graphic 117212 Version 2.0

Alternative approaches to vancomycin dosing for children and adolescents with norma
kidney function

Subsequent dose and interval

Strategy Initial dose and interval
adjustments

Traditional approach for children >1
month and adolescents
Typically 15 mg/kg per dose IV every
6 to 8 hours [1] :
Use the every-6-hour interval
for serious infections*
Maximum daily dose: 4 g/day
Either:
Continue initial dose (for most
children, particularly if duration
of vancomycin is expected to be
<3 days) ¶
Based on trough-guided serum
concentration monitoring for
select children (eg, those with
renal dysfunction, infective
endocarditis, risk factors for
altered vancomycin kinetics [eg
fluid overload, critical illness])

AUC-guided approach Δ [2] Generally requires consultation with Based on AUC-guided serum
a clinical pharmacist concentration monitoring (generally
requires consultation with a clinical
pharmacist)

The approach to vancomycin dosing is generally determined at the institutional level. Refer to UpToDate content on
invasive staphylococcal infections in children for details of trough-guided and AUC-guided vancomycin dosing and
traditional dosing of vancomycin for neonates.

IV: intravenous; AUC: area under the curve; MRSA: methicillin-resistant Staphylococcus aureus.

* Serious infections may include, but are not limited to, infective endocarditis, pneumonia requiring hospitalization,
osteomyelitis, central nervous system infection, and infection causing critical illness.

¶ The value of trough-monitoring before achieving steady state (usually on day 2 to 3 of treatment) is uncertain.

Δ Some experts suggest this approach for serious* MRSA infections in children of all ages.

References:
1. American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2021-2024 Report of the Committee on Infectious
Diseases, 32 nd ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.876.
2. Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A
revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America,
the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2020; 77:835.

Graphic 129344 Version 4.0

Important aspects of the history in a child with pneumonia

Historical feature Possible significance

Age of the child Viral etiologies are most common in infants and preschool children

Atypical bacterial pathogens are more common in school-age children

Recent viral upper respiratory May predispose to bacterial superinfection with Streptococcus pneumoniae or
tract infection Staphylococcus aureus

Associated symptoms Mycoplasma pneumoniae is often associated with extrapulmonary manifestations

(eg, headache, sore throat, conjunctivitis, photophobia, rash)

Cough, chest pain, shortness of "Classic" features of pneumonia, but nonspecific

breath, difficulty breathing

Increased work of breathing in Sugestivo de neumonía grave.

the absence of stridor or
wheezing

Ingesta de líquidos y nutrientes. La dificultad o incapacidad para alimentarse sugiere una enfermedad grave.

episodio de asfixia Puede indicar aspiración de cuerpo extraño.

Duración de los síntomas La tos crónica (>4 semanas) sugiere una etiología distinta a la neumonía aguda
(consulte el tema de UpToDate sobre las causas de la tos crónica en niños)

Episodios anteriores Los episodios recurrentes pueden indicar aspiración, anomalía anatómica
congénita o adquirida, fibrosis quística, inmunodeficiencia, asma, cuerpo extraño
perdido.

Estado de vacunación Completar la serie primaria de vacunas contra Haemophilus influenzae tipo b, S.
pneumoniae , Bordetella pertussis y la influenza estacional disminuye, pero no
elimina, el riesgo de infección por estos organismos.

Terapia antibiótica previa Aumenta la probabilidad de bacterias resistentes a los antibióticos.

Historia materna de clamidia Puede indicar infección por Chlamydia trachomatis

durante el embarazo (para bebés
<4 meses de edad)

Exposición a la tuberculosis Puede indicar infección por Mycobacterium tuberculosis

contactos enfermos Más común con etiologías virales.

Viaje o residencia en ciertas Sarampión: países con recursos limitados

áreas que sugieren patógenos Coccidioidomicosis: suroeste de Estados Unidos, norte de México, Centro y
endémicos Sudamérica
Blastomicosis: Sudeste y Centro de Estados Unidos; estados ribereños de los
Grandes Lagos
Histoplasmosis: valles de los ríos Ohio, Missouri y Mississippi en Estados
Unidos; Canadá; Centroamérica; Europa oriental y meridional; partes de África
Asia Oriental; y Australia
 Hantavirus: al oeste del río Mississippi; región de las cuatro esquinas de los
Estados Unidos (donde se encuentran las fronteras de Colorado, Nuevo
México, Arizona y Utah)
Síndrome respiratorio de Oriente Medio (MERS): países en o cerca de la
Península Arábiga

Exposición de animales Puede indicar histoplasmosis, psitacosis, fiebre Q

Asistencia a guardería Exposición a virus y bacterias resistentes a los antibióticos.

Gráfico 52510 Versión 13.0

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