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 Pediatric Infectious Diseases Society/Infectious Diseases Society of America and the British Thoracic Society have developed clinical practice guidelines for the evaluation and treatment of CAP in children [1,2].
The outpatient treatment of CAP in infants and children in resource-abundant settings will be reviewed here. Neonatal pneumonia, coronavirus disease 2019-related pneumonia, and the etiology, clinical features, diagnosis, and inpatient treatment of pneumonia in children are discussed separately.
●(See "Neonatal pneumonia".)
●(See "COVID-19: Clinical manifestations and diagnosis in children".)
●(See "Pneumonia in children: Epidemiology, pathogenesis, and etiology".)
●(See "Community-acquired pneumonia in children: Clinical features and diagnosis".)
●(See "Pneumonia in children: Inpatient treatment".)
INDICATIONS FOR HOSPITALIZATION — The decision to hospitalize a child with 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 normoxemic and relatively asymptomatic. Hospitalization is also warranted for a child of any age whose caregivers cannot provide appropriate care and assure compliance with the therapeutic regimen. Additional indications for hospitalization include [1,2]:
●Hypoxemia (oxygen saturation <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 per minute for infants <12 months of age and >50 breaths per minute for older children; difficulty breathing (grunting, nasal flaring, retractions); apnea
●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, even viral pneumonia (eg, metabolic disorder) or may adversely affect response to treatment (eg, immunocompromised host)
●Complications (eg, effusion/empyema, necrotizing process, abscess) (see "Epidemiology, clinical presentation, and evaluation of parapneumonic effusion and empyema in children" and "Management and prognosis of parapneumonic effusion and empyema in children")
●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) (see 'Treatment failure' below)
EMPIRIC THERAPY
Factors influencing choice of regimen — Children with CAP who are treated in the outpatient setting typically are treated empirically; tests to identify a bacterial etiology are not recommended for most children who are well enough to be treated in the outpatient setting [1,2]. Decisions regarding empiric therapy are complicated by the substantial overlap in the clinical presentation of bacterial and nonbacterial pneumonias [2,5,6].
Treatment decisions are usually based upon algorithms that include patient age (table 2), epidemiologic and clinical information (table 3), and diagnostic laboratory and imaging studies (if such studies are obtained) [4,7]. Consultation with a specialist in infectious diseases may be helpful in children with medication allergies or comorbid conditions. (See "Community-acquired pneumonia in children: Clinical features and diagnosis" and "Pneumonia in children: Epidemiology, pathogenesis, and etiology", section on 'Etiologic agents'.)
There are few randomized controlled trials to guide the choice of empiric antibiotics in children with CAP. Factors that must be considered include the spectrum of likely pathogens, antimicrobial susceptibility, simplicity, tolerability, palatability, safety, and cost [8]. The recommendations of most guidelines are based upon observations regarding the susceptibility of the most likely pathogen or pathogens, rather than on evidence of the superiority of one antibiotic over another [1,2]. The clinical response to the most commonly used antimicrobials appears to be similar, regardless of etiology [9-11]. The response within the first 48 to 72 hours of empiric therapy (or lack of therapy if a viral etiology is most likely) helps to determine whether additional evaluation or changes in therapy are necessary. (See 'Monitoring response' below.)
Children <5 years
Neonates — The treatment of neonatal pneumonia is discussed separately. (See "Neonatal pneumonia".)
One to six months — Infants younger than three to six months of age with suspected bacterial CAP or who are hypoxemic (oxygen saturation <90 percent in room air at sea level) should be admitted to the hospital for empiric therapy. (See "Pneumonia in children: Inpatient treatment", section on 'Empiric therapy'.)
In afebrile infants one to four months of age with CAP, the most likely bacterial pathogen is C. trachomatis (ie, "afebrile pneumonia of infancy") [4,12]. Infants who are thought to have afebrile pneumonia of infancy can be treated in the outpatient setting if they are not hypoxemic and remain afebrile [4]. (See "Chlamydia trachomatis infections in the newborn", section on 'Treatment'.)
Bordetella pertussis is a less common, but more severe, cause of pneumonia in young infants; fever may or may not be present. Like C. trachomatis, B. pertussis is susceptible to the macrolides [4]. However, young infants who are thought to have B. pertussis-associated pneumonia should be admitted to the hospital because they are at risk for complications (eg, hypoxia, apnea, pulmonary hypertension, etc). (See "Pertussis infection in infants and children: Clinical features and diagnosis", section on 'Infants younger than 12 months' and "Pertussis infection in infants and children: Treatment and prevention", section on 'Hospitalization'.)
Six months to five years
Suspected viral etiology — Viral etiologies predominate during early childhood. Viral pneumonia (suggested by gradual onset, preceding upper respiratory tract symptoms, diffuse findings on auscultation, lack of toxic appearance (table 3)) should not be treated with antibiotics. (See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Clues to etiology' and "Pneumonia in children: Epidemiology, pathogenesis, and etiology", section on 'Etiologic agents'.)
Infants and young children with known or suspected chronic disease (eg, cardiopulmonary disease, neuromuscular disease, etc) are at increased risk for severe or complicated viral lower respiratory tract infection (LRTI). If such children are not admitted to the hospital, they merit close monitoring in the outpatient setting.
Antiviral agents generally are not used for viral pneumonia in the outpatient setting, with the exception of antiviral therapy for influenza pneumonia and possibly for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia (eg, nirmatrelvir-ritonavir for children ≥12 years of age who weigh ≥40 kg [via emergency use authorization]).
●Suspected influenza – In children with suspected influenza who are at increased risk of complications (table 4), initiation of antiviral treatment is recommended as soon as possible; 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: Clinical features and diagnosis", section on 'Clinical features' and "Seasonal influenza in children: Management", section on 'Antiviral therapy'.)
●Suspected SARS-CoV-2 pneumonia – SARS-CoV-2 pneumonia may be suspected in children with known exposure or circulation in the local community, school, or site of child care. The management of SARS-CoV-2 in children is discussed separately. (See "COVID-19: Management in children".)
Suspected bacterial etiology — Streptococcus pneumoniae is the most frequent cause of "typical" bacterial pneumonia in children of all ages [1,2]. Less frequent etiologies include S. aureus, Streptococcus pyogenes (group A Streptococcus), and the unusual typeable and nontypeable Haemophilus influenzae and Moraxella catarrhalis. Bacterial pneumonia in preschool children usually causes more severe infection, with abrupt onset and moderate to severe respiratory distress, which may require inpatient therapy. (See 'Indications for hospitalization' above and "Pneumonia in children: Inpatient treatment", section on 'Empiric therapy'.)
●Preferred regimen – For appropriately immunized, healthy children younger than five years who are thought to have bacterial CAP based upon clinical presentation, examination findings, and supportive radiographic or laboratory data if obtained (eg, lobar consolidation on radiograph, white blood cell count >15,000/microL, C-reactive protein >35 to 60 mg/L [3.5 to 6 mg/dL] (table 3)), but do not require inpatient therapy, amoxicillin is usually considered the drug of choice [1,2,13]. We suggest high-dose amoxicillin (90 to 100 mg/kg per day divided into two or three doses; maximum dose 4 g/day) (table 2). High-dose amoxicillin-clavulanate (90 mg/kg per day of the amoxicillin component divided into two or three doses) is an alternative for children aged six months to five years given the possibility of H. influenzae and M. catarrhalis in this age group.
Amoxicillin is preferred because it will be effective in the majority of episodes of bacterial CAP in this age group, is well tolerated, and is inexpensive [1,2]. Amoxicillin is more active in vitro than any of the oral cephalosporins against isolates of S. pneumoniae.
The higher dose of amoxicillin is suggested because of the concern for antibiotic-resistant S. pneumoniae isolated from patients with community-acquired respiratory tract infections [14-16], although there is some evidence that lower doses may be sufficient. In a 2 x 2 multicenter randomized trial, 591 young children (age ≥6 months with weight between 6 and 24 kg) discharged from the emergency department with a clinical diagnosis of CAP and treated with amoxicillin were assigned to a lower (35 to 50 mg/kg per day) or higher (70 to 90 mg/kg per day) dose administered twice per day for three or seven days [17]. None of the participants were colonized with penicillin-resistant pneumococci. The rates of antibiotic retreatment for respiratory infection within 28 days of randomization were similar in the lower and higher dose groups (11.7 versus 12.8 percent; difference -1.5 percent, 90% CI -6.0 to 3.0 percent).
Although the prevalence of penicillin-resistant pneumococci initially decreased after universal infant immunization with the 7-valent pneumococcal conjugate vaccine (PCV7) and replacement of PCV7 with the 13-valent pneumococcal conjugate vaccine (PCV13) in 2010 [1,18], surveillance since 2013 suggests increasing antibiotic nonsusceptibility among pneumococcal strains that are not included in PCV13 (eg, 11A, 35B, 35F) [16]. Continued surveillance is needed. In the United States, a 15-valent PCV (PCV15) was licensed for people ≥6 weeks of age in 2022 and a 20-valent PCV (PCV20) was licensed for people ≥18 years of age in 2021 (table 5) [19,20]. (See "Resistance of Streptococcus pneumoniae to beta-lactam antibiotics".)
Although there are prospective, comparative data supporting the efficacy of twice daily dosing of amoxicillin for the treatment of acute otitis media [21-23], similar data are not available for documented pneumococcal pneumonia in children. Unless the etiologic agent is identified as a S. pneumoniae isolate with a minimum inhibitory concentration (MIC) of <2 mcg/mL, dividing the total daily 90 to 100 mg/kg dose of amoxicillin into three doses may be warranted. Twice daily dosing for pneumonia due to a S. pneumoniae isolate with an MIC of 2 mcg/mL is predicted to achieve a clinical and microbiologic cure in only 65 percent of children, whereas the same total daily dose divided in three equal portions is predicted to achieve a cure in 90 percent [24].
●Alternative regimens
•History of reaction to a penicillin – Regimens for children with a history of drug reaction to a penicillin depend upon the type of reaction (table 6). (See "Penicillin allergy: Immediate reactions", section on 'Clinical history'.)
-Children with nonallergic reactions to a penicillin may be treated with amoxicillin.
-For children with mild reactions to a penicillin and no features of an immunoglobulin (IgE)-mediated reaction, options include amoxicillin or a third-generation cephalosporin [1]. The choice is individualized according to the drug allergy history and the ability to safely conduct an oral challenge if necessary [25,26]. This is discussed in detail separately. (See "Choice of antibiotics in penicillin-allergic hospitalized patients", section on 'Management of mild reactions WITHOUT history of features of immediate allergy (minimal risk of immediate allergy)'.)
-For children with IgE-mediated or serious delayed reactions to a penicillin, clindamycin, levofloxacin, or linezolid may be used [1,2].
Doses are provided in the table (table 2).
•Inability to tolerate oral therapy – For the infant or child who is suspected to have bacterial CAP and is unable to tolerate liquids at the time of presentation, a single initial dose of ceftriaxone (50 to 75 mg/kg) may be administered intramuscularly or intravenously before starting oral antibiotics [27,28]. Administration of intramuscular ceftriaxone to children with uncomplicated CAP who are able to tolerate liquids is expensive and provides no benefit over oral antibiotics.
Suspected atypical pneumonia — Mycoplasma pneumoniae and Chlamydia pneumoniae are less common than S. pneumoniae in children younger than five years with CAP [5]. However, they can occur in this age group and should be considered in children without a pneumonia-associated complication who fail to improve after 48 to 72 hours of empiric therapy for S. pneumoniae (eg, amoxicillin), at which time a macrolide could be added or substituted (table 2). (See 'Treatment failure' below.)
Children ≥5 years
Suspected typical or atypical bacterial etiology — S. pneumoniae is the most frequent cause of "typical" bacterial pneumonia in children of all ages [1,2]. However, in otherwise healthy children five years and older with CAP who are not ill enough to require hospitalization, M. pneumoniae and C. pneumoniae are the most likely pathogens [4,12,29].
For children ≥5 years with clinical features strongly suggestive of typical bacterial or S. pneumoniae pneumonia (table 3), amoxicillin is the drug of choice (table 2) [1]. (See 'Suspected bacterial etiology' above.)
We suggest macrolide antibiotics for initial empiric therapy for suspected atypical CAP (table 3) in children older than five years who are treated as outpatients (table 2). Macrolide antibiotics provide coverage for atypical pathogens and some coverage for S. pneumoniae, although macrolide resistance exists among both M. pneumoniae and S. pneumoniae.
The prevalence of macrolide-resistant M. pneumoniae is increasing in some geographic regions, including Asia, Europe, Israel, and the United States [30-38]. The reported prevalence of resistance among M. pneumoniae isolates ranges from approximately 10 percent in the United States to 90 percent in China and some parts of Japan [32,35,39-41]. Alternative agents include levofloxacin and doxycycline [1]. The long-held concern for enamel staining associated with doxycycline in children younger than eight years use is unfounded [42,43].
Among the macrolide antibiotics, clarithromycin and azithromycin have a more convenient dosing schedule and fewer side effects than erythromycin, but erythromycin is less expensive [9,44,45]. Macrolide antibiotics may provide coverage for S. pneumoniae, which is the most frequent typical bacterial pathogen for all age groups [46-48]. However, approximately 40 to 50 percent of S. pneumoniae isolates are resistant to macrolides. Failure to respond to macrolide therapy may indicate the development of a complication, a macrolide-resistant pathogen, and/or the need to alter therapy to provide better pneumococcal coverage. (See 'Treatment failure' below.)
Given the significant resistance of S. pneumoniae to macrolides, fluoroquinolones (eg, levofloxacin, moxifloxacin) are another reasonable alternative for the outpatient treatment of CAP in the older child when typical pneumonia is also a consideration based on clinical findings (table 3). 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, and C. pneumoniae [49]. However, S. pneumoniae resistant to levofloxacin have been identified [50].
Suspected influenza — Initiation of antiviral treatment for influenza (eg, oseltamivir) as soon as possible is recommended for children with suspected influenza who are at high risk for complications of influenza pneumonia (table 4); 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'.)
Suspected SARS-CoV-2 — SARS-CoV-2 pneumonia may be suspected in children with known exposure or circulation in the local community, school, or site of child care. The management of SARS-CoV-2 in children is discussed separately. (See "COVID-19: Management in children".)
Suspected aspiration pneumonia — Community-acquired aspiration pneumonia is usually treated with amoxicillin-clavulanate. Clindamycin is an alternative for patients with IgE-mediated or serious delayed reaction to a penicillin (table 6). Doses are provided in the table (table 2). In neurologically compromised adolescents who may be prone to aspiration events, empiric treatment with moxifloxacin (400 mg once per day) is an alternative. Moxifloxacin is active against anaerobic bacteria, as well as the usual treatable causes of CAP: S. pneumoniae, M. pneumoniae, and C. pneumoniae. Fluoroquinolone antibiotics generally are not recommended for children younger than 18 years of age when there is a safe and effective alternative. (See "Fluoroquinolones", section on 'Children'.)
Duration — The duration of therapy for children with CAP in resource-abundant countries generally is based upon the age of the host, likely causative agent, and severity of disease:
●For infants ≥4 months and children with uncomplicated pneumonia suspected or confirmed to be caused by routine bacterial pathogens (ie, S. pneumoniae, M. pneumoniae, C. pneumoniae), the usual suggested duration of antimicrobial therapy with agents other than azithromycin is seven days. For children with mild disease (table 1) and adequate follow-up, five days may be sufficient provided that the child has been afebrile for 24 hours and shows clinical improvement. The course of azithromycin is five days [1,9].
●The duration of treatment for C. trachomatis pneumonia in young infants (<4 months) is discussed separately. (See "Chlamydia trachomatis infections in the newborn", section on 'Treatment'.)
Limited evidence from randomized trials in resource-abundant countries supports a five-day course for outpatient treatment of nonsevere CAP in select children [17,51-55]. In a meta-analysis of randomized trials evaluating short (3 to 5 days) and longer (7 to 10 days) antimicrobial therapy for uncomplicated CAP treated in the outpatient setting in resource-abundant countries [17,51-53], the rates of retreatment (approximately 8 percent; three trials, 1288 participants), hospitalization (0 percent; two trials, 478 participants), and the composite outcome of retreatment or hospitalization within one month of randomization (approximately 8 percent; four trials, 1541 participants) were similar between groups, as were rates of adverse events (approximately 62 percent; two trials, 1194 participants) [54]. Adverse events were typically mild (eg, diarrhea, rash). Trials focusing on treatment of atypical pneumonias were excluded. The mean age of the children in the trials ranged from 28 to 36.8 months. In three trials, amoxicillin was the only antibiotic used; in the fourth trial, children were treated with amoxicillin, amoxicillin-clavulanate, or cefdinir.
Although these results suggest that three to five days of antimicrobial therapy may be sufficient for the outpatient treatment of uncomplicated CAP in resource-abundant settings, we continue to treat for at least five days. The mean age of study participants was <37 months, an age group in which viral pathogens predominate. Respiratory viruses were detected in >80 percent of participants in the only trial that tested for them [51]. The results of the meta-analysis cannot be generalized to older children who are more likely to have bacterial pathogens.
Evidence from randomized trials that supports ≤5 days of antibiotic therapy for outpatient treatment of pneumonia in resource-limited settings cannot be generalized to resource-abundant settings [56-58]. In resource-limited settings, pneumonia is typically diagnosed according to World Health Organization criteria using respiratory rate thresholds and clinical findings [59]; many cases may be caused by viral pathogens.
Monitoring response — Children with CAP who are treated as outpatients (including those who were not initially treated with antibiotics) should have follow-up within 24 to 48 hours [1,2]. Follow-up may be performed by phone. Children with CAP who are appropriately treated generally show signs of improvement within 48 to 72 hours.
Treatment failure — Among patients who do not improve as anticipated, the following possibilities must be considered [1,2,15,60]:
●Alternative or coincident diagnoses (eg, foreign body aspiration) (see "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Differential diagnosis')
●Development of complications (see "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Complications')
●Ineffective antibiotic coverage (lack of coverage for the actual etiology or resistant organism)
●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).
Worsened condition — Patients whose condition has worsened require additional evaluation and hospitalization. They also should undergo radiologic evaluation to look for the development of complications. Laboratory tests should be performed to try to establish a microbiologic diagnosis. (See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Laboratory evaluation' and "Pneumonia in children: Inpatient treatment", section on 'Hospitalization'.)
Failure to improve — In patients who fail to improve but have not worsened, it may be reasonable to add or strengthen coverage for S. pneumoniae or atypical bacteria if these organisms were not covered in the initial therapy (table 2) [1,4]. It is also important to consider underlying or comorbid conditions (eg, immunodeficiency, anatomic abnormality). (See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Differential diagnosis'.)
●Patients initially treated with beta-lactam antibiotics – Failure to improve while being treated with a beta-lactam antibiotic (amoxicillin or cephalosporin) may indicate infection caused by penicillin-resistant S. pneumoniae or S. aureus (either methicillin-susceptible or -resistant) [61]. If penicillin-resistant S. pneumoniae is suspected, a change in antibiotic therapy to clindamycin or linezolid may be indicated. Levofloxacin is an option if there is a high rate of pneumococcal resistance to clindamycin. Doses are provided in the table (table 2). If S. aureus is suspected based upon a rapidly worsening clinical course with progressive radiographic findings that may include multiple patchy alveolar infiltrates coalescing to form large consolidated areas in a young, immunocompetent host often with a preceding viral illness, the child should be hospitalized given the increased risk of complications (eg, necrosis, abscess, empyema, pneumatocele) and death. (See "Pneumonia in children: Inpatient treatment".)
●Patients initially treated with macrolide antibiotics – Failure to improve while being treated with a macrolide antibiotic may indicate the need to perform a diagnostic test (eg, polymerase chain reaction) to confirm an M. pneumoniae etiologic diagnosis and/or alter therapy to provide better coverage for S. pneumoniae or macrolide-resistant M. pneumoniae. (See "Mycoplasma pneumoniae infection in children", section on 'Pneumonia'.)
For patients initially treated with macrolides, better pneumococcal coverage can be achieved by the addition of high-dose amoxicillin, a cephalosporin (eg, cefdinir, cefpodoxime), a fluoroquinolone (eg, levofloxacin, moxifloxacin), linezolid, or clindamycin (the latter two also provide coverage for most S. aureus infections). Among these options, we prefer high-dose amoxicillin because it is well tolerated and inexpensive. Amoxicillin, cephalosporins, and fluoroquinolones may provide coverage for other potential, albeit less common causes, of bacterial pneumonia in older children (eg, H. influenzae type b, nontypeable H. influenzae, M. catarrhalis, group A Streptococcus) [12], although amoxicillin does not provide coverage against beta-lactamase-producing strains of H. influenzae and M. catarrhalis. For children who have an IgE-mediated or serious delayed reaction (table 6) to penicillins, clindamycin, linezolid, or a fluoroquinolone (eg, levofloxacin, moxifloxacin) may be used. Doxycycline or fluoroquinolones can be used if macrolide-resistant M. pneumoniae is suspected [62]. Fluoroquinolones also provide coverage for most typical bacterial etiologies of CAP except S aureus. Doses are provided in the table (table 2). (See "Mycoplasma pneumoniae infection in children", section on 'Management'.)
SUPPORTIVE CARE — The caregivers of children who are managed as outpatients should be instructed regarding management of fever and pain, maintaining adequate hydration, and identification of deterioration (eg, persistent fever, increased retractions, use of accessory muscles, grunting, inability to feed) [2].
●Children with pneumonia usually have fever and may have pleuritic chest pain, which can lead to shallow breathing and impaired ability to cough [2]. Administration of antipyretics and/or analgesics can be used to keep the child comfortable. Adequate pain control may promote coughing, which facilitates airway clearance. Antitussives should be avoided as none have been found to be effective in pneumonia [63]. Symptomatic treatment of cough is discussed separately. (See "The common cold in children: Management and prevention", section on 'Cough'.)
●Infants and young children with respiratory distress may be better able to maintain hydration if fluids are provided in small volumes more frequently than in large volumes less often.
●Gentle suction of the nares may be helpful in infants and children whose nares are blocked by nasal secretions.
FOLLOW-UP
Clinical course — Children who are appropriately treated for CAP gradually improve with time [64]. The symptoms associated with viral lower respiratory tract infections, particularly cough, usually resolve in less than one month in healthy infants and children but may rarely last for up to three to four months. Cough may also persist for as long as three to four months after 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 [64].
Radiographs — Follow-up radiographs are not necessary in asymptomatic children with uncomplicated CAP, including round pneumonia (ie, pulmonary consolidation that appears to be spherical) [65]. Follow-up radiographs two to three weeks after completion of therapy may be helpful in assessing alternate diagnoses or coincident conditions in children with recurrent pneumonia, persistent symptoms, severe atelectasis, or unusually located infiltrates [1,2,66]. Other conditions that should be considered if a round pneumonia fails to resolve on follow-up imaging, if obtained, include congenital lung sequestration, pulmonary arteriovenous malformation, metastatic Wilms tumor, cavitary necrosis, pleural pseudocyst, and primary lung carcinoma [65-70]. (See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Differential diagnosis'.)
Several studies have evaluated the utility of follow-up radiographs in cohorts of children with acute radiologically proven CAP [71-76]. Three of the studies included clinical as well as radiologic follow-up at three to seven weeks after initial diagnosis [71-74]. 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 who develop pneumonia recover without any long-term sequelae [48]. Although some prospective studies suggest that pneumonia in childhood is associated with subsequent symptoms of asthma that may persist into adulthood, 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 CAP [77,78].
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 education" and the keyword[s] of interest.)
●Basics topic (see "Patient education: Pneumonia in children (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Definition – 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. The clinical manifestations and diagnosis of CAP are discussed separately. (See "Community-acquired pneumonia in children: Clinical features and diagnosis".)
●Indications for hospitalization – The decision to hospitalize a child with pneumonia must be individualized and is based upon age, underlying medical problems, and severity of illness (table 1). (See 'Indications for hospitalization' above.)
●Empiric antimicrobial therapy – Children with CAP who are treated in the outpatient setting are treated empirically. It is not necessary to obtain laboratory or radiographic data in an attempt to suggest a bacterial etiology in children who are well enough to be treated as outpatients. 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. (See 'Factors influencing choice of regimen' above.)
•Age <6 months – Infants younger than three to six months of age with suspected bacterial CAP or who are hypoxemic should be admitted to the hospital for management.
Afebrile infants one to four months of age who are thought to have afebrile pneumonia of infancy (eg, Chlamydia trachomatis) can be treated in the outpatient setting if they are not hypoxemic and remain afebrile. (See "Pneumonia in children: Inpatient treatment" and "Chlamydia trachomatis infections in the newborn".)
•Age 6 months to 5 years – We recommend that empiric antibiotic therapy for CAP in children six months to five years of age who are thought to have bacterial pneumonia (eg, abrupt onset, moderate to severe respiratory distress, and supportive laboratory data if obtained (table 3)) include coverage for Streptococcus pneumoniae (table 2) (Grade 1B). We prefer high-dose amoxicillin for S. pneumoniae coverage. (See 'Children <5 years' above.)
•Age ≥5 years
-Suspected typical bacterial pneumonia – For children ≥5 years with clinical features strongly suggestive of typical bacterial (eg, S. pneumoniae) pneumonia (table 3), amoxicillin is the drug of choice (table 2).
-Suspected atypical bacterial pneumonia – We initiate a macrolide antibiotic for initial empiric therapy for suspected atypical CAP (table 3) in children ≥5 years who are treated as outpatients. (See 'Children ≥5 years' above.)
●Duration of antimicrobial therapy – In infants and children four months and older with uncomplicated pneumonia, the usual duration of antimicrobial therapy is seven days for agents other than azithromycin; for children with mild disease and adequate follow-up, five days may be sufficient, provided that the child has been afebrile for 24 hours and shows clinical improvement. The course of azithromycin is five days. (See 'Duration' above.)
●Follow-up and clinical course – Children who are treated for CAP as outpatients should have follow-up within 24 to 48 hours. Those whose condition has worsened at follow-up should be evaluated for potential complications and hospitalized. (See 'Monitoring response' above and "Pneumonia in children: Inpatient treatment".)
Children recovering from CAP may continue to 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 in children with uncomplicated CAP who remain asymptomatic are not needed. 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.)
