Cir 531

IDSA GUIDELINES
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
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John S. Bradley,1,a Carrie L. Byington,2,a Samir S. Shah,3,a Brian Alverson,4 Edward R. Carter,5 Christopher Harrison,6
Sheldon L. Kaplan,7 Sharon E. Mace,8 George H. McCracken Jr,9 Matthew R. Moore,10 Shawn D. St Peter,11
Jana A. Stockwell,12 and Jack T. Swanson13
1Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, San Diego, California;
2Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah; 3Departments of Pediatrics, and Biostatistics and Epidemiology,
University of Pennsylvania School of Medicine, and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
4Department of Pediatrics, Rhode Island Hospital, Providence, Rhode Island; 5Pulmonary Division, Seattle Children's Hospital, Seattle Washington;
6Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri; 7Department of Pediatrics, Baylor College of Medicine, Houston, Texas;
8Department of Emergency Medicine, Cleveland Clinic, Cleveland, Ohio; 9Department of Pediatrics, University of Texas Southwestern, Dallas, Texas;
10Centers for Disease Control and Prevention, Atlanta, Georgia; 11Department of Pediatrics, University of Missouri–Kansas City School of Medicine,
Kansas City, Missouri; 12Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; and 13Department of Pediatrics, McFarland
Clinic, Ames, Iowa
Evidenced-based guidelines for management of infants and children with community-acquired pneumonia
(CAP) were prepared by an expert panel comprising clinicians and investigators representing community
pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine,
infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and
subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in
both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive
surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.
EXECUTIVE SUMMARY of a child with CAP. They do not represent the only
approach to diagnosis and therapy; there is considerable
Guidelines for the management of community-acquired variation among children in the clinical course of pe-
pneumonia (CAP) in adults have been demonstrated to diatric CAP, even with infection caused by the same
decrease morbidity and mortality rates [1, 2]. These pathogen. The goal of these guidelines is to decrease
guidelines were created to assist the clinician in the care morbidity and mortality rates for CAP in children by
presenting recommendations for clinical management
that can be applied in individual cases if deemed ap-
propriate by the treating clinician.
Received 1 July 2011; accepted 8 July 2011.
a
J. S. B., C. L. B., and S. S. S. contributed equally to this work.
This document is designed to provide guidance in the
Correspondence: John S. Bradley, MD, Rady Children's Hospital San Diego/ care of otherwise healthy infants and children and ad-
UCSD, 3020 Children's Way, MC 5041, San Diego, CA 92123 ([email protected]).
dresses practical questions of diagnosis and management
Clinical Infectious Diseases 2011;53(7):e25–e76
Ó The Author 2011. Published by Oxford University Press on behalf of the
of CAP evaluated in outpatient (offices, urgent care
Infectious Diseases Society of America. All rights reserved. For Permissions, clinics, emergency departments) or inpatient settings in
please e-mail: [email protected].
1058-4838/2011/537-0024$14.00
the United States. Management of neonates and young
DOI: 10.1093/cid/cir531 infants through the first 3 months, immunocompromised
Pediatric Community Pneumonia Guidelines d CID 2011:53 (1 October) d e25

children, children receiving home mechanical ventilation, and 7. A child should be admitted to an ICU or a unit with
children with chronic conditions or underlying lung disease, such continuous cardiorespiratory monitoring capabilities if the child
as cystic fibrosis, are beyond the scope of these guidelines and are has impending respiratory failure. (strong recommendation;
not discussed. moderate-quality evidence)
Summarized below are the recommendations made in the new 8. A child should be admitted to an ICU or a unit with
2011 pediatric CAP guidelines. The panel followed a process used continuous cardiorespiratory monitoring capabilities if the child
in the development of other Infectious Diseases Society of has sustained tachycardia, inadequate blood pressure, or need for
America (IDSA) guidelines, which included a systematic weight- pharmacologic support of blood pressure or perfusion. (strong
ing of the quality of the evidence and the grade of the recom- recommendation; moderate-quality evidence)
mendation [3] (Table 1). A detailed description of the methods, 9. A child should be admitted to an ICU if the pulse
background, and evidence summaries that support each of the oximetry measurement is ,92% on inspired oxygen of $0.50.
recommendations can be found in the full text of the guidelines. (strong recommendation; low-quality evidence)
10. A child should be admitted to an ICU or a unit with

continuous cardiorespiratory monitoring capabilities if the
SITE-OF-CARE MANAGEMENT DECISIONS
child has altered mental status, whether due to hypercarbia or
hypoxemia as a result of pneumonia. (strong recommendation;
I. When Does a Child or Infant With CAP Require Hospitalization?
low-quality evidence)
Recommendations
11. Severity of illness scores should not be used as the sole
1. Children and infants who have moderate to severe CAP, criteria for ICU admission but should be used in the context of
as defined by several factors, including respiratory distress and other clinical, laboratory, and radiologic findings. (strong
hypoxemia (sustained saturation of peripheral oxygen [SpO2], recommendation; low-quality evidence)
,90 % at sea level) (Table 3) should be hospitalized for
management, including skilled pediatric nursing care. (strong
DIAGNOSTIC TESTING FOR PEDIATRIC CAP
recommendation; high-quality evidence)
2. Infants less than 3–6 months of age with suspected
III. What Diagnostic Laboratory and Imaging Tests Should Be
bacterial CAP are likely to benefit from hospitalization. (strong
Used in a Child With Suspected CAP in an Outpatient or
recommendation; low-quality evidence) Inpatient Setting?
3. Children and infants with suspected or documented Recommendations
CAP caused by a pathogen with increased virulence, such as Microbiologic Testing
community-associated methicillin-resistant Staphylococcus aureus Blood Cultures: Outpatient
(CA-MRSA) should be hospitalized. (strong recommendation; low-
quality evidence) 12. Blood cultures should not be routinely performed in
4. Children and infants for whom there is concern about nontoxic, fully immunized children with CAP managed in the
careful observation at home or who are unable to comply with outpatient setting. (strong recommendation; moderate-quality
therapy or unable to be followed up should be hospitalized. evidence)
(strong recommendation; low-quality evidence) 13. Blood cultures should be obtained in children who fail to
demonstrate clinical improvement and in those who have
progressive symptoms or clinical deterioration after initiation
II. When Should a Child With CAP Be Admitted to an Intensive of antibiotic therapy (strong recommendation; moderate-quality
Care Unit (ICU) or a Unit With Continuous Cardiorespiratory
evidence).
Monitoring?
Recommendations Blood Cultures: Inpatient
5. A child should be admitted to an ICU if the child requires 14. Blood cultures should be obtained in children requiring
invasive ventilation via a nonpermanent artificial airway hospitalization for presumed bacterial CAP that is moderate to
(eg, endotracheal tube). (strong recommendation; high-quality severe, particularly those with complicated pneumonia. (strong
evidence) recommendation; low-quality evidence)
6. A child should be admitted to an ICU or a unit with 15. In improving patients who otherwise meet criteria
continuous cardiorespiratory monitoring capabilities if the for discharge, a positive blood culture with identification or
child acutely requires use of noninvasive positive pressure susceptibility results pending should not routinely preclude
ventilation (eg, continuous positive airway pressure or bilevel discharge of that patient with appropriate oral or intravenous
positive airway pressure). (strong recommendation; very low- antimicrobial therapy. The patient can be discharged if close
quality evidence) follow-up is assured. (weak recommendation; low-quality evidence)
e26 d CID 2011:53 (1 October) d Bradley et al

Table 1. Strength of Recommendations and Quality of Evidence
Strength of recommendation Clarity of balance between Methodologic quality of supporting

and quality of evidence desirable and undesirable effects evidence (examples) Implications
Strong recommendation
High-quality evidence Desirable effects clearly Consistent evidence from well- Recommendation can apply to
outweigh undesirable effects, performed RCTsa or exceptionally most patients in most
or vice versa strong evidence from unbiased circumstances; further
observational studies research is unlikely to change
our confidence in the
estimate of effect.
Moderate-quality evidence Desirable effects clearly Evidence from RCTs with important Recommendation can apply to
outweigh undesirable effects, limitations (inconsistent results, most patients in most
or vice versa methodologic flaws, indirect, or circumstances; further
imprecise) or exceptionally strong research (if performed) is
evidence from unbiased likely to have an important

observational studies impact on our confidence in
the estimate of effect and
may change the estimate.
Low-quality evidence Desirable effects clearly Evidence for $1 critical outcome Recommendation may change
outweigh undesirable effects, from observational studies, RCTs when higher quality evidence
or vice versa with serious flaws or indirect becomes available; further
evidence research (if performed) is
likely to have an important
impact on our confidence in
the estimate of effect and is
likely to change the estimate.
Very low-quality evidence Desirable effects clearly Evidence for $1 critical outcome Recommendation may change
(rarely applicable) outweigh undesirable effects, from unsystematic clinical when higher quality evidence
or vice versa observations or very indirect becomes available; any
evidence estimate of effect for $1
critical outcome is very
uncertain.
Weak recommendation
High-quality evidence Desirable effects closely Consistent evidence from well- The best action may differ
balanced with undesirable performed RCTs or exceptionally depending on circumstances
effects strong evidence from unbiased or patients or societal values;
observational studies further research is unlikely to
change our confidence in the
estimate of effect.
Moderate-quality evidence Desirable effects closely Evidence from RCTs with important Alternative approaches are likely
balanced with undesirable limitations (inconsistent results, to be better for some patients
effects methodologic flaws, indirect, or under some circumstances;
imprecise) or exceptionally strong further research (if performed)
evidence from unbiased is likely to have an important
observational studies impact on our confidence in
the estimate of effect and
may change the estimate.
Low-quality evidence Uncertainty in the estimates of Evidence for $1 critical outcome Other alternatives may be equally
desirable effects, harms, and from observational studies, from reasonable; further research is
burden; desirable effects, RCTs with serious flaws or indirect very likely to have an important
harms, and burden may be evidence impact on our confidence in the
closely balanced estimate of effect and is likely
to change the estimate.
Very low-quality evidence Major uncertainty in estimates Evidence for $1 critical outcome from Other alternatives may be equally
of desirable effects, harms, unsystematic clinical observations or reasonable; any estimate of
and burden; desirable effects 2very indirect evidence effect, for at $1 critical
may or may not be balanced outcome, is very uncertain.
with undesirable effects
may be closely balanced
a
RCTs, randomized controlled trials.

Table 2. Complications Associated With Community-Acquired Urinary Antigen Detection Tests
Pneumonia
19. Urinary antigen detection tests are not recommended
Pulmonary for the diagnosis of pneumococcal pneumonia in children;
Pleural effusion or empyema false-positive tests are common. (strong recommendation; high-
Pneumothorax quality evidence)
Lung abscess
Testing For Viral Pathogens
Bronchopleural fistula
Necrotizing pneumonia 20. Sensitive and specific tests for the rapid diagnosis of
Acute respiratory failure influenza virus and other respiratory viruses should be used in
Metastatic the evaluation of children with CAP. A positive influenza test
Meningitis may decrease both the need for additional diagnostic studies
Central nervous system abscess and antibiotic use, while guiding appropriate use of antiviral
Pericarditis
agents in both outpatient and inpatient settings. (strong

Endocarditis
Osteomyelitis
21. Antibacterial therapy is not necessary for children, either
Septic arthritis
outpatients or inpatients, with a positive test for influenza virus
Systemic
Systemic inflammatory response syndrome or sepsis in the absence of clinical, laboratory, or radiographic findings
Hemolytic uremic syndrome that suggest bacterial coinfection. (strong recommendation;
high-quality evidence).
22. Testing for respiratory viruses other than influenza virus
Follow-up Blood Cultures can modify clinical decision making in children with suspected
16. Repeated blood cultures in children with clear clinical pneumonia, because antibacterial therapy will not routinely be
improvement are not necessary to document resolution of required for these children in the absence of clinical, laboratory,
pneumococcal bacteremia. (weak recommendation; low-quality or radiographic findings that suggest bacterial coinfection.
evidence) (weak recommendation; low-quality evidence)
17. Repeated blood cultures to document resolution of Testing for Atypical Bacteria
bacteremia should be obtained in children with bacteremia
23. Children with signs and symptoms suspicious for
caused by S. aureus, regardless of clinical status. (strong
Mycoplasma pneumoniae should be tested to help guide
recommendation; low-quality evidence)
antibiotic selection. (weak recommendation; moderate-quality
Sputum Gram Stain and Culture evidence)
18. Sputum samples for culture and Gram stain should be 24. Diagnostic testing for Chlamydophila pneumoniae is not
obtained in hospitalized children who can produce sputum. recommended as reliable and readily available diagnostic tests
(weak recommendation; low-quality evidence) do not currently exist. (strong recommendation; high-quality
evidence)
Table 3. Criteria for Respiratory Distress in Children With Ancillary Diagnostic Testing
Pneumonia Complete Blood Cell Count
Signs of Respiratory Distress

25. Routine measurement of the complete blood cell count is
not necessary in all children with suspected CAP managed in the
1. Tachypnea, respiratory rate, breaths/mina
outpatient setting, but in those with more serious disease it may
Age 0–2 months: .60
Age 2–12 months: .50
provide useful information for clinical management in the
Age 1–5 Years: .40 context of the clinical examination and other laboratory and
Age .5 Years: .20 imaging studies. (weak recommendation; low-quality evidence)
2. Dyspnea 26. A complete blood cell count should be obtained for
3. Retractions (suprasternal, intercostals, or subcostal) patients with severe pneumonia, to be interpreted in the context
4. Grunting of the clinical examination and other laboratory and imaging
5. Nasal flaring studies. (weak recommendation; low-quality evidence)
6. Apnea
7. Altered mental status Acute-Phase Reactants
8. Pulse oximetry measurement ,90% on room air 27. Acute-phase reactants, such as the erythrocyte sedimentation
a
Adapted from World Health Organization criteria. rate (ESR), C-reactive protein (CRP) concentration, or serum

procalcitonin concentration, cannot be used as the sole determinant Table 4. Criteria for CAP Severity of Illness in Children with
to distinguish between viral and bacterial causes of CAP. (strong Community-Acquired Pneumonia
28. Acute-phase reactants need not be routinely Criteria
measured in fully immunized children with CAP who are Major criteria
managed as outpatients, although for more serious disease, Invasive mechanical ventilation
acute-phase reactants may provide useful information for Fluid refractory shock
Acute need for NIPPV
clinical management. (strong recommendation; low-quality
Hypoxemia requiring FiO2 greater than inspired concentration or
evidence) flow feasible in general care area
29. In patients with more serious disease, such as those Minor criteria
requiring hospitalization or those with pneumonia-associated Respiratory rate higher than WHO classification for age
complications, acute-phase reactants may be used in Apnea
conjunction with clinical findings to assess response to Increased work of breathing (eg, retractions, dyspnea, nasal flaring,

grunting)
therapy. (weak recommendation; low-quality evidence)
PaO2/FiO2 ratio ,250
Pulse Oximetry Multilobar infiltrates
PEWS score .6
30. Pulse oximetry should be performed in all children with Altered mental status
pneumonia and suspected hypoxemia. The presence of Hypotension
hypoxemia should guide decisions regarding site of care and Presence of effusion
further diagnostic testing. (strong recommendation; moderate- Comorbid conditions (eg, HgbSS, immunosuppression,
immunodeficiency)
quality evidence)
Unexplained metabolic acidosis
Chest Radiography Modified from Infectious Diseases Society of America/American Thoracic
Society consensus guidelines on the management of community-acquired
Initial Chest Radiographs: Outpatient
pneumonia in adults [27, table 4]. Clinician should consider care in an intensive
care unit or a unit with continuous cardiorespiratory monitoring for the child
31. Routine chest radiographs are not necessary for the having $1 major or $2 minor criteria.
confirmation of suspected CAP in patients well enough to be Abbreviations: FiO2, fraction of inspired oxygen; HgbSS, Hemoglobin SS
treated in the outpatient setting (after evaluation in the disease; NIPPV, noninvasive positive pressure ventilation; PaO2, arterial
oxygen pressure; PEWS, Pediatric Early Warning Score [70].
office, clinic, or emergency department setting). (strong
32. Chest radiographs, posteroanterior and lateral, should 35. Repeated chest radiographs should be obtained in
be obtained in patients with suspected or documented children who fail to demonstrate clinical improvement and
hypoxemia or significant respiratory distress (Table 3) and in in those who have progressive symptoms or clinical
those with failed initial antibiotic therapy to verify the presence deterioration within 48–72 hours after initiation of
or absence of complications of pneumonia, including antibiotic therapy. (strong recommendation; moderate-quality
parapneumonic effusions, necrotizing pneumonia, and evidence)
pneumothorax. (strong recommendation; moderate-quality 36. Routine daily chest radiography is not recommended
evidence) in children with pneumonia complicated by parapneumonic
effusion after chest tube placement or after video-
Initial Chest Radiographs: Inpatient
assisted thoracoscopic surgery (VATS), if they remain
33. Chest radiographs (posteroanterior and lateral) should be clinically stable. (strong recommendation; low-quality
obtained in all patients hospitalized for management of CAP to evidence)
document the presence, size, and character of parenchymal 37. Follow-up chest radiographs should be obtained in
infiltrates and identify complications of pneumonia that may patients with complicated pneumonia with worsening
lead to interventions beyond antimicrobial agents and supportive respiratory distress or clinical instability, or in those with
medical therapy. (strong recommendation; moderate-quality persistent fever that is not responding to therapy over 48-72
evidence) hours. (strong recommendation; low-quality evidence)
38. Repeated chest radiographs 4–6 weeks after the
Follow-up Chest Radiograph
diagnosis of CAP should be obtained in patients with
34. Repeated chest radiographs are not routinely required in recurrent pneumonia involving the same lobe and in
children who recover uneventfully from an episode of CAP. patients with lobar collapse at initial chest radiography
(strong recommendation; moderate-quality evidence) with suspicion of an anatomic anomaly, chest mass, or

foreign body aspiration. (strong recommendation; moderate- M. pneumoniae should be performed if available in a clinically
quality evidence) relevant time frame. Table 5 lists preferred and alternative agents
for atypical pathogens. (weak recommendation; moderate-quality
IV. What Additional Diagnostic Tests Should Be Used in a Child evidence)
With Severe or Life-Threatening CAP? 45. Influenza antiviral therapy (Table 6) should be
Recommendations administered as soon as possible to children with moderate
to severe CAP consistent with influenza virus infection during
39. The clinician should obtain tracheal aspirates for Gram
widespread local circulation of influenza viruses, particularly
stain and culture, as well as clinically and epidemiologically
for those with clinically worsening disease documented at the
guided testing for viral pathogens, including influenza virus, at
time of an outpatient visit. Because early antiviral treatment has
the time of initial endotracheal tube placement in children
been shown to provide maximal benefit, treatment should not be
requiring mechanical ventilation. (strong recommendation; low-
delayed until confirmation of positive influenza test results.
quality evidence)
Negative results of influenza diagnostic tests, especially rapid

40. Bronchoscopic or blind protected specimen brush
antigen tests, do not conclusively exclude influenza disease.
sampling, bronchoalveolar lavage (BAL), percutaneous lung
Treatment after 48 hours of symptomatic infection may still
aspiration, or open lung biopsy should be reserved for the
provide clinical benefit to those with more severe disease. (strong
immunocompetent child with severe CAP if initial diagnostic
recommendation; moderate-quality evidence)
tests are not positive. (weak recommendation; low-quality
evidence)
Inpatients
46. Ampicillin or penicillin G should be administered to the

ANTI-INFECTIVE TREATMENT fully immunized infant or school-aged child admitted to
a hospital ward with CAP when local epidemiologic data
V. Which Anti-Infective Therapy Should Be Provided to a Child
document lack of substantial high-level penicillin resistance for
With Suspected CAP in Both Outpatient and Inpatient Settings?
invasive S. pneumoniae. Other antimicrobial agents for empiric
Recommendations
therapy are provided in Table 7. (strong recommendation;
Outpatients
moderate-quality evidence)
41. Antimicrobial therapy is not routinely required for 47. Empiric therapy with a third-generation parenteral
preschool-aged children with CAP, because viral pathogens are cephalosporin (ceftriaxone or cefotaxime) should be
responsible for the great majority of clinical disease. (strong prescribed for hospitalized infants and children who are
recommendation; high-quality evidence) not fully immunized, in regions where local epidemiology of
42. Amoxicillin should be used as first-line therapy for invasive pneumococcal strains documents high-level
previously healthy, appropriately immunized infants and penicillin resistance, or for infants and children with life-
preschool children with mild to moderate CAP suspected to threatening infection, including those with empyema
be of bacterial origin. Amoxicillin provides appropriate (Table 7). Non–b-lactam agents, such as vancomycin, have
coverage for Streptococcus pneumoniae, the most prominent not been shown to be more effective than third-generation
invasive bacterial pathogen. Table 5 lists preferred agents and cephalosporins in the treatment of pneumococcal
alternative agents for children allergic to amoxicillin (strong pneumonia for the degree of resistance noted currently in
recommendation; moderate-quality evidence) North America. (weak recommendation; moderate-quality
43. Amoxicillin should be used as first-line therapy for evidence)
previously healthy appropriately immunized school-aged 48. Empiric combination therapy with a macrolide (oral or
children and adolescents with mild to moderate CAP for parenteral), in addition to a b-lactam antibiotic, should be
S. pneumoniae, the most prominent invasive bacterial prescribed for the hospitalized child for whom M. pneumoniae
pathogen. Atypical bacterial pathogens (eg, M. pneumoniae), and C. pneumoniae are significant considerations; diagnostic
and less common lower respiratory tract bacterial pathogens, as testing should be performed if available in a clinically relevant
discussed in the Evidence Summary, should also be considered in time frame (Table 7). (weak recommendation; moderate-quality
management decisions. (strong recommendation; moderate- evidence)
quality evidence) 49. Vancomycin or clindamycin (based on local susceptibility
44. Macrolide antibiotics should be prescribed for treatment data) should be provided in addition to b-lactam therapy if
of children (primarily school-aged children and adolescents) clinical, laboratory, or imaging characteristics are consistent
evaluated in an outpatient setting with findings compatible with infection caused by S. aureus (Table 7). (strong
with CAP caused by atypical pathogens. Laboratory testing for recommendation; low-quality evidence)

Table 5. Selection of Antimicrobial Therapy for Specific Pathogens
Oral therapy (step-down therapy

Pathogen Parenteral therapy or mild infection)
Streptococcus pneumoniae with Preferred: ampicillin (150–200 mg/kg/day every Preferred: amoxicillin (90 mg/kg/day in
MICs for penicillin #2.0 lg/mL 6 hours) or penicillin (200 000–250 000 U/kg/day 2 doses or 45 mg/kg/day in 3 doses);
every 4–6 h);
Alternatives: second- or third-generation
Alternatives: ceftriaxone cephalosporin (cefpodoxime, cefuroxime,
(50–100 mg/kg/day every 12–24 hours) (preferred cefprozil); oral levofloxacin, if susceptible
for parenteral outpatient therapy) or cefotaxime (16–20 mg/kg/day in 2 doses for children
(150 mg/kg/day every 8 hours); may also be 6 months to 5 years old and 8–10 mg/kg/day
effective: clindamycin (40 mg/kg/day every once daily for children 5 to 16 years old;
6–8 hours) or vancomycin (40–60 mg/kg/day every maximum daily dose, 750 mg) or oral
6–8 hours) linezolid (30 mg/kg/day in 3 doses for
children ,12 years old and 20 mg/kg/day
in 2 doses for children $12 years old)

S. pneumoniae resistant to Preferred: ceftriaxone (100 mg/kg/day every Preferred: oral levofloxacin (16–20 mg/kg/day
penicillin, with MICs 12–24 hours); in 2 doses for children 6 months to 5 years
$4.0 lg/mL and 8–10 mg/kg/day once daily for children
Alternatives: ampicillin 5–16 years, maximum daily dose, 750 mg),
(300–400 mg/kg/day every 6 hours), levofloxacin if susceptible, or oral linezolid (30 mg/kg/day
(16–20 mg/kg/day every 12 hours for children in 3 doses for children ,12 years and
6 months to 5 years old and 8–10 mg/kg/day 20 mg/kg/day in 2 doses for children
once daily for children 5–16 years old; maximum $12 years);
daily dose, 750 mg), or linezolid (30 mg/kg/day
every 8 hours for children ,12 years old and Alternative: oral clindamycina
20 mg/kg/day every 12 hours for children $12 years (30–40 mg/kg/day in 3 doses)
old); may also be effective: clindamycina
(40 mg/kg/day every 6–8 hours) or vancomycin
(40–60 mg/kg/day every 6–8 hours)
Group A Streptococcus Preferred: intravenous penicillin (100 000–250 000 Preferred: amoxicillin (50–75 mg/kg/day in
U/kg/day every 4–6 hours) or ampicillin 2 doses), or penicillin V (50–75 mg/kg/day in
(200 mg/kg/day every 6 hours); 3 or 4 doses);
Alternatives: ceftriaxone (50–100 mg/kg/day every Alternative: oral clindamycina

12–24 hours) or cefotaxime (150 mg/kg/day every (40 mg/kg/day in 3 doses)
8 hours); may also be effective: clindamycin, if
susceptible (40 mg/kg/day every 6–8 hours) or
vancomycinb (40–60 mg/kg/day every 6–8 hours)
Stapyhylococcus aureus, Preferred: cefazolin (150 mg/kg/day every 8 hours) or Preferred: oral cephalexin (75–100 mg/kg/day
methicillin susceptible semisynthetic penicillin, eg oxacillin in 3 or 4 doses);
(combination therapy not (150–200 mg/kg/day every 6–8 hours);
well studied) Alternative: oral clindamycina
Alternatives: clindamycina (40 mg/kg/day every (30–40 mg/kg/day in 3 or 4 doses)
6–8 hours) or >vancomycin (40–60 mg/kg/day
every 6–8 hours)
S. aureus, methicillin resistant, Preferred: vancomycin (40–60 mg/kg/day every Preferred: oral clindamycin (30–40 mg/kg/day
susceptible to clindamycin 6–8 hours or dosing to achieve an AUC/MIC ratio of in 3 or 4 doses);
(combination therapy not .400) or clindamycin (40 mg/kg/day every 6–8 hours);
well-studied) Alternatives: oral linezolid
Alternatives: linezolid (30 mg/kg/day every 8 hours (30 mg/kg/day in 3 doses for children
for children ,12 years old and 20 mg/kg/day every ,12 years and 20 mg/kg/day in 2 doses
12 hours for children $12 years old) for children $12 years)
S. aureus, methicillin resistant, Preferred: vancomycin (40–60 mg/kg/day every Preferred: oral linezolid (30 mg/kg/day in
resistant to clindamycin 6-8 hours or dosing to achieve an AUC/MIC ratio of 3 doses for children ,12 years and
(combination therapy not .400); 20 mg/kg/day in 2 doses for children
well studied) $12 years old);
Alternatives: linezolid (30 mg/kg/day every
8 hours for children ,12 years old and 20 mg/kg/day Alternatives: none; entire treatment course with
every 12 hours for children $12 years old) parenteral therapy may be required

Table 5. (Continued)
Oral therapy (step-down therapy
Pathogen Parenteral therapy or mild infection)
Haemophilus influenza, typeable Preferred: intravenous ampicillin (150-200 mg/kg/day Preferred: amoxicillin (75-100 mg/kg/day in
(A-F) or nontypeable every 6 hours) if b-lactamase negative, ceftriaxone 3 doses) if b-lactamase negative) or
(50–100 mg/kg/day every 12-24 hours) if b-lactamase amoxicillin clavulanate (amoxicillin
producing, or cefotaxime (150 mg/kg/day every component, 45 mg/kg/day in 3 doses or
8 hours); 90 mg/kg/day in 2 doses) if b-lactamase
producing;
Alternatives: intravenous ciprofloxacin (30 mg/kg/day
every 12 hours) or intravenous levofloxacin Alternatives: cefdinir, cefixime,
(16-20 mg/kg/day every 12 hours for cefpodoxime, or ceftibuten
children 6 months to 5 years old
and 8-10 mg/kg/day once daily for children 5 to
16 years old; maximum daily dose, 750 mg)
Mycoplasma pneumoniae Preferred: intravenous azithromycin Preferred: azithromycin (10 mg/kg on day 1,
(10 mg/kg on days 1 and 2 of therapy; followed by 5 mg/kg/day once daily on

transition to oral therapy if possible); days 2–5);
Alternatives: intravenous erythromycin lactobionate Alternatives: clarithromycin

(20 mg/kg/day every 6 hours) or levofloxacin (15 mg/kg/day in 2 doses) or oral
(16-20 mg/kg/day every 12 hours; maximum daily erythromycin (40 mg/kg/day in 4 doses);
dose, 750 mg) for children .7 years old, doxycycline
(2–4 mg/kg/day in 2 doses; for adolescents
with skeletal maturity, levofloxacin
(500 mg once daily) or moxifloxacin
(400 mg once daily)
Chlamydia trachomatis or Preferred: intravenous azithromycin Preferred: azithromycin (10 mg/kg on day 1,
Chlamydophila pneumoniae (10 mg/kg on days 1 and 2 of therapy; followed by 5 mg/kg/day once daily
transition to oral therapy if possible); days 2–5);
Alternatives: intravenous erythromycin lactobionate Alternatives: clarithromycin

(20 mg/kg/day every 6 hours) or levofloxacin (15 mg/kg/day in 2 doses) or oral
(16-20 mg/kg/day in 2 doses for children 6 months erythromycin (40 mg/kg/day in 4 doses);
to 5 years old and 8-10 mg/kg/day once daily for for children .7 years old, doxycycline
children 5 to 16 years old; maximum daily dose, (2-4 mg/kg/day in 2 doses); for adolescents
750 mg) with skeletal maturity, levofloxacin
(500 mg once daily) or moxifloxacin
(400 mg once daily)
Doses for oral therapy should not exceed adult doses.

Abbreviations: AUC, area under the time vs. serum concentration curve; MIC, minimum inhibitory concentration.
a
Clindamycin resistance appears to be increasing in certain geographic areas among S. pneumoniae and S. aureus infections.
b
For b-lactam–allergic children.
VI. How Can Resistance to Antimicrobials Be Minimized? VII. What Is the Appropriate Duration of Antimicrobial Therapy
Recommendations for CAP?
Recommendations
50. Antibiotic exposure selects for antibiotic resistance;
therefore, limiting exposure to any antibiotic, whenever 54. Treatment courses of 10 days have been best studied,
possible, is preferred. (strong recommendation; moderate-quality although shorter courses may be just as effective, particularly
evidence) for more mild disease managed on an outpatient basis. (strong
51. Limiting the spectrum of activity of antimicrobials to recommendation; moderate-quality evidence)
that specifically required to treat the identified pathogen is 55. Infections caused by certain pathogens, notably CA-
preferred. (strong recommendation; low-quality evidence) MRSA, may require longer treatment than those caused by
52. Using the proper dosage of antimicrobial to be able to S. pneumoniae. (strong recommendation; moderate-quality
achieve a minimal effective concentration at the site of infection evidence)
is important to decrease the development of resistance. (strong
recommendation; low-quality evidence) VIII. How Should the Clinician Follow the Child With CAP for the
Expected Response to Therapy?
53. Treatment for the shortest effective duration will
Recommendation
minimize exposure of both pathogens and normal microbiota
to antimicrobials and minimize the selection for resistance. 56. Children on adequate therapy should demonstrate clinical
(strong recommendation; low-quality evidence) and laboratory signs of improvement within 48–72 hours. For

Table 6. Influenza Antiviral Therapy
Dosing recommendations
Treatment Prophylaxisa
Drug [186187] Formulation Children Adults Children Adults
Oseltamivir 75-mg capsule; $24 months old: 150 mg/day in #15 kg: 30 mg/day; .15 to 75 mg/day
(Tamiflu) 60 mg/5 mL 4 mg/kg/day in 2 doses for 23 kg: 45 mg/day; .23 to once daily
Suspension 2 doses, for a 5 days 40 kg: 60 mg/day; .40 kg:
5-day treatment 75 mg/day (once daily in
course each group)
#15 kg: 60 mg/day;
.15 to 23 kg: 90 mg/day;
.23 to 40 kg: 120 mg/day;
.40 kg: 150 mg/day
(divided into 2 doses
for each group)

9–23 months old: 9–23 months old: 3.5 mg/kg
7 mg/kg/day in once daily; 3–8 months old:
2 doses; 0–8 months 3 mg/kg once daily; not
old: 6 mg/kg/day in routinely recommended for
2 doses; premature infants ,3 months old
infants: 2 mg/kg/day owing to limited data in
in 2 doses this age group
Zanamivir 5 mg per inhalation, $7 years old: 2 inhalations 2 inhalations $5 years old: 2 inhalations 2 inhalations
(Relenza) using a Diskhaler (10 mg total per dose), (10 mg total per (10 mg total per dose), (10 mg total
twice daily for 5 days dose), twice daily once daily for 10 days per dose),
for 5 days once daily
for 10 days
Amantadine 100-mg tablet; 1–9 years old: 5–8 mg/kg/day 200 mg/day, as 1–9 years old: Same as
(Symmetrel)b 50 mg/5 mL as single daily dose or in single daily dose same as treatment
suspension 2 doses, not to exceed or in 2 doses treatment dose; dose
150 mg/day; 9–12 years old: 9–12 years old:
200 mg/day in 2 doses (not same as
studied as single daily dose) treatment dose
Rimantadine 100-mg tablet; Not FDA approved for 200 mg/day, either FDA approved for 200 mg/day,
(Flumadine)b 50 mg/5 mL treatment in children, but as a single daily prophylaxis down to as single
suspension published data exist on safety dose, or divided 12 months of age. daily dose
and efficacy in children; into 2 doses 1–9 years old: or in
suspension: 1–9 years old: 5 mg/kg/day 2 doses
6.6 mg/kg/day once daily, not to exceed
(maximum 150 mg/kg/day) in 150 mg; $10 years old:
2 doses; $10 years old: 200 mg/day as single daily
200 mg/day, as single daily dose or in 2 doses
dose or in 2 doses
NOTE. Check Centers for Disease Control and Prevention Website (http://www.flu.gov/) for current susceptibility data.
a
In children for whom prophylaxis is indicated, antiviral drugs should be continued for the duration of known influenza activity in the community because of the
potential for repeated and unknown exposures or until immunity can be achieved after immunization.
b
Amantadine and rimantadine should be used for treatment and prophylaxis only in winter seasons during which a majority of influenza A virus strains isolated
are adamantine susceptible; the adamantanes should not be used for primary therapy because of the rapid emergence of resistance. However, for patients requiring
adamantane therapy, a treatment course of 7 days is suggested, or until 24–48 hours after the disappearance of signs and symptoms.
children whose condition deteriorates after admission and but chest radiography should be used to confirm the presence of
initiation of antimicrobial therapy or who show no pleural fluid. If the chest radiograph is not conclusive, then
improvement within 48–72 hours, further investigation should further imaging with chest ultrasound or computed
be performed. (strong recommendation; moderate-quality evidence) tomography (CT) is recommended. (strong recommendation;
high-quality evidence)
ADJUNCTIVE SURGICAL AND NON–
ANTI-INFECTIVE THERAPY FOR PEDIATRIC CAP X. What Factors Are Important in Determining Whether Drainage
of the Parapneumonic Effusion Is Required?
IX. How Should a Parapneumonic Effusion Be Identified? Recommendations
Recommendation
58. The size of the effusion is an important factor that
57. History and physical examination may be suggestive of determines management (Table 8, Figure 1). (strong
parapneumonic effusion in children suspected of having CAP, recommendation; moderate-quality evidence)

Table 7. Empiric Therapy for Pediatric Community-Acquired Pneumonia (CAP)
Empiric therapy
Presumed bacterial Presumed atypical Presumed influenza
Site of care pneumonia pneumonia pneumoniaa
Outpatient
,5 years old (preschool) Amoxicillin, oral (90 mg/kg/day Azithromycin oral (10 mg/kg on Oseltamivir
in 2 dosesb) day 1, followed by 5 mg/kg/day
once daily on days 2–5);
Alternative:
oral amoxicillin clavulanate Alternatives: oral clarithromycin
(amoxicillin component, (15 mg/kg/day in 2 doses
90 mg/kg/day in 2 dosesb) for 7-14 days) or oral
erythromycin (40 mg/kg/day
in 4 doses)
$5 years old Oral amoxicillin (90 mg/kg/day in Oral azithromycin (10 mg/kg on Oseltamivir or zanamivir

2 dosesb to a maximum day 1, followed by 5 mg/kg/day (for children 7 years
of 4 g/dayc); for children once daily on days 2–5 to a and older); alternatives:
with presumed bacterial maximum of 500 mg on day 1, peramivir, oseltamivir
CAP who do not have clinical, followed by 250 mg on days 2–5); and zanamivir
laboratory, or radiographic alternatives: oral clarithromycin (all intravenous) are
evidence that distinguishes (15 mg/kg/day in 2 doses to a under clinical
bacterial CAP from maximum of 1 g/day); investigation in children;
atypical CAP, a macrolide erythromycin, doxycycline for intravenous zanamivir
can be added to a b-lactam children .7 years old available for
antibiotic for empiric therapy; compassionate use
alternative: oral amoxicillin
clavulanate (amoxicillin
component, 90 mg/kg/day
in 2 dosesb to a maximum
dose of 4000 mg/day,
eg, one 2000-mg tablet
twice dailyb)
Inpatient (all ages)d
Fully immunized with Ampicillin or penicillin G; Azithromycin (in addition to Oseltamivir or zanamivir
conjugate vaccines for alternatives: b-lactam, if diagnosis of (for children $7 years old;
Haemophilus influenzae ceftriaxone or cefotaxime; atypical pneumonia is in alternatives: peramivir,
type b and Streptococcus addition of vancomycin or doubt); alternatives: oseltamivir and
pneumoniae; local clindamycin for clarithromycin or zanamivir (all intravenous)
penicillin resistance in suspected CA-MRSA erythromycin; are under clinical
invasive strains of doxycycline for children investigation
pneumococcus is minimal .7 years old; levofloxacin in children; intravenous
for children who have zanamivir available for
reached growth maturity, compassionate use
or who cannot tolerate
macrolides
Not fully immunized for H, Ceftriaxone or cefotaxime; addition of Azithromycin (in addition to As above
influenzae type b and vancomycin or clindamycin for b-lactam, if diagnosis in
S. pneumoniae; local suspected CA-MRSA; alternative: doubt); alternatives:
penicillin resistance in levofloxacin; addition of vancomycin clarithromycin or erythromycin;
invasive strains of or clindamycin for suspected doxycycline for children .7 years
pneumococcus is CA-MRSA old; levofloxacin for children
significant who have reached growth
maturity or who cannot
tolerate macrolides
For children with drug allergy to recommended therapy, see Evidence Summary for Section V. Anti-Infective Therapy. For children with a history of possible,
nonserious allergic reactions to amoxicillin, treatment is not well defined and should be individualized. Options include a trial of amoxicillin under medical
observation; a trial of an oral cephalosporin that has substantial activity against S. pneumoniae, such as cefpodoxime, cefprozil, or cefuroxime, provided under
medical supervision; treatment with levofloxacin; treatment with linezolid; treatment with clindamycin (if susceptible); or treatment with a macrolide (if susceptible).
For children with bacteremic pneumococcal pneumonia, particular caution should be exercised in selecting alternatives to amoxicillin, given the potential for
secondary sites of infection, including meningitis.
Abbreviation: CA-MRSA, community-associated methicillin-resistant Staphylococcus aureus.
a
See Table 6 for dosages.
b
See text for discussion of dosage recommendations based on local susceptibility data. Twice daily dosing of amoxicillin or amoxicillin clavulanate may be
effective for pneumococci that are susceptible to penicillin.
c
Not evaluated prospectively for safety.
d
See Table 5 for dosages.

Table 8. Factors Associated with Outcomes and Indication for Drainage of Parapneumonic Effusions
Risk of poor Tube drainage with or

Size of effusion Bacteriology outcome without fibrinolysis or VATSa
Small: ,10 mm on lateral Bacterial culture and Gram Low No; sampling of pleural fluid is not
decubitus radiograph or stain results unknown or routinely required
opacifies less than negative
one-fourth of hemithorax
Moderate: .10 mm rim of Bacterial culture and/or Gram Low to moderate No, if the patient has no respiratory
fluid but opacifies less than stain results negative or compromise and the pleural fluid
half of the hemithorax positive (empyema) is not consistent with empyema
(sampling of pleural fluid by
simple thoracentesis may
help determine presence or absence
of empyema and need for a drainage
procedure, and sampling with a
drainage catheter may provide both

diagnostic and therapeutic benefit);
Yes, if the patient has respiratory

compromise or if pleural fluid is
consistent with empyema
Large: opacifies more than Bacterial culture and/or Gram High Yes in most cases
half of the hemithorax stain results
positive (empyema)
a
VATS, video-assisted thoracoscopic surgery.
59. The child’s degree of respiratory compromise is an 65. Moderate parapneumonic effusions associated with
important factor that determines management of parapneumonic respiratory distress, large parapneumonic effusions, or
effusions (Table 8, Figure 1) (strong recommendation; moderate- documented purulent effusions should be drained. (strong
quality evidence) recommendation; moderate-quality evidence)
66. Both chest thoracostomy tube drainage with the addition
XI. What Laboratory Testing Should Be Performed on Pleural of fibrinolytic agents and VATS have been demonstrated to be
Fluid? effective methods of treatment. The choice of drainage procedure
Recommendation depends on local expertise. Both of these methods are associated
with decreased morbidity compared with chest tube drainage
60. Gram stain and bacterial culture of pleural fluid should
alone. However, in patients with moderate-to-large effusions that
be performed whenever a pleural fluid specimen is obtained.
are free flowing (no loculations), placement of a chest tube
(strong recommendation; high-quality evidence)
without fibrinolytic agents is a reasonable first option. (strong
61. Antigen testing or nucleic acid amplification through
polymerase chain reaction (PCR) increase the detection of
pathogens in pleural fluid and may be useful for management.
XIII. When Should VATS or Open Decortication Be Considered in
(strong recommendation; moderate-quality evidence)
Patients Who Have Had Chest Tube Drainage, With or Without
62. Analysis of pleural fluid parameters, such as pH and
Fibrinolytic Therapy?
levels of glucose, protein, and lactate dehydrogenase, rarely
Recommendation
change patient management and are not recommended. (weak
recommendation; very low-quality evidence) 67. VATS should be performed when there is persistence of
63. Analysis of the pleural fluid white blood cell (WBC) count, moderate-large effusions and ongoing respiratory compromise
with cell differential analysis, is recommended primarily to help despite 2–3 days of management with a chest tube and
differentiate bacterial from mycobacterial etiologies and from completion of fibrinolytic therapy. Open chest débridement
malignancy. (weak recommendation; moderate-quality evidence) with decortication represents another option for management
of these children but is associated with higher morbidity rates.
(strong recommendation; low-quality evidence)
XII. What Are the Drainage Options for Parapneumonic Effusions?
Recommendations XIV. When Should a Chest Tube Be Removed Either After Primary
Drainage or VATS?
64. Small, uncomplicated parapneumonic effusions should
not routinely be drained and can be treated with antibiotic therapy 68. A chest tube can be removed in the absence of an
alone. (strong recommendation; moderate-quality evidence) intrathoracic air leak and when pleural fluid drainage is

Figure 1. Management of pneumonia with parapneumonic effusion; abx, antibiotics; CT, computed tomography; dx, diagnosis; IV, intravenous; US,
ultrasound; VATS, video-assisted thoracoscopic surgery.
,1 mL/kg/24 h, usually calculated over the last 12 hours. MANAGEMENT OF THE CHILD NOT
(strong recommendation; very low-quality evidence) RESPONDING TO TREATMENT
XV. What Antibiotic Therapy and Duration Is Indicated for the XVI. What Is the Appropriate Management of a Child Who Is Not
Treatment of Parapneumonic Effusion/Empyema? Responding to Treatment for CAP?
Recommendations Recommendation
69. When the blood or pleural fluid bacterial culture identifies 72. Children who are not responding to initial therapy after
a pathogenic isolate, antibiotic susceptibility should be used to 48–72 hours should be managed by one or more of the following:
determine the antibiotic regimen. (strong recommendation; high-
quality evidence) a. Clinical and laboratory assessment of the current
70. In the case of culture-negative parapneumonic effusions, severity of illness and anticipated progression in order to
antibiotic selection should be based on the treatment determine whether higher levels of care or support are
recommendations for patients hospitalized with CAP (see required. (strong recommendation; low-quality evidence)
Evidence Summary for Recommendations 46–49). (strong b. Imaging evaluation to assess the extent and progression
recommendation; moderate-quality evidence) of the pneumonic or parapneumonic process. (weak
71. The duration of antibiotic treatment depends on the recommendation; low-quality evidence)
adequacy of drainage and on the clinical response c. Further investigation to identify whether the original
demonstrated for each patient. In most children, antibiotic pathogen persists, the original pathogen has developed
treatment for 2–4 weeks is adequate. (strong recommendation; resistance to the agent used, or there is a new secondary
low-quality evidence) infecting agent. (weak recommendation; low-quality evidence)

73. A BAL specimen should be obtained for Gram stain and are able to administer and children are able to comply
culture for the mechanically ventilated child. (strong adequately with taking those antibiotics before discharge.
recommendation; moderate-quality evidence) (weak recommendation; very low-quality evidence)
74. A percutaneous lung aspirate should be obtained for Gram 83. For children who have had a chest tube and meet the
stain and culture in the persistently and seriously ill child for requirements listed above, hospital discharge is appropriate
whom previous investigations have not yielded a microbiologic after the chest tube has been removed for 12–24 hours, either
diagnosis. (weak recommendation; low-quality evidence) if there is no clinical evidence of deterioration since removal or
75. An open lung biopsy for Gram stain and culture should if a chest radiograph, obtained for clinical concerns, shows
be obtained in the persistently and critically ill, mechanically no significant reaccumulation of a parapneumonic effusion
ventilated child in whom previous investigations have not or pneumothorax. (strong recommendation; very low-quality
yielded a microbiologic diagnosis. (weak recommendation; evidence)
low-quality evidence) 84. In infants and children with barriers to care, including
concern about careful observation at home, inability to comply

XVII. How Should Nonresponders With Pulmonary Abscess or with therapy, or lack of availability for follow-up, these issues
Necrotizing Pneumonia Be Managed? should be identified and addressed before discharge. (weak
Recommendation recommendation; very low-quality evidence)
76. A pulmonary abscess or necrotizing pneumonia identified

in a nonresponding patient can be initially treated with XIX. When Is Parenteral Outpatient Therapy Indicated, In
intravenous antibiotics. Well-defined peripheral abscesses Contrast to Oral Step-Down Therapy?
without connection to the bronchial tree may be drained under Recommendations
imaging-guided procedures either by aspiration or with a drainage 85. Outpatient parenteral antibiotic therapy should be
catheter that remains in place, but most abscesses will drain offered to families of children no longer requiring skilled
through the bronchial tree and heal without surgical or invasive nursing care in an acute care facility but with a demonstrated
intervention. (weak recommendation; very low-quality evidence) need for ongoing parenteral therapy. (weak recommendation;
moderate-quality evidence)
86. Outpatient parenteral antibiotic therapy should be
DISCHARGE CRITERIA offered through a skilled pediatric home nursing program
or through daily intramuscular injections at an appropriate
XVIII. When Can a Hospitalized Child With CAP Be Safely
pediatric outpatient facility. (weak recommendation; low-quality
Discharged?
evidence)
Recommendations
87. Conversion to oral outpatient step-down therapy when
77. Patients are eligible for discharge when they have possible, is preferred to parenteral outpatient therapy. (strong
documented overall clinical improvement, including level of recommendation; low-quality evidence)
activity, appetite, and decreased fever for at least 12–24 hours.
(strong recommendation; very low-quality evidence)
78. Patients are eligible for discharge when they demonstrate PREVENTION
consistent pulse oximetry measurements .90% in room air
XX. Can Pediatric CAP Be Prevented?
for at least 12–24 hours. (strong recommendation; moderate-
Recommendations
quality evidence)
79. Patients are eligible for discharge only if they demonstrate 88. Children should be immunized with vaccines for bacterial
stable and/or baseline mental status. (strong recommendation; pathogens, including S. pneumoniae, Haemophilus influenzae
very low-quality evidence) type b, and pertussis to prevent CAP. (strong recommendation;
80. Patients are not eligible for discharge if they have high-quality evidence)
substantially increased work of breathing or sustained tachypnea 89. All infants $6 months of age and all children and
or tachycardia (strong recommendation; high-quality evidence) adolescents should be immunized annually with vaccines for
81. Patients should have documentation that they can tolerate influenza virus to prevent CAP. (strong recommendation; high-
their home anti-infective regimen, whether oral or intravenous, quality evidence)
and home oxygen regimen, if applicable, before hospital 90. Parents and caretakers of infants ,6 months of age,
discharge. (strong recommendation; low-quality evidence) including pregnant adolescents, should be immunized with
82. For infants or young children requiring outpatient oral vaccines for influenza virus and pertussis to protect the infants
antibiotic therapy, clinicians should demonstrate that parents from exposure. (strong recommendation; weak-quality evidence)

91. Pneumococcal CAP after influenza virus infection is a lower respiratory tract infection (LRTI), may also be defined in
decreased by immunization against influenza virus. (strong a way that is clinically oriented, to assist practitioners with di-
recommendation; weak-quality evidence) agnosis and management.
92. High-risk infants should be provided immune
prophylaxis with respiratory syncytial virus (RSV)–specific Etiology
monoclonal antibody to decrease the risk of severe pneumonia Many pathogens are responsible for CAP in children, most
and hospitalization caused by RSV. (strong recommendation; prominently viruses and bacteria [6, 7, 14–18]. Investigators
high-quality evidence) have used a variety of laboratory tests to establish a microbial
etiology of CAP. For example, diagnosis of pneumococcal
INTRODUCTION pneumonia has been based on positive cultures of blood, anti-
body responses, antigen detection, and nucleic acid detection.
Burden of Disease Each test has different sensitivity, specificity, and positive and
Pneumonia is the single greatest cause of death in children negative predictive values that are dependent on the prevalence

worldwide [4]. Each year, .2 million children younger than of the pathogen at the time of testing. Therefore, comparing
5 years die of pneumonia, representing 20% of all deaths in etiologies of pneumonia between published studies is challeng-
children within this age group [5]. Although difficult to quan- ing. More recent investigations have used a variety of sensitive
tify, it is believed that up to 155 million cases of pneumonia molecular techniques including nucleic acid detection, particu-
occur in children every year worldwide [5]. larly for viral identification. In many children with LRTI, di-
In the developed world, the annual incidence of pneumonia is agnostic testing may identify 2 or 3 pathogens, including
3–4 cases per 100 children ,5 years old [6, 7]. In the United combinations of both viruses and bacteria, making it difficult to
States, outpatient visit rates for CAP between 1994–1995 and determine the significance of any single pathogen [19–21].
2002–2003 were defined using International Classification of Furthermore, unique to pediatrics, the developing immune
Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) di- system and age-related exposures result in infection caused by
agnosis codes and reported in the National Ambulatory Medical different bacterial and viral pathogens, requiring that the in-
Care Survey and the National Hospital Ambulatory Medical cidence of CAP and potential pathogens be defined separately
Care Survey and identified rates ranging from 74 to 92 per 1000 for each age group [7].
children ,2 years old to 35–52 per 1000 children 3–6 years old The advent of polysaccharide-protein conjugate vaccines
[8]. In 2006, the rate of hospitalization for CAP in children for H. influenzae type b and 7 serotypes of S. pneumoniae
through age 18 years, using data from the Healthcare Cost (7-valent pneumococcal conjugate vaccine [PCV7]) dramat-
Utilization Project’s Kids’ Inpatient Database, also based on ically decreased the incidence of infection, including CAP,
ICD-9-CM discharge diagnosis codes, was 201.1 per 100 000 [9]. caused by these bacteria. Newer vaccines that protect against
Infants ,1 year old had the highest rate of hospitalization (912.9 a greater number of pneumococcal serotypes are in various
per 100 000) whereas children 13–18 years had the lowest rate stages of clinical development, with a newly licensed 13-valent
(62.8 per 100 000) [9]. Data from the Centers for Disease pneumococcal conjugate vaccine (PCV13) available in the
Control and Prevention (CDC) document that in 2006, United States. Reports of epidemiologic investigations on the
525 infants and children ,15 years old died in the United States etiology of CAP before the widespread use of these vaccines
as a result of pneumonia and other lower respiratory tract in- cited S. pneumoniae as the most common documented
fections [10]. The reported incidence of pneumonia in children, bacterial pathogen, occurring in 4%–44% of all children
both pathogen specific and as a general diagnosis, varies across investigated [14–16, 18].
published studies based on definitions used, tests performed, In some studies, viral etiologies of CAP have been docu-
and the goals of the investigators. CAP in children in the United mented in up to 80% of children younger than 2 years; in contrast,
States, the focus of these guidelines, is defined simply as the investigations of older children, 10–16 years, who had both
presence of signs and symptoms of pneumonia in a previously clinical and radiographic evidence of pneumonia, documented
healthy child caused by an infection that has been acquired a much lower percentage of viral pathogens [15, 16, 18, 20].
outside of the hospital [11, 12]. However, pneumonia defi- Of viral pathogens, RSV is consistently the most frequently
nitions can also be designed to be very sensitive for epidemio- detected, representing up to 40% of identified pathogens in those
logic considerations (eg, fever and cough) or very specific, as younger than 2 years, but rarely identified in older children
defined by government regulatory agencies for approval of with CAP. Less frequently detected are adenoviruses, bocavirus,
antimicrobials to treat pneumonia (eg, clinical symptoms and human metapneumovirus, influenza A and B viruses, para-
signs in combination with radiologic documentation or mi- influenza viruses, coronaviruses and rhinovirus [14, 16, 18, 22, 23].
crobiologic confirmation) [13]. Pneumonia, broadly defined as Epidemiologic investigations of hospitalized children with CAP

document that 2%–33% are simultaneously infected by 2 or XI. What laboratory testing should be performed on pleural
more viruses [19, 20]. fluid?
Epidemiologic studies that have assessed both viral and bac- XII. What are the drainage options for parapneumonic effu-
terial pathogens have reported bacterial pathogens isolated in sions?
2%–50% of children with CAP; inpatient studies that enroll XIII. When should VATS or open surgical decortication be
more seriously ill children often document higher rates of bac- considered in patients who have had chest tube drainage with or
terial infection compared with outpatient studies [16, 17, 20, 21]. without fibrinolytic therapy?
Pathogens responsible for ‘‘atypical pneumonia’’ have been XIV. When should a chest tube be removed either after pri-
identified in 3%–23% of children studied, with M. pneumoniae mary drainage or VATS?
most often identified in older children and C. pneumoniae in XV. What antibiotic therapy and duration is indicated for the
infants [14–18]. Atypical pneumonia caused by Mycoplasma is treatment of parapneumonic effusion/empyema? (see also sec-
characteristically slowly progressing, with malaise, sore throat, tion on Anti-infective Treatment)
low-grade fever, and cough developing over 3–5 days. In con- Management in the Child Not Responding to Treatment

trast to adults with pneumonia, Legionella sp. has only rarely XVI. What is the appropriate management of a child who is
been identified in children [24]. not responding to treatment for CAP?
Although CAP caused by Mycobacterium tuberculosis and the XVII. How should the nonresponder with a pulmonary ab-
nontuberculous mycobacteria have been well-documented, scess or necrotizing pneumonia be managed?
the incidence of these serious infections in the United States Discharge Criteria
is far less than that of viral or bacterial CAP and is often linked XVIII. When can a hospitalized child with CAP be safely
to high-risk exposures [25]. Likewise, fungal pneumonia in discharged?
normal hosts caused by Histoplasma, Coccidioides, Blastomyces, XIX. When is parenteral outpatient therapy indicated, in
and Cryptococcus is uncommon, and in most epidemiologic contrast to oral step-down therapy?
studies, children with fungal pneumonia are not identified. Prevention
Mycobacterial and fungal pneumonia are not addressed in these XX. Can pediatric CAP be prevented?
guidelines. There are many aspects to the clinical management of CAP and
its complications (Table 2). Clinical practice recommendations
Clinical Questions Addressed by the Expert Panel regarding the daily management of children hospitalized with
Site-of-Care Management Decisions CAP, including intravenous fluid management, techniques for
I. When does a child or infant with CAP require hospitalization? delivery of and monitoring oxygenation, and management of
II. When should a child with CAP be admitted to an intensive respiratory tract secretions as well as important economic and
care unit (ICU) or a unit with continuous cardiorespiratory social issues were beyond the scope of this first edition of the
monitoring? pediatric CAP guidelines and were not addressed by the panel.
Diagnostic Testing for Pediatric CAP
III. What diagnostic laboratory and imaging tests should be METHODOLOGY
used in a child with suspected CAP in a clinic or hospital ward
Practice Guidelines
setting?
Practice guidelines are ‘‘systematically developed statements to
IV. What additional diagnostic tests should be used in a child
assist practitioners and patients in making decisions about ap-
with severe or life-threatening CAP?
propriate health care for specific clinical circumstances’’ [26].
Anti-Infective Treatment
Attributes of good guidelines include validity, reliability, re-
V. Which anti-infective therapy should be provided to a child
producibility, clinical applicability, clinical flexibility, clarity,
with suspected CAP in both the outpatient and inpatient settings?
multidisciplinary process, review of evidence, and documenta-
VI. How can resistance to antimicrobials be minimized?
tion [26].
VII. What is the appropriate duration of antimicrobial ther-
apy for CAP? Panel Composition
VIII. How should the clinician follow up the child with CAP The Pediatric Infectious Diseases Society (PIDS) and the IDSA
for the expected response to therapy? Standards and Practice Guidelines Committee (SPGC) convened
Adjunctive Surgical and Non–Anti-infective Therapy for experts in pediatric CAP from the fields of community pediat-
Pediatric CAP rics, public health, and the pediatric subspecialties of critical care
IX. How should a parapneumonic effusion be identified? medicine, emergency medicine, hospital medicine, infectious
X. What factors are important in determining whether diseases, pulmonology, and surgery. Panel participants included
drainage of the parapneumonic effusion is required? representatives from the following collaborating organizations:

American Academy of Pediatrics (AAP), American College of All members of the panel participated in the preparation and
Emergency Physicians, American Thoracic Society–Pediatric review of the draft guidelines. Feedback was solicited from ex-
Section, Society for Hospital Medicine, the Society of Critical ternal peer reviewers and from the organizations represented on
Care Medicine, and the American Pediatric Surgical Association. the expert panel. These guidelines have been endorsed by the
In addition, expert consultants in diagnostic microbiology AAP, the American College of Emergency Physicians, the
including virology, and interventional radiology were asked to American Society of Microbiology, the American Thoracic So-
review and provide feedback on the draft guidelines. ciety, the Society for Hospital Medicine, and the Society of
Critical Care Medicine. The guidelines were reviewed and ap-
Process Overview proved by the PIDS Clinical Affairs Committee, the IDSA SPGC,
As with other clinical practice guidelines developed by IDSA, the Council of the PIDS, and the Board of Directors of the IDSA
a need for guidelines for pediatric CAP was demonstrated and before dissemination.
the goals for the guidelines were similar to those for CAP in
adults [27]. Clinical questions were developed by the writing Guidelines and Conflict of Interest

group and approved by the IDSA SPGC. Computerized litera- All members of the expert panel complied with the IDSA
ture searches of the National Library of Medicine PubMed da- policy on conflicts of interest that requires disclosure of any
tabase were performed to identify data published through May financial or other interest that might be construed as consti-
2010, although more recent articles with particular relevance to tuting an actual, potential, or apparent conflict. They were
these guidelines have been included. Relevant abstracts from given the IDSA conflicts of interest disclosure statement
recent professional meetings and existing guidelines on pediatric and were asked to identify ties to companies developing
CAP were also identified, collected, and reviewed. products that might be affected by promulgation of the
As with all IDSA clinical practice guidelines initiated after guidelines. Information was requested regarding employ-
1 October 2008, the expert panel employed the GRADE (Grades ment, consultancies, stock ownership, honoraria, research
of Recommendation, Assessment, Development, and Evalua- funding, expert testimony, and membership on company
tion) method of assigning strength of recommendation and advisory committees. The panel made decisions on a case-
quality of the evidence to each recommendation (see Table 2) by-case basis as to whether an individual’s role should be
[3]. As applied to these guidelines, the writing group believes limited as a result of a conflict. Potential conflicts are listed in
that in circumstances for which the quality of evidence is low or the Acknowledgments section.
very low, there are likely to be situations in which even strong
recommendations may not apply to specific subgroups within GUIDELINE RECOMMENDATIONS FOR
a population that is intended for that recommendation. For MANAGEMENT OF CAP IN INFANTS AND
many conditions that lack moderate- or high-quality evidence, CHILDREN
clinical judgment still plays an important role in management.
Unfortunately, for many situations, current, prospectively col- Site-of-Care Management Decisions
lected, high-quality evidence was not available, highlighting the I. When Does a Child or Infant With CAP Require
critical need for further investigation in order to establish a solid Hospitalization?
basis for future recommendations. Recommendations
1. Children and infants who have moderate to severe CAP as
Consensus Development Based on Evidence defined by several factors, including respiratory distress and
The expert panel met initially on 3 occasions via teleconference hypoxemia (sustained SpO2, ,90 % at sea level) (Table 3)
to complete the organizational work of the guideline, and in should be hospitalized for management including skilled
person at the 2009 Annual Meeting of the IDSA. Within the pediatric nursing care. (strong recommendation; high-quality
panel, subgroups were formed for each clinical question. evidence)
Each subgroup reviewed the literature relevant to that clinical 2. Infants ,3–6 months of age with suspected bacterial
question and was responsible for drafting the recom- CAP are likely to benefit from hospitalization. (strong
mendation(s) and evidence summaries for their assigned sec- recommendation; low-quality evidence)
tion. The drafts were circulated within the panel for 3. Children and infants with a suspicion or documentation
commentary and discussed in additional conference calls and of CAP caused by a pathogen with increased virulence, such as
during a face-to-face meeting held in conjunction with the 2010 CA-MRSA, should be hospitalized. (strong recommendation;
Pediatric Academic Societies meeting. Further refinement of low-quality evidence)
the recommendations and evidence summaries occurred in 4. Children and infants for whom there is concern about
4 subsequent teleconference calls. careful observation at home or who are unable to comply with

therapy or unable to be followed up should be hospitalized. scoring systems that have been demonstrated to be useful in
(strong recommendation; low-quality evidence) predicting both which adults should be hospitalized and which
Evidence Summary adults require intensive care [27, 32–38]. Unfortunately, these
These guidelines are primarily designed to address infants and scoring systems have not been validated in children and do not
children living in the United States, with reasonable access to consider pediatric comorbid conditions, developmental stage, or
healthcare. The history, presentation, and examination of the psychosocial factors that influence the treating clinician’s de-
child are the major determinants of the severity of the illness and cision on the site of treatment for pediatric patients with CAP
the appropriate level of care with respect to outpatient or in- [39].
patient management. The physician’s overall assessment of the Validated scoring systems to predict which children with
child’s status, at the time of examination and the anticipated pneumonia should be hospitalized do not exist. Scores to predict
clinical course should determine the site of care. However, the mortality in critically ill children hospitalized in pediatric ICUs
guidelines writing group recognizes that data from chest radi- have existed for 2 decades [40]. Severity of illness scores built
ography, pulse oximetry, or laboratory studies are used variably upon multiple logistic regression models, such as the Pediatric

by practitioners to support medical decision making. For these Risk of Mortality score and the Pediatric Index of Mortality
guidelines, we define ‘‘simple pneumonia’’ as either broncho- predict the risk of death for children in ICU settings. These may
pneumonia (primary involvement of airways and surrounding facilitate outcome prediction in the ICU but do not reliably help
interstitium), or lobar pneumonia involving a single lobe. the clinician to discriminate severity of illness in the less acutely
‘‘Complicated pneumonia’’ is defined as a pulmonary paren- ill child, thereby limiting utility in level-of-care decision making
chymal infection complicated by parapneumonic effusions, [41–44].
multilobar disease, abscesses or cavities, necrotizing pneumonia, More directly relevant to evaluating severity of disease in CAP
empyema, pneumothorax or bronchopleural fistula; or pneu- is the simple measurement of oxygenation by pulse oximetry.
monia that is a complication of bacteremic disease that includes Hypoxemia is well established as a risk factor for poor outcome
other sites of infection. in children and infants with any type of disease, especially re-
For resource-poor regions of the world, the World Health spiratory diseases. The use of pulse oximetry to detect hypox-
Organization (WHO) defines pneumonia primarily as cough or emia has confirmed this relationship such that guidelines and
difficult breathing and age-adjusted tachypnea: (age 2–11 months, clinical decision rules usually recommend pulse oximetry in any
$50/min; 1–5 years, $40/min; $5 years, .20 breaths/min) patient with pneumonia. In the developing world, for pediatric
[5]. Furthermore, severe pneumonia is defined as ‘‘cough or patients with nonsevere pneumonia (as defined by WHO),
difficulty breathing plus one of the following: lower chest in- a pulse oximetric SpO2 measurement of ,90% at the initial visit
drawing, nasal flaring, or grunting.’’ Very severe pneumonia is has been documented to be predictive of failure of outpatient
defined as ‘‘cough or difficulty breathing plus one of the fol- oral amoxicillin treatment [45]. In adults, hypoxemia is an in-
lowing: cyanosis, severe respiratory distress, inability to drink dicator for respiratory failure requiring ICU admission in pa-
or vomiting everything, or lethargy/unconsciousness/con- tients with pneumonia [46, 47] and has also been independently
vulsions.’’ Such definitions of various levels of severity and associated with short-term mortality [32, 48]. Widespread
studies to validate interventions for each level of severity are not agreement exists that admission is indicated in a previously
well characterized for children living in resource-rich areas of healthy child with CAP and an oxygen saturation in room air
the world. (at sea level) of ,90%, although some would hospitalize chil-
At the more severe end of the spectrum of clinical pre- dren who have oxygen saturations as high as 93% [49]. At higher
sentation, most experts and professional societies recommend altitudes, lower oxygen saturations may be more appropriate to
that any child or infant with respiratory distress (Table 3) should define respiratory failure, as demonstrated in Bolivia [50].
be admitted to the hospital for management [28–31]. Com- Clinical surrogates exist for adequate oxygenation, or, con-
parative studies from the developed world, evaluating the out- versely, for hypoxemia and severe pneumonia. The child or
comes of children with various degrees of respiratory distress infant’s overall general assessment and ability to be consoled
who are managed as outpatients compared with those managed usually denote normal oxygenation [51]. ‘‘A moderate or severe
as inpatients, have not been published. A ‘‘toxic appearance,’’ alteration of general status’’ was an independent risk factor for
which is not well defined but is represented by the components death in children hospitalized in the developing world with an
provided in Table 3, is universally accepted as an indication for acute LRTI [52]. Although cyanosis may sometimes be difficult
admission to the hospital [28, 29]. to detect, its presence denotes severe hypoxemia [52]. A sys-
In the past few decades, many consensus guidelines and tematic review of published studies, primarily in the developing
clinical decision rules have been proposed for adults with CAP world, found that central cyanosis had a higher specificity for
[27, 32–38]. There are multiple adult studies that describe predicting hypoxemia in children than other signs [53].

Tachypnea is a nonspecific clinical sign, but may represent genetic syndromes, and neurocognitive disorders [17]. Tan and
a marker for respiratory distress and/or hypoxemia. ‘‘Rapid colleagues from 8 pediatric tertiary care centers found that 36%
breathing as perceived by the mother’’ was statistically associated of children hospitalized for pneumococcal pneumonia had un-
with hypoxemia in a study of children with pneumonia [50]. An derlying comorbid conditions that also included immunologic
increase in the age-specific respiratory rate or tachypnea has disorders and hematologic, cardiac, and chronic pulmonary
been linked to treatment failure in children with severe pneu- conditions [62]. Children with a comorbid condition and in-
monia in the developing world [54]. Although tachypnea in fluenza infection are more likely to require hospitalization than
infants with pneumonia may correlate with presence of hyp- otherwise healthy children [23, 63, 64]. Although children who
oxemia, tachypnea may also be caused by fever, dehydration, or have chronic conditions may be at greater risk of pneumonia,
a concurrent metabolic acidosis [55]. In a study from a pediatric these conditions are extremely diverse, so specific management
emergency department in Boston of children ,5 years old un- issues for comorbid conditions will not be addressed in these
dergoing chest radiography for possible pneumonia, the re- guidelines [65, 66].
spiratory rates for those with documented pneumonia did not Young age is an additional risk factor for severity of pneu-

differ significantly from those for children without pneumonia. monia and need for hospitalization. The incidence of pneu-
However, of children with WHO-defined tachypnea, 20% had monia and risk of severe pneumonia are greater in infants and
confirmed pneumonia, compared with 12% without tachypnea young children. The attack rates are 35–40 per 1000 infants
[56]. (age, ,12 months), 30–35 per 1000 preschool-aged children
Retractions and grunting have also been found to be in- (2–5 years), 15 per 1000 school-aged children (5–9 years), and
dicators of increased severity of LRTIs in children hospitalized in 6–12 per 1000 children .9 years old [67]. Furthermore, infants
Argentina [57]. Retractions, whether intercostal, suprasternal or and young children tend to have more severe pneumonia with
subcostal indicate a greater severity of pneumonia [29]. Nasal a greater need for hospitalization and a higher risk of respiratory
flaring and ‘‘head bobbing’’ have also been statistically associ- failure. One independent risk factor for death in children hos-
ated with hypoxemia [50]. pitalized for acute respiratory tract infections in the Central
Dehydration, vomiting, or inability to take oral medication African Republic was age between 2 and 11 months [52].
are additional considerations for hospitalization. Children in However, malnutrition may also contribute to severity of disease
whom oral outpatient antimicrobial therapy has been attempted in the developing world, tempering conclusions about mortality
unsuccessfully and who demonstrate new and progressive re- in this age group from respiratory tract disease alone [68].
spiratory distress (Table 3) will most often require hospitaliza- A clinical tool designed to predict which child with severe
tion. Furthermore, those with psychosocial concerns, such as pneumonia would have failure of oral antimicrobial therapy in
noncompliance with therapy or lack of reliable follow-up for any the developing world found that the age of the child was one of
reason, may warrant admission [28, 29, 31]. Studies from both the most important clinical predictors (highly significant for
the United States [58] and Canada [59] found that children and those ,6 months of age) [54]. In the developed world, pro-
infants with pneumonia were more likely to be hospitalized if spectively collected data have not been published documenting
they were of lower socioeconomic status. This may be attributed, a cutoff age below which hospitalization is necessary for im-
in part, to nonmedical issues, including inaccessibility to ade- proved outcomes. In the United States, very young infants (up
quate outpatient services. to 3 months of age) with CAP are generally admitted to the
Children with pneumonia caused by CA-MRSA, as described hospital for initial management. Given the increased risk of
in case series, have a high incidence of necrotizing pneumonia morbidity, the admission of infants up to 6 months of age with
and frequently require ICU admission [60, 61]. In a retrospec- suspected bacterial CAP is also prudent [29, 69].
tive study of both adults and children with Panton-Valentine
leukocidin–positive S. aureus CAP, 78% required mechanical II. When Should a Child with CAP Be Admitted to an Intensive
ventilation [43]. If there is high suspicion for or documentation Care Unit (ICU) or a Unit With Continuous Cardiorespiratory
of CA-MRSA as a causative organism, the clinician should Monitoring?
hospitalize the child for treatment with parenteral antimicrobial Recommendations
therapy and close observation, even if the respiratory symptoms 5. A child should be admitted to an ICU if the child requires
are not severe at the time of initial evaluation. invasive ventilation via a nonpermanent artificial airway (eg,
The presence of significant comorbid conditions is also a risk endotracheal tube). (strong recommendation; high-quality
factor for the development of pneumonia; the presence of evidence)
pneumonia often results in a worsening of the underlying 6. A child should be admitted to an ICU or a unit with
condition. In Dallas, Texas, 20% of children admitted with CAP continuous cardiorespiratory monitoring capabilities if the
had comorbid conditions, including reactive airway disease, child acutely requires use of noninvasive positive pressure

ventilation (eg, continuous positive airway pressure or bilevel and potential respiratory insufficiency include increased work of
positive airway pressure). (strong recommendation; very low- breathing (as evidenced by retractions [suprasternal, subcostal,
quality evidence) or intercostals]), nasal flaring, and use of accessory muscles),
7. A child should be admitted to an ICU or a unit with recurrent apnea, or grunting. Grunting, when present, is a sign
continuous cardiorespiratory monitoring capabilities if the child of severe disease and impending respiratory failure [71]. Oxygen
has impending respiratory failure. (strong recommendation; saturation by pulse oximetry is usually monitored continuously
moderate-quality evidence) for a child with increased work of breathing or significant dis-
8. A child should be admitted to an ICU or a unit with tress, particularly if he or she has a decreased level of activity or
continuous cardiorespiratory monitoring capabilities if the agitation [51].
child has sustained tachycardia, inadequate blood pressure, or The child’s overall clinical appearance and behavior may
need for pharmacologic support of blood pressure or perfusion. predict as much about the severity of illness as any score avail-
(strong recommendation; moderate-quality evidence) able. The exclusive use of severity of illness scores at hospital
9. A child should be admitted to an ICU if the pulse admission does not reliably provide the clinician with enough

oximetry measurement is #92% with inspired oxygen of data to determine the need for ICU-level care.
$0.50. (strong recommendation; low-quality evidence) The arterial oxygen pressure PaO2/FiO2 ratio provides an
10. A child should be admitted to an ICU or a unit with indication of the degree of respiratory insufficiency and im-
continuous cardiorespiratory monitoring capabilities if the child paired oxygen diffusion and, in conjunction with clinical ex-
has altered mental status, whether due to hypercarbia or due to amination, will enhance the determination of illness severity.
hypoxemia as a result of pneumonia. (strong recommendation; This test requires an arterial blood gas determination of the
low-quality evidence) PaO2, so its use is warranted only in evaluation of severe CAP
11. Severity of illness scores should not be used as the sole with interpretation of the PaO2/FiO2 ratio by a physician
criterion for ICU admission but should be used in the context experienced in treating children with respiratory failure.
of other clinical, laboratory, and radiologic findings. (strong The severity of pneumonia and need for ICU admission may
recommendation; low-quality evidence) be defined in part by the etiology. In a retrospective review of
Evidence Summary children admitted to a pediatric tertiary care center with invasive
When a child requires hospitalization for CAP, the clinician pneumococcal infection, those with concurrently positive viral
needs to consider the capabilities of the accepting facility or unit. studies (influenza, rhinovirus, adenovirus, RSV), were admitted
Variations in the level of monitoring and in the skills of the to pediatric ICU more frequently and found to have longer
bedside providers (nurse, respiratory therapist, and physician) pediatric ICU stays [72]. In 2 retrospective case series of pedi-
will influence the decision on where to effectively monitor and atric patients, CA-MRSA pneumonia has been shown to have
treat the ill child. Appropriate placement of the ill child with a high incidence of necrotizing pneumonia, a need for ICU care,
increased work of breathing, tachypnea, or hypoxemia optimizes and high associated mortality [60, 61].
the use of ICU and general care area resources. Consultation
with a specialist in pediatric critical care medicine is recom-
mended if there is any concern regarding appropriate patient DIAGNOSTIC TESTING FOR PEDIATRIC CAP
placement based on severity of disease (Table 4). ICU-level care is
not typically required for children with CAP. However, in a study III. What Diagnostic Laboratory and Imaging Tests Should Be
from Dallas, Texas, 6.5% of children hospitalized with CAP re- Used in a Child With Suspected CAP in an Outpatient or
quired mechanical ventilation [17], and 1.3% of children with Inpatient Setting?
CAP died, although almost one-third had comorbid conditions. Recommendations
A greater proportion of those with mixed bacterial and viral Microbiologic Testing
infections required mechanical ventilation (8.3%); mortality was Blood Cultures: Outpatient
5.6% in this subgroup of children hospitalized with CAP [17]. 12. Blood cultures should not be routinely performed in
Hypoxemia is present in many children with CAP, and in nontoxic, fully immunized children with CAP managed in the
many cases low-flow supplemental oxygen provided by nasal outpatient setting. (strong recommendation; moderate-quality
cannula or face mask will suffice to restore oxygenation satu- evidence)
ration for management on a hospital ward. Children requiring 13. Blood cultures should be obtained in children who fail to
a fraction of inspired oxygen (FiO2) of $0.50 to maintain sat- demonstrate clinical improvement and in those who have
uration .92% should be cared for in a unit capable of contin- progressive symptoms or clinical deterioration after initiation
uous cardiorespiratory monitoring and rapid response should of antibiotic therapy (strong recommendation; moderate-quality
the clinical situation worsen. Other signs of respiratory distress evidence).

Blood Cultures: Inpatient or radiographic findings that suggest bacterial coinfection.
(weak recommendation; low-quality evidence)
14. Blood cultures should be obtained in children requiring
hospitalization for presumed bacterial CAP that is moderate to Testing for Atypical Bacteria
severe, particularly those with complicated pneumonia. (strong
23. Children with signs and symptoms suspicious for
recommendation, low-quality evidence)
M. pneumoniae should be tested to help guide antibiotic
15. In improving patients who otherwise meet criteria for
selection. (weak recommendation; moderate-quality evidence)
discharge, a positive blood culture with identification or
24. Diagnostic testing for C. pneumoniae is not recommended
susceptibility results pending should not routinely preclude
as reliable, and readily available diagnostic tests do not currently
discharge of that patient with appropriate oral or intravenous
exist. (strong recommendation; high-quality evidence)
antimicrobial therapy. The patient can be discharged if close
follow-up is assured. (weak recommendation; low-quality Ancillary Diagnostic Testing
evidence) Complete Blood Cell Count

Follow-up Blood Cultures 25. Routine measurement of the complete blood cell count is
16. Repeat blood cultures in children with clear clinical not necessary in all children with suspected CAP managed in the
improvement are not necessary to document resolution of outpatient setting, but for those with more serious disease it may
pneumococcal bacteremia. (weak recommendation; low-quality provide useful information for clinical management in the
evidence) context of the clinical examination and other laboratory and
17. Repeat blood cultures to document resolution of imaging studies. (weak recommendation; low-quality evidence)
bacteremia should be performed in children with bacteremia 26. A complete blood cell count should be obtained for
caused by S. aureus, regardless of clinical status. (strong patients with severe pneumonia, to be interpreted in the context
recommendation; low-quality evidence) of the clinical examination and other laboratory and imaging
studies. (weak recommendation; low-quality evidence)
Sputum Gram Stain and Culture
18. Sputum samples for culture and Gram stain should be Acute-Phase Reactants
obtained in hospitalized children who can produce sputum. 27. Acute-phase reactants such as the ESR, CRP, or serum
(weak recommendation; low-quality evidence) procalcitonin cannot be used as the sole determinant to
Urinary Antigen Detection Tests distinguish between viral and bacterial causes of CAP. (strong
19. Urinary antigen detection tests are not recommended 28. Acute-phase reactants need not be routinely measured in
for the diagnosis of pneumococcal pneumonia in children; fully immunized children with CAP who are managed as
false-positive results are common. (strong recommendation; outpatients, although for more serious disease, they may
high-quality evidence) provide useful information for clinical management. (strong
Testing For Viral Pathogens 29. In patients with more serious disease, such as those
20. Sensitive and specific tests for the rapid diagnosis of requiring hospitalization or those with pneumonia-associated
influenza virus and other respiratory viruses should be used in complications, acute-phase reactants may be used in
the evaluation of children with CAP. A positive influenza test conjunction with clinical findings to assess response to
result may both decrease the need for additional diagnostic therapy. (weak recommendation; low-quality evidence)
studies and decrease antibiotic use, while guiding appropriate
Pulse Oximetry
use of antiviral agents in both outpatient and inpatient settings.
(strong recommendation; high-quality evidence) 30. Pulse oximetry should be performed in all children with
21. Antibacterial therapy is not necessary for children, either pneumonia and suspected hypoxemia. The presence of hypoxia
outpatients, or inpatients, with a positive test result for should guide decisions regarding site of care and further
influenza virus in the absence of clinical, laboratory, or diagnostic testing. (strong recommendation; moderate-quality
radiographic findings that suggest bacterial coinfection. evidence)
Chest Radiography
22. Testing for respiratory viruses other than influenza virus
Initial Chest Radiographs: Outpatient
can modify clinical decision making in children with suspected
pneumonia, because antibacterial therapy will not routinely be 31. Routine chest radiographs are not necessary for the
required for these children in the absence of clinical, laboratory, confirmation of suspected CAP in patients well enough to be

treated in the outpatient setting (after evaluation in the hospitalized, potentially shorter inpatient stays. Unfortunately,
office, clinic, or emergency department setting). (strong in the diagnosis of CAP, particularly bacterial CAP, there are no
recommendation; high-quality evidence) single diagnostic tests that can be considered the reference
32. Chest radiographs, posteroanterior and lateral, should be standard [73].
performed in patients with suspected or documented Microbiologic Testing
hypoxemia or significant respiratory distress (Table 3) and in Microbiologic testing, when recommended, is intended to iden-
patients with failed initial antibiotic therapy to verify the tify a pathogen so that narrow-spectrum antimicrobial therapy
presence or absence of complications of pneumonia, including directed at a specific bacterium or virus can be initiated. The
parapneumonic effusions, necrotizing pneumonia, and narrowest treatment possible is considered ideal, because it will
pneumothorax. (strong recommendation; moderate-quality most often lead to less antimicrobial pressure for the selection of
evidence) resistance, fewer adverse drug reactions, and reduced costs.
Initial Chest Radiographs: Inpatient Blood Cultures: Outpatient
Blood cultures, when positive, provide documentation of the

33. Chest radiographs (posteroanterior and lateral) should be causative agent and important epidemiologic data; however,
obtained in all patients hospitalized for management of CAP to most blood cultures obtained from fully immunized children
document the presence, size, and character of parenchymal with nonsevere pneumonia are sterile. Furthermore, cultures of
infiltrates and identify complications of pneumonia that may blood fail to detect many important causes of childhood CAP,
lead to interventions beyond antimicrobial agents and supportive including M. pneumoniae and all viral pathogens. Therefore,
medical therapy. (strong recommendation; moderate-quality blood cultures help define the etiology in only a small pro-
evidence) portion of children with CAP who are treated as outpatients.
Follow-up Chest Radiographs Most current studies of blood cultures in the outpatient
evaluation of children with CAP were conducted after licensure
34. Repeat chest radiographs are not routinely required in
of the H. influenzae type b conjugate vaccine and before licen-
children who recover uneventfully from an episode of CAP.
sure of PCV7. In these studies, blood cultures were positive for
pathogenic bacteria in ,2% of patients with pneumonia who
35. A repeated chest radiograph should be obtained
were well enough to be managed in the outpatient setting
in children who fail to demonstrate clinical improvement and
[74–78]. In a randomized trial of PCV7, blood cultures were
in those who have progressive symptoms or clinical
positive in ,1% of vaccine recipients who developed pneu-
deterioration within 48–72 hours after initiation of antibiotic
monia [79]. The rate of detection of ‘‘true-positive’’ cases of
therapy. (strong recommendation; moderate-quality evidence)
bacteremia in children with CAP managed in the outpatient
36. Routine daily chest radiography is not recommended in
setting is lower than the rate of ‘‘false-positive’’ blood cultures
children with pneumonia complicated by parapneumonic
reported in studies of childhood CAP (1.0%–8.2%) [74, 77, 80]
effusion after chest tube placement or after VATS, if they
and in studies evaluating the role of blood cultures in the
remain clinically stable. (strong recommendation; low-quality
emergency department evaluation of young children with fever
evidence)
(1.2%–2.8%) [81–84]. It is not known to what extent this re-
37. Follow-up chest radiographs should be obtained in
lationship is attributable to the effect of preculture antibiotics,
patients with complicated pneumonia with worsening
inadequate blood culture technique, insufficient blood volume
respiratory distress or clinical instability or in those with
for culture, or some combination of these factors [85–87]. Blood
persistent fever that is not responding to therapy over 48–72
volumes sampled for bacterial culture in infants and children are
hours. (strong recommendation; low-quality evidence)
less than those in adults. Most published series used FDA-
38. Repeated chest radiographs 4–6 weeks after the diagnosis
approved pediatric blood culture diagnostic tests, optimized for
of CAP should be obtained in patients with recurrent
2-3 ml of blood, but children were included in data analyses if
pneumonia involving the same lobe and in patients with lobar
blood volumes were as low as 0.5 ml [75, 80-82].
collapse on initial chest radiography with suspicion of an
Blood Cultures: Inpatient
anatomic anomaly, chest mass, or foreign body aspiration.
(strong recommendation; moderate-quality evidence) In contrast to evaluation for outpatients, blood cultures are
more frequently positive for pathogenic bacteria in children
Evidence Summary requiring hospitalization for CAP, with reported rates ranging
An accurate and rapid diagnosis of the pathogen responsible for from 1.4% to 3.4% in most studies [74, 78, 80, 88]. However,
CAP provides for informed decision making, resulting in investigators in Utah, using stringent criteria for bacterial
improved care with focused antimicrobial therapy, fewer CAP, reported that 11.4% of blood cultures were positive in
unnecessary tests and procedures, and, for those who are patients requiring hospitalization for CAP [89] with half of the

organisms identified as S. pneumoniae, serotype 1, a serotype not in adults, and therefore antigen detection is routinely used to
included in PCV7 but present in the 13-valent formulation diagnose pneumococcal pneumonia in adults [27]. In children,
(PVC13). Blood cultures were not routinely performed in urine antigen tests were positive in 47 of 62 (76%) with lobar
all children hospitalized with CAP in prior studies [74, 78, pneumonia [102]; however, because the etiology of pneumonia
88, 89]. It is likely that blood cultures were performed dispro- could not be confirmed, the relevance of this finding is not clear.
portionately in children with greater illness severity; thus, these Of even greater concern, positive results occurred in 15% of
prior studies may overestimate the true rate of bacteremia in febrile children without evidence of invasive pneumococcal
children hospitalized with uncomplicated CAP. Among patients disease; it was not clear whether these were false-positive results
with pneumonia complicated by parapneumonic effusion, rates attributable to pneumococcal nasopharyngeal colonization or
of bacteremia also vary, ranging from 13.0% to 26.5% [80, 89–93]. true-positive results in the context of early pulmonary disease
The prevalence of bacteremia was 7.8% (95% confidence interval, that did not produce characteristic radiographic findings or
2.2%–18.9%) among children with any pneumonia-associated whether they were associated with spontaneously resolved
complication, including sepsis and organ dysfunction [80]. pneumococcal infection [102]. Dowell et al found no significant

Despite the low overall yield of blood cultures in patients who difference in the proportion of positive pneumococcal urinary
require hospitalization, knowledge of the causative organism antigen results (35%) in children with pneumonia compared
provides information that allows the treating physician to target with children with dermatitis or diarrhea; however, a positive
antibiotic therapy to the causative agent. Culture-directed result was strongly associated with pneumococcal colonization
antimicrobial selection may be associated with improved clinical [103]. Other studies also suggest that positive results can be
outcomes in only a minority of pediatric cases, as has been attributed to nasopharyngeal colonization with S. pneumoniae in
shown in studies of adults with CAP [94–96]. In contrast to .15% of children [104, 105]. Positive results of pneumococcal
adults with CAP, in whom positive blood cultures infrequently urinary antigen tests do not reliably distinguish children with
affect clinical management [97], positive blood cultures did pneumococcal pneumonia from those who are merely colo-
result in narrowing or broadening of therapy in 5 of 6 patients nized. In the absence of a true reference standard, there is in-
with positive cultures, among 291 children from whom blood sufficient information on the negative predictive value of this
cultures were obtained [80]. However, the overall impact of test to recommend its use for excluding pneumococcal disease.
blood cultures on clinical management may be small because of Testing For Viral Pathogens
the low prevalence of bacteremia. In addition, it is worth noting There is substantial evidence that the risk of serious bacterial
that epidemiologic data derived from blood culture results have infection is low in children with laboratory-confirmed viral in-
been essential in creating an evidence-based pneumococcal fection [106–112]. However, the diffuse lower respiratory tract
vaccination policy in the United States [98, 99]. inflammation induced by viral respiratory tract infections pre-
When blood cultures are positive because of contaminant disposes to bacterial superinfection, making it difficult to ex-
nonpathogenic bacteria (ie, false-positive cultures), results may clude concurrent bacterial pneumonia with certainty in children
lead to unnecessary broadening of antibiotic therapy. It may be with laboratory-confirmed viral infections. Viral and bacterial
difficult to determine whether broader therapy contributed to coinfections were detected in 23% of children with pneumonia
a patient’s clinical improvement or led to a prolonged, in- evaluated at a tertiary-care children’s hospital [17].
appropriate treatment course. The cost-effectiveness of obtaining Randomized clinical trials [106, 107] and prospective studies
blood cultures in all children hospitalized with CAP is not known. [108–110] of rapid influenza testing demonstrate significant
Sputum Gram Stain and Culture reductions in ancillary testing and antibiotic use among children
Gram stain and culture of expectorated sputum are recom- evaluated in the emergency department during influenza season.
mended for adults hospitalized with CAP [27]. These tests are Bonner et al enrolled 391 patients (aged 2 months to 21 years)
infrequently performed in children with CAP, because children with fever and influenzalike illness [106]. Rapid influenza tests
cannot always provide adequate specimens for testing. Gram stain were performed on nasopharyngeal specimens for all patients,
and culture of expectorated sputum should be attempted in older with 52% positive for influenza. Patients were then randomized
children and adolescents with more severe disease, including in- so that the treating physician was either provided or not pro-
patients, or in those in whom outpatient therapy has failed. Better vided with the results of influenza testing. Antibiotics were
diagnostic tests are needed, particularly for children with non- prescribed to 7.3% of patients for whom the physician was aware
severe pneumonia, in whom the benefits of aggressive, invasive of a positive influenza test result, compared with 24.5% of pa-
diagnostic procedures may not be worth the risk to the child. tients for whom the physician was not aware of the results.
Urinary Antigen Detection Tests Similar reductions were noted in the performance of chest ra-
Urinary antigen tests for the detection of S. pneumoniae diography and other ancillary tests. No patient had lobar
correlate well with sputum culture for S. pneumoniae [100, 101] pneumonia [106]. Esposito et al [107] randomized 957 children

who presented to their clinic with influenzalike illness to rapid for diagnosis. Because early influenza antiviral therapy provides
influenza testing or no testing, with 43 (8.9%) children testing the greatest benefit to the child, a clinician should not wait to
positive. Antibiotics were prescribed to 32.6% of influenza- start empiric antiviral therapy until after obtaining respiratory
positive compared with 64.8% of influenza-negative patients; of tract samples for diagnosis [115, 116].
those who were randomized to no testing, 61.8% were given Some children with viral LRTI may also have an associated
antibiotics. No significant difference was noted in the perfor- bacterial LRTI. In a study of 23 seriously ill, ventilated infants
mance of chest radiographs between groups. In a retrospective with documented RSV CAP, Levin et al found that 39% had
cohort study of hospitalized adults with laboratory-confirmed specimens suggestive of concomitant bacterial infection based
influenza infection, a positive rapid influenza test result was on tracheal aspirate cultures. They concluded from their pa-
associated with 6-fold higher odds to discontinue or withhold tients and a literature review that evidence of bacterial pneu-
antibiotic therapy compared with influenza-positive patients monia in otherwise low-risk infants with RSV presenting with
whose diagnosis was delayed because positive PCR results were respiratory failure is present in $20%, and the use of empiric
not readily available [112]. antibiotics for 24–48 hours pending culture results may be

Doan et al conducted an open-label randomized controlled justified until concomitant bacterial infection is excluded
trial in which children 3–36 months of age were randomized to [117]. However, for infants who do not have respiratory failure
receive a multiviral rapid diagnostic test by direct immuno- or any other findings that suggest bacterial coinfection, care
fluorescence assay (IFA) (n 5 90) or routine care (n 5 110) process models have the potential to decrease inappropriate
[111]. At least one virus was detected in 66% of patients ran- antibiotic use when they discourage such use in children who
domized to viral testing. Differences in antibiotic prescribing or are documented to have a positive rapid test for a respiratory
in the performance of chest radiography or other ancillary tests virus.
between virus-positive and virus-negative or untested patients Testing for Atypical Bacteria
were not statistically significant. However, patients undergoing The precise role of testing and treating for M. pneumoniae LRTI
viral testing were less likely to receive antibiotics when sub- in children is not well defined, because high-quality data on the
sequently seeing their primary care physician for the same illness natural history of disease and impact of treatment are not
within 1 week of discharge from the emergency department. In available. For younger children in particular, decisions regarding
a retrospective review, Byington and colleagues documented testing are made more difficult by uncertainty regarding the
a significant decrease in antibiotic prescribing, with respect to extent to which treatment of confirmed M. pneumoniae
inpatient intravenous therapy and oral antibiotic therapy at infections improves clinical outcomes in this population (see
discharge, for hospitalized children who tested positive for RSV, Evidence Summary for Recommendation 44). For treatment of
parainfluenza 1, 2, 3, or adenovirus, compared with those who CAP in children, it is important to minimize unnecessary pre-
tested negative [113]. scribing of macrolide therapy, which may be inadequate for
Although positive tests for viral pathogens are helpful, the treatment of S. pneumoniae, while offering the best care for
sensitivity and specificity of rapid viral tests are not 100%, and children with CAP caused by M. pneumoniae. Testing for
false-negative and false-positive tests occur. For influenza, the M. pneumoniae may be most useful when the pretest probability
sensitivity of each type of test varies by both method and sam- for M. pneumoniae infection is intermediate or high. The age at
pling technique, and for the rapid tests, may also vary by the which one should begin to strongly consider M. pneumoniae as the
strains of influenza circulating in any given year. For example, cause of CAP is not well defined. M. pneumoniae is increasingly
the sensitivity of rapid influenza tests during 2009 pandemic being diagnosed serologically as a cause of LRTI in young children
H1N1 was poor compared with the performance of tests for [15, 17, 18, 118–122]. Testing may not be necessary in children
seasonal influenza [114]. For children with influenzalike illness with a low likelihood of M. pneumoniae infection (eg, younger
in a community with documented influenza virus circulation, children with symptoms more compatible with a primary viral
a negative rapid influenza virus test in a child with CAP and upper respiratory tract infection), in whom the positive predictive
symptoms compatible with influenza may reflect inaccuracies of value of a positive test may only be modest (ie, false-positive
the test, rather than reliably excluding influenza virus as a path- results will occur). Testing may be most useful in guiding deci-
ogen. For children with influenza, particularly those who require sions regarding empiric antibiotic therapy in school-aged children
mechanical ventilation, initial results of nasopharyngeal testing and adolescents who have findings consistent with but not classic
for influenza may be negative, even with reverse-transcriptase for M. pneumoniae infection. In these situations, a positive test
PCR techniques, because of many factors, including poor-quality result for M. pneumoniae may warrant treatment, whereas a neg-
specimens, sampling of the upper rather than lower respiratory ative result makes the diagnosis of M. pneumoniae pneumonia
tract, and prolonged duration from illness onset to specimen unlikely. Epidemiologic aspects of M. pneumoniae infection and
collection. Multiple specimens on multiple days may be required commonly available tests are summarized below.

A variety of tests exist for detection of M. pneumoniae in- children [127]. Direct comparison of studies using PCR is dif-
fections, including culture, cold agglutinating antibodies, se- ficult because specimens were obtained from different sites (eg,
rology, and molecular-based methods such as PCR assays, each nasal wash, nasopharyngeal swab, throat, sputum) using dif-
with different performance characteristics (sensitivity, specific- ferent primer sets and amplification techniques [128–132], but
ity, positive and negative predictive values). The complex nu- PCR-based testing is neither readily available nor practical in
tritional requirements and slow growth of M. pneumoniae on office, emergency department, or community hospital settings
culture media make its identification impractical for most lab- using currently available test systems. In summary, we believe
oratories; additionally, results from culture for M. pneumoniae that testing for Mycoplasma infection is important to optimize
are not available in a clinically relevant time frame. The presence use of macrolides in children. However, no single currently
of cold-reacting antibodies against red blood cells in the serum of available test offers the sensitivity and specificity desired in
patients with primary atypical pneumonia is well known [123]. a clinically relevant time frame. Therefore, the clinician should
Cold agglutinin titers .1:64 are present at the time of acute be knowledgeable regarding the performance characteristics of
illness in 75% of adults with pneumonia due to M. pneumoniae. the tests offered by local laboratories.

Because the test is less well studied in children, its accuracy in None of the many diagnostic assays used worldwide to
detecting respiratory infection due to M. pneumoniae is not identify C. pneumoniae has received approval by the US Food
known. The specificity of a titer ,1:64 is low because a variety of and Drug Administration for clinical use. Recommendations for
other respiratory tract pathogens provoke modest increases in standardized approaches to culture, PCR testing, serology, and
cold agglutinins. Performance of the cold agglutinin test at the immunohistochemistry were published in 2001 by the CDC and
bedside lacks the rigorous standards of high sensitivity and the Canadian Laboratory Centres for Disease Control (LCDC)
specificity and reproducibility currently expected of medical [133]. Serology has been the primary means of clinical di-
diagnostics and is not recommended in any setting. agnostic testing for C. pneumoniae because of its widespread
Serologic methods include complement fixation, enzyme- availability and relative simplicity. However, many of the
linked immunosorbent assays (ELISAs), and rapid enzyme im- available assays, including complement fixation, whole inclusion
munoassay cards. Enzyme assays are less time consuming and fluorescence, and various enzyme immunoassays, perform
have thus largely replaced complement fixation tests in the poorly or have not been adequately validated; micro-
laboratory setting for detection of immunoglobulin (Ig) M. immunofluorescence testing remains the only endorsed ap-
Rapid serologic tests typically have results available within proach [133]. During primary infection, IgM antibody appears
10 min. The ImmunoCard rapid IgM test (Meridian Bioscience) 2–3 weeks after illness onset. IgG antibody may not reach a di-
has been compared with other serology tests but not with PCR. agnostically high titer until 6–8 weeks after the onset of illness.
Alexander et al studied 896 specimens submitted to clinical Therefore, confirmation of primary acute infection requires
laboratories for M. pneumoniae serologic testing. When com- documenting an IgM titer of 1:16 or greater or a 4-fold rise in
pared with 2 M. pneumoniae IgM-specific assays (IFA and IgG titer between acute and convalescent serum specimens. In
ELISA) and a standard complement fixation procedure, the case of reinfection, IgM antibody may not appear, and the level
ImmunoCard had sensitivities ranging from 74% (compared of IgG antibody titer may rise quickly within 1–2 weeks of in-
with ELISA) to 96% (compared with complement fixation), fection [133]. IgG titers of 1:16 or greater are consistent with
with inconsistent results resolved using IFA as the reference previous exposure and are seen in approximately half of adults.
standard [124]. ImmunoCard specificities ranged from 85% Therefore, a single elevated IgG titer does not confirm the di-
(compared with IgM-specific ELISA) to 98% (compared with agnosis of C. pneumoniae infection. The organism or its DNA
IgM-specific IFA), with inconsistencies resolved using medical can be directly identified by means of culture or PCR testing in
record review [124]. Results were similar in a subsequent study specimens from nasopharyngeal or throat swabs, sputum, blood,
of 145 children referred for M. pneumoniae testing [125]. or tissue. Few published PCR assays met the validation criteria
However, the specificity of IgM detection described during an proposed by the CDC and LCDC [133]. In summary, no widely
outbreak of M. pneumoniae pneumonia was only 43% for available and timely test exists for the diagnosis of C. pneumoniae
children 10–18 years of age and 82% for those $19 years of age, infection.
compared with a case definition reference standard for diagnosis Ancillary Diagnostic Testing
[126]. A combined IgG-IgM assay (Remel; Thermo Fisher Sci- Complete Blood Cell Count
entific) assessed during this outbreak had a higher specificity in Results of a complete blood cell count with WBC differential
children 10–18 years of age (74%) but a lower sensitivity (52%) may influence therapy in ill children. In addition to evaluation
compared with IgM detection (89%) [126]. An IgM assay of WBCs, the presence of anemia or thrombocytopenia may
(Platelia IgM capture; Sanofi Diagnostics) appears to be as guide subsequent therapeutic interventions and raise concern
sensitive as PCR for detection of M. pneumoniae in CAP in for hemolytic-uremic syndrome, a rare complication of

pneumococcal pneumonia [134–137]. The specificity of the oxygenation. Evidence supporting the routine use of pulse
WBC count in making the diagnosis of bacterial pneumonia is oximetry measurements is discussed in the Evidence Summary
poor. Although the WBC count is elevated in many children for Recommendation 1.
with bacterial pneumonia, the degree of elevation does not re- Chest Radiography
liably distinguish bacterial from viral infection [138]. A radio- Initial Chest Radiographs
graphic infiltrate has been detected in some children who Chest radiographs cannot reliably distinguish viral from
present for medical care only with fever and leukocytosis in the bacterial CAP and do not reliably distinguish among the various
absence of clinical signs of LRTI; the relevance of this finding of possible bacterial pathogens. Therefore, chest radiographs do
‘‘occult’’ pneumonia is not clear [139–141]. Occult pneumonia not have a substantial impact on clinical outcomes [150–152]. In
is addressed in the Evidence Summary for Recommendation 31. addition, it may be impractical to obtain chest radiographs,
Acute-Phase Reactants especially in the office setting. Studies have documented that
Acute-phase reactants, including peripheral WBC count with chest radiographs performed in children with suspected acute
differential analysis, ESR, CRP, and procalcitonin do not reliably LRTI led to changes in the diagnosis or the use of antibiotics in

distinguish bacterial from viral infections when used as the sole 25% of children evaluated in a clinic or emergency department
diagnostic test. Korppi et al found that the WBC count, CRP, setting but rarely affected decisions regarding hospitalization
and ESR were significantly higher in children with pneumo- [153, 154]. Chest radiographs in these studies were least useful
coccal pneumonia than in those with viral or atypical pneu- when information from history and clinical examination were
monia [138]. However, the number of patients with consistent with the diagnosis of pneumonia, suggesting that
pneumococcal disease, diagnosed most often by serology, was chest radiographs are not necessary in outpatients in whom the
relatively small (n 5 29), there was considerable overlap in diagnosis of CAP is strongly suspected on the basis of clinical
values between the 2 groups, and the sensitivity and positive findings. In a study of the utility of chest radiographs, Alario and
predictive value for their specified WBC count criteria for colleagues studied 102 children between 1 month and 18 years of
pneumonia were low. The sensitivities for a CRP .6.0 mg/dL age with fever or respiratory symptoms for whom a resident
or an ESR .35 mm/h were 26% and 25%, respectively, ordered a chest radiograph in an outpatient setting [153]. Before
but increased when the 2 results were combined. The positive
the chest radiograph was obtained, clinical assessments were
predictive value for a CRP .6.0 mg/dL or an ESR .35 mm/h
performed, and management plans were recorded by an expe-
was 43% and 38%, respectively [138]. Other Finnish inves-
rienced attending physician. For the experienced physician, the
tigators found wide variation in WBC count, CRP, and
chest radiographs supported the diagnosis of pneumonia in 11
ESR values between children with CAP attributable to bacteria
of 12 patients (92%) with a preradiograph diagnosis of pneu-
and viruses; the values did not differ significantly between
monia [153]. The diagnosis of viral or bacterial pneumonia was
the 2 groups [142]. Procalcitonin, although promising as a sen-
made in an another 6 of 40 patients (15%) with a preradiograph
sitive marker of serious bacterial infection, has limited value in
diagnosis of ‘‘no LRTI’’ [153]. Data from a developing country
distinguishing nonserious bacterial from viral pneumonia
also suggest that the changes in management resulting from
in children because the values are widely distributed. Elevated
chest radiographs in the outpatient setting are not typically
procalcitonin concentrations in children with documented
viral infections raise the possibility that some children identified associated with improved clinical outcomes [151, 155].
as having viral pneumonia may actually have a viral-bacterial Radiographic infiltrates have been reported in 5%–19% of
coinfection [143–148]. However, low values may be helpful children with fever in the absence of tachypnea, hypoxemia,
in distinguishing viral pneumonia from bacterial pneumonia respiratory distress, or signs of LRTI; this phenomenon has been
associated with bacteremia [149]. Acute-phase reactants can referred to as ‘‘occult’’ pneumonia [139–141]. The proportion
also be measured at baseline for patients requiring of children ,5 years old who had occult pneumonia decreased
hospitalization. Declining values of CRP or procalcitonin may from 15% before to 9% after recommendation for universal
correlate with improvement in clinical symptoms and thus vaccination with PCV7 [141]. Clinical features associated with
have the potential to serve as objective measures of disease a higher likelihood of occult pneumonia included presence of
resolution. cough, fever for .5 days, fever .39°C, and leukocytosis (WBC
Pulse Oximetry count .20 000/lL) [140]. Outcome data in the absence of
Hypoxemia is well established as a risk factor for poor out- antibiotic therapy is not available for these patients, making the
come in children and infants with systemic disease, especially relevance of the occult pneumonia diagnosis uncertain. Chest
respiratory diseases. Criteria associated with hypoxemia include radiography, though not routinely required, should be per-
those provided in Table 3. Oxygen saturation measurements formed in patients with prolonged fever and cough even in the
provide a simple, reliable, noninvasive estimate of arterial absence of tachypnea or respiratory distress.

The rate of radiographically confirmed pneumonia among of atelectasis were the most commonly noted findings [169].
children with wheezing is low (4.9% overall), particularly in the Long-term follow-up 8–10 years later did not reveal any illnesses
absence of fever (2%) [156]. Among children with fever in the attributable to the initial episode of CAP [169]. In a prospective
context of wheezing, radiographic infiltrates were detected in study of adults hospitalized with severe CAP, chest radiographs
6.9% of those without hypoxemia and in 20.6% of those with were repeated 7 and 28 days after admission [173]. At day 7 and
hypoxemia (defined as percutaneous oxygen saturation ,92%) day 28, 75% and 47% of patients, respectively, still had abnormal
[156]. Therefore, chest radiography for the diagnosis of pneu- findings. Delayed resolution of radiographic abnormalities was
monia is not routinely recommended in patients with wheezing associated with multilobar disease, dullness to percussion at
in the absence of fever or hypoxemia. examination, higher CRP levels, and documented pneumococcal
Abdominal pain is occasionally the predominant presenting infection. However, delayed resolution of radiographic abnor-
complaint in children with CAP, especially for those ,5 years of malities did not portend failure of antimicrobial therapy or
age. Although routine chest radiographs are not necessary in a worse clinical outcome. In summary, routine follow-up chest
children with abdominal pain, they should be considered in radiographs do not provide additional clinical value but repre-

those with unexplained abdominal pain, especially in the context sent unnecessary radiation exposure to infants and children.
of tachypnea, cough, or fever [156, 157]. A subset of patients, such as those with lobar collapse or
The evaluation of chest radiographs is subjective. As a conse- recurrent pneumonia involving the same lobe, may benefit from
quence, there is variation even among experts regarding the repeat chest radiography. Pathology affecting a single region can
presence or absence of radiographic features used for diagnosis of be related to obstruction of the airway lumen to that region, to
CAP [158–163]. There is greater consensus regarding the pres- extrinsic compression of the airway, to intrinsic narrowing of
ence of alveolar consolidation compared with other radiographic the airway, or to an abnormality of the involved parenchyma,
features of pneumonia [159, 164, 165]. The WHO Vaccine Trial such as a chest mass, that may appear to represent pneumonia at
Investigators’ Radiology Working Group has proposed standards imaging [174]. A detailed discussion of recurrent pneumonia is
for interpretation of pediatric chest radiographs for the diagnosis beyond the scope of this document.
of pneumonia [166]. These standards include reporting of film
quality, classification of specific findings, and explicit statements
IV. What Additional Diagnostic Tests Should Be Used in a Child
regarding radiograph interpretation. High agreement in identi- With Severe or Life-Threatening CAP?
fying radiographically confirmed pneumonia was achieved using Recommendations
standardized definitions and training; the kappa index was .0.6
for 19 of 20 radiologists and clinicians in a review of 92 chest 39. The clinician should obtain tracheal aspirates for Gram
radiographs [166]. Identification of an infiltrate on chest radio- stain and culture, as well as clinically and epidemiologically
guided testing for viral pathogens, including influenza virus, at
graph by attending clinicians compared with radiologists does
the time of initial endotracheal tube placement in children
not consistently lead to meaningful differences in clinical
requiring mechanical ventilation. (strong recommendation; low-
management or outcomes [167]. Widespread adoption of stan-
quality evidence)
dard definitions may facilitate comparison of future studies of
40. Bronchoscopic or blind protected specimen brush
childhood pneumonia.
sampling, BAL, percutaneous lung aspiration, or open lung
Follow-up Chest Radiographs
biopsy should be reserved for the immunocompetent child with
Routine follow-up chest radiographs are not warranted in
severe CAP if initial diagnostic test results are not positive.
children who recover uneventfully from an episode of CAP.
(weak recommendation; low-quality evidence)
Radiologic abnormalities are known to lag behind clinical res-
olution. Follow-up chest radiographs obtained 3–6 weeks after Evidence Summary
initial imaging reveal persistent or residual abnormalities in The infectious etiologies of CAP are diverse. Multiple common
10%–30% of children with radiographically confirmed CAP pathogens present with a spectrum of clinical disease from mild
[168–172]. Persistent abnormalities are more likely in patients to life threatening. The clinician, when faced with a child with
with signs or symptoms of pneumonia at the time of follow-up severe manifestations of CAP, should weigh the benefit of di-
radiography (up to 50% in one study) [168]; however, these agnostic modalities targeted to identify specific pathogens with
abnormalities rarely alter clinical management. Few studies have the impact on management decisions. The goal of performing
systematically followed up children with radiographic abnor- diagnostic testing is to obtain evidence of the causative pathogen
malities for extended periods of time. Radiographs performed in order to avoid unnecessary use of antibiotics and to provide
3–7 weeks after an episode of radiographically confirmed CAP optimal, pathogen-directed care for the child.
revealed residual or new changes in 59 (30%) of 196 children; Tracheal aspirates are commonly obtained in the pediatric
persistence of interstitial infiltrates and the interval development ICU by suctioning a specimen from the endotracheal tube using

a standard suction catheter and specimen trap. Blind tracheal because it requires a larger bronchoscope, and thus a larger en-
aspirates may not adequately identify the pathogen of interest, dotracheal tube [180]. However, blind protected BAL, can pro-
because the catheter may collect organisms from sources other vide qualitative and quantitative cultures in children. Gauvin et al
than infected lung during the procurement process, merely re- reported that this technique in ventilated children was re-
flecting the organisms colonizing the endotracheal tube or tra- producible and easy to perform at the bedside, yet complications
chea. For children with influenza virus as the suspected etiology were frequent. The majority of complications were minor and
of CAP, rapid PCR testing of pulmonary secretions obtained transitory, though 2 significant adverse events were reported
through an endotracheal tube may yield positive results when (pneumothorax requiring a chest tube, and increased intracranial
nasopharyngeal test results are negative [175]. pressure) [181]. A similar technique, used in infants as young as
BAL can provide quantitative data, but in the pediatric pop- 7 days, involves blindly inserting a double-sheathed protected
ulation the procedure is more complex because of patients’ small specimen brush, to a point just beyond the endotracheal tube tip.
airways, particularly for neonates. Flexible bronchoscopes with The inner catheter is then extended 1 cm further and the pro-
the ability to obtain samples through a suction port can be used tective plug expelled, allowing the brush to be advanced another

for the child without intubation or the child with a preexisting 1-2 cm, and then retracted into the sheath and removed [182].
endotracheal tube , particularly with newer ultrathin broncho- Other techniques for obtaining definitive cultures include
scopes. In general, flexible fiberoptic bronchoscopy and BAL, percutaneous needle aspiration of the affected lung area. Vuori-
which is directed to an area of concern, is well tolerated in me- Holopainen in a study of Finnish children with CAP used non–
chanically ventilated children; the BAL procedure does not result CT-guided aspiration at the bedside of 34 patients. Analysis of the
in significant reductions in PaO2/FiO2 ratios, nor an increase in aspirated samples provided a definitive diagnosis in 20 (59%) of
adverse effects on blood pH or PaCO2 arterial carbon dioxide 34 patients, with a total of 21 bacteria and 2 viruses identified. In
pressure [176]. In Bar-Zohar and Sivan’s series, 25 ventilated the 26 patients from whom a return of fluid (adequate sample)
children had blind tracheal aspirates and subsequent BAL. was obtained, a pathogen was detected in 69%. Eighteen percent
The recovery of organisms by blind tracheal aspirate and BAL of the children had evidence of a pneumothorax on the post-
were not concordant. Blind tracheal aspirates before BAL were procedure radiograph, although none required chest tube place-
positive in 22 of 25 cases (88%), with negative BAL findings in 11 ment and all showed resolution with 3 days [183]. Imaging (CT
of these 22 aspirate-positive cases (50%). In only 4 patients (36%) or ultrasound)–guided percutaneous needle aspiration presents
were the organisms isolated identical from both techniques [176]. another option for direct culture of infected lung tissue [184].
These investigators found that 50% of children had antimicrobial Finally, for children with life-threatening CAP of unknown
treatment changed as a consequence of the culture results from etiology, an open or thoracoscopic lung biopsy can be a useful,
bronchoscopy. In a study of BAL in children with a variety of though high-risk, diagnostic procedure. A retrospective review
respiratory diagnoses, Tang and Chen found that a positive or of 31 children undergoing open lung biopsy demonstrated that
negative culture resulted in a treatment change in 23.4% of their in 76% the open lung biopsy led to a pertinent change in clinical
patients [177]. management and in 80% of cases, open lung biopsy provided an
In a prospective study of 88 hospitalized adults with CAP, infectious diagnosis, when a preceding BAL was inadequate. Of
routine sputum culture followed by bronchoscopy with a pro- note, open lung biopsy was associated with a 45% complication
tected specimen brush technique and then by BAL within the rate, thereby limiting its use to critical situations [185].
first 8 hours after admission revealed that BAL was the most
sensitive; 37.5% had a positive conventional sputum culture, ANTI-INFECTIVE TREATMENT
64.7% had a positive protected specimen brush culture, and
73.8% had a positive BAL culture [178]. The advantage of using V. Which Anti-Infective Therapy Should Be Provided to a Child
With Suspected CAP in Both Outpatient and Inpatient Settings?
invasive techniques (bronchoscopic protected specimen brush
Recommendations
and BAL, with quantitative microbiologic studies) was docu-
Outpatients
mented by Fagon et al in a prospective, randomized study in-
cluding 413 ventilated adults. They demonstrated decreased 41. Antimicrobial therapy is not routinely required for
usage of antibiotics and lower mortality rates as enhanced cul- preschool-aged children with CAP, because viral pathogens are
ture data from invasive techniques allowed for more pathogen- responsible for the great majority of clinical disease. (strong
specific therapy [179]. Invasive techniques can decrease the recommendation; high-quality evidence)
number of cases treated incorrectly because of tracheal coloni- 42. Amoxicillin should be used as first-line therapy for
zation, thus allowing a more judicious use of antimicrobials. previously healthy, appropriately immunized infants and
Standard protected specimen brush technique through preschool-aged children with mild to moderate CAP
a bronchoscope is not routinely used in ventilated children suspected to be of bacterial origin. Amoxicillin provides

appropriate coverage for S. pneumoniae, the most prominent be more effective than third-generation cephalosporins in the
invasive bacterial pathogen. Table 5 lists preferred agents and treatment of pneumococcal pneumonia for the degree of
alternative agents for children allergic to amoxicillin (strong resistance noted currently in North America. (weak
recommendation; moderate-quality evidence) recommendation; moderate-quality evidence)
43. Amoxicillin should be used as first-line therapy for 48. Empiric combination therapy with a macrolide (oral or
previously healthy, appropriately immunized school-aged parenteral), in addition to a b-lactam antibiotic, should be
children and adolescents with mild to moderate CAP for prescribed for the hospitalized child for whom M. pneumoniae
S. pneumoniae, the most prominent invasive bacterial pathogen. and C. pneumoniae are significant considerations; diagnostic
Atypical bacterial pathogens (eg, M. pneumoniae) and less testing should be performed if available in a clinically relevant
common lower respiratory tract bacterial pathogens, as discussed time frame (Table 7). (weak recommendation; moderate-quality
in the Evidence Summary, should also be considered in evidence)
management decisions. (strong recommendation; moderate- 49. Vancomycin or clindamycin (based on local susceptibility
quality evidence) data) should be provided in addition to b-lactam therapy if

44. Macrolide antibiotics should be prescribed for treatment clinical, laboratory, or imaging characteristics are consistent with
of children (primarily school-aged children and adolescents) infection caused by S. aureus (Table 7). (strong recommendation;
evaluated in an outpatient setting with findings compatible low-quality evidence)
with CAP caused by atypical pathogens. Laboratory testing for Evidence Summary
M. pneumoniae should be performed if available in a clinically Most preschool-aged children with pediatric CAP, when
relevant time frame. Table 5 lists preferred and alternative tested with sensitive PCR techniques for respiratory viruses
agents for atypical pathogens. (weak recommendation; (such as rhinovirus, RSV, human metapneumovirus, para-
moderate-quality evidence) influenza viruses, influenza A and B viruses, adenovirus,
45. Influenza antiviral therapy (Table 6) should be coronavirus, and human bocavirus), and bacteria (including
administered as soon as possible to children with moderate S. pneumoniae, H. influenzae, and M. pneumoniae) are found
to severe CAP consistent with influenza virus infection during to be positive for respiratory viruses more often than for
widespread local circulation of influenza viruses, particularly bacteria [20], although the sensitivity of molecular tests to
for those with clinically worsening disease documented at the diagnose viral pathogens currently exceeds that of conven-
time of an outpatient visit. Because early antiviral treatment has tional microbiologic tests for bacterial pathogens. In young
been shown to provide maximal benefit, treatment should not children with clinical characteristics compatible with upper
be delayed for confirmation of positive influenza test results. and lower respiratory tract viral infection, antibiotics are not
Negative influenza diagnostic tests, especially rapid antigen helpful, may cause drug toxicity, and will facilitate the
tests, do not conclusively exclude influenza disease. Treatment development of antimicrobial resistance.
after 48 hours of symptomatic infection may still provide Children with suspected bacterial CAP that is serious enough
clinical benefit to those with more severe disease. (strong to warrant hospitalization should routinely be treated with
recommendation; moderate-quality evidence) parenteral antibiotics to provide reliable blood and tissue con-
centrations (Table 7). If the pathogen has been identified from
Inpatients blood culture or culture of an appropriately collected respiratory
46. Ampicillin or penicillin G should be administered to the tract specimen, narrow-spectrum, safe, and effective therapy can
fully immunized infant or school-aged child admitted to be chosen. Before the widespread use of pneumococcal conju-
a hospital ward with CAP when local epidemiologic data gate vaccines, 1% of children with pneumococcal bacteremia
document lack of substantial high-level penicillin-resistance for were documented to also have bacterial meningitis. The clinician
invasive S. pneumoniae. Other antimicrobial agents for empiric should be aware that the dosages of most antimicrobials, in-
therapy are provided in Table 7. (strong recommendation; cluding all b-lactam agents, are greater for the child with
moderate-quality evidence) meningitis than for the child with pneumonia.
47. Empiric therapy with a third-generation parenteral Bacterial Pathogens in CAP
cephalosporin (ceftriaxone or cefotaxime) should be Empiric oral antimicrobial therapy for outpatients is designed to
prescribed for hospitalized infants and children who are not provide effective treatment for the bacterial pathogens most
fully immunized, in regions where local epidemiology likely to cause LRTI, with particular emphasis on S. pneumoniae,
of invasive pneumococcal strains documents high-level which is both the most common bacterial pathogen and one
penicillin resistance, or for infants and children with life- that, when untreated or treated inadequately, may lead to seri-
threatening infection, including empyema (Table 7). Non– ous sequelae [188]. Much less common lower respiratory tract
b-lactam agents such as vancomycin have not been shown to pathogens such as nontypeable strains of H. influenzae do not

routinely require empiric therapy. Of more concern are LRTIs with the same total daily dose divided into 2 equal doses [192].
caused by S. aureus (including CA-MRSA), for which inpatient However, for fully susceptible strains, a dosage of 90 mg/kg/day
management and initial parenteral therapy may minimize in 2 divided portions, as indicated for otitis media, is likely to be
morbidity and mortality rates. successful [193]. With the success of the 7-valent pneumococcal
Bacterial-viral coinfections have been well documented to vaccine in decreasing invasive pneumococcal infection,
occur with influenza virus and S. pneumoniae, S. aureus (both a decrease in the degree of penicillin resistance in circulating
methicillin-susceptible and methicillin-resistant strains), and strains has been documented [194], suggesting that the appro-
group A streptococcus. For some children, empiric therapy may priate dosage of amoxicillin may decrease to that recommended
require both antimicrobial and antiviral agents. in the prevaccine era. However, with the emergence of antibi-
Streptococcus pneumoniae otic-resistant serotype 19A strains of pneumococcus, most
For treatment of pneumococcal infections, penicillin G rep- experts believe that, when pneumococcal pneumonia is sus-
resents the most narrow-spectrum, effective antimicrobial agent. pected and oral therapy is appropriate, high-dosage amoxicillin
The interpretation of in vitro tests of susceptibility to penicillin is still preferred. Although serotype 19A is included in the newer

has been revised recently, with the knowledge that higher doses 13-valent pneumococcal vaccine, it is too soon to evaluate the
of parenterally administered penicillin can achieve tissue con- impact of this intervention on invasive disease or on the
centrations that will be effective against organisms with mini- emergence of antibiotic resistance to non-PCV13 serotypes.
mum inhibitory concentrations (MICs) up to 2 lg/mL, may be Although amoxicillin has a broader spectrum of activity than
effective for strains with MICs of 4 lg/mL, and are not likely to penicillin, it is recommended for oral therapy of pneumonia
be effective for those with MICs of $8 lg/mL [189]. However, caused by S. pneumoniae owing to better absorption from the
with clear limitations on the ability to absorb orally adminis- gastrointestinal tract yielding higher serum concentrations (with
tered penicillin and its salts from the gastrointestinal tract, there the ability to treat less susceptible organisms), a longer serum
has been no change in interpretation of MIC values for pneu- half-life that allows for less frequent dosing, and better taste and
mococci treated with oral therapy: penicillin-susceptible strains tolerability for young children.
remain defined as having MICs , 0.06 lg/mL, intermediately No oral cephalosporin at doses studied in children provides
susceptible strains having MICs between 0.12 and 1.0 lg/mL, activity at the site of infection that equals high-dose amoxicillin.
and resistant strains as having MICs $2.0 lg/mL. Compared Most second- or third-generation oral cephalosporins provide
with penicillin, amoxicillin displays more favorable pharmaco- adequate activity against only 60%–70% of currently isolated
kinetics and tolerability with respect to oral therapy. The doses strains of pneumococcus. Clindamycin provides in vitro activity
of antimicrobials recommended for effective treatment are di- against 60%–85% of pneumococci in certain geographic re-
rectly related to the susceptibility of the strains of S. pneumoniae gions, whereas oral levofloxacin or linezolid provide activity
being treated. against .95% of strains. Daily intramuscular injections of cef-
At the time of initial pediatric registration trials for amoxi- triaxone can be used for outpatient therapy, with in vitro activity
cillin in the early 1970s, the vast majority of isolates were highly documented against .95% of pneumococci [195], with step-
susceptible, and ‘‘standard’’ dosage therapy (40–45 mg/kg/day down oral therapy after the child has demonstrated a clinical
divided into 3 equal doses) appeared to be uniformly successful. response to parenteral therapy.
With the development of widespread pneumococcal resistance Significant macrolide resistance exists in currently isolated
to penicillin in the 1990s, high-dosage amoxicillin (90 mg/kg/ strains of S. pneumoniae; therefore, currently available macrolides
day) was studied in an attempt to overcome resistance in (erythromycin, azithromycin, clarithromycin) are not recom-
pneumococcus and found to be successful for acute otitis media mended as empiric therapy when pneumococcal CAP is suspected.
when given twice daily [190]. The half-life of amoxicillin in Furthermore, azithromycin, with a prolonged serum elimination
middle ear fluid was documented to be 4–6 hours, compared half-life and prolonged exposure to organisms on respiratory tract
with 1 hour in serum, providing supporting evidence for twice- mucosa, has been associated with the selection of resistant or-
daily dosing for acute otitis media. Similar prospective, com- ganisms on mucosal surfaces of treated patients and may represent
parative data supporting a recommendation for twice-daily a source of resistant organisms to others in the community [196].
dosing have not been collected for documented pneumococcal For those children with a history of nonserious allergic re-
pneumonia in children [191]. To achieve the appropriate actions to amoxicillin, treatment is not well defined and should
amoxicillin exposure in lung infected by relatively resistant be individualized. Options include a trial of amoxicillin under
pneumococci (MICs of 2.0 lg/mL), a high total daily dose medical observation for the first dose or a trial of an oral
(90 mg/kg/day) in 3 equally divided portions is predicted to cephalosporin that has substantial activity against S. pneumo-
achieve a clinical and microbiologic cure in about 90% of niae, such as cefpodoxime, cefprozil, or cefuroxime [197], also
children treated, compared with only 65% of children treated under medical supervision. For more serious allergies, including

a history of anaphylaxis, treatment options include a respiratory With respect to the decision regarding the selection of paren-
fluoroquinolone, such as levofloxacin, linezolid, a macrolide teral versus oral empiric therapy of CAP, few prospective data
(recognizing that up to 40% of community isolates of S. pneu- exist to specifically address this issue. Before widespread use of
moniae may be resistant to this class of antibiotic), or clinda- the pneumococcal conjugate vaccine, a retrospective review of
mycin (if susceptible). For those children with bacteremic children with pneumococcal bacteremia documented that among
pneumococcal pneumonia, particular caution should be exer- 61 children with pneumonia, those receiving initial parenteral
cised in selecting alternatives to amoxicillin, given the potential antibiotic therapy in the emergency department before discharge
for secondary sites of infection, including meningitis. were more likely to have clinical improvement, including lower
For parenteral therapy of inpatients, higher dosages of magnitude of fever, and less likely to require subsequent hospi-
b-lactams are also used in the treatment of nonsusceptible talization than those receiving only oral antibiotic therapy [200].
strains of pneumococcus than those used for treatment of fully The relevance of this finding to current management is unclear,
susceptible strains. For regions in which high-level penicillin particularly with widespread use of pneumococcal conjugate
resistance (MIC .8 lg/mL) among invasive strains is sub- vaccines, but the finding suggests that parenteral therapy may be

stantial (.25%), higher doses of penicillin G (up to 300 000 U/ associated with a more rapid response.
kg/day given every 4 hours) or ampicillin (up to 400 mg/kg/day Haemophilus influenzae
given every 6 hours) may be used, similar to dosages demon- Universal recommendation of H. influenzae type b conjugate
strated to be safe for the treatment of meningitis. The required vaccine for the past 25 years has virtually eliminated this path-
dosing interval for penicillin G is more frequent than for am- ogen in children. Therefore, it is not considered a routine
picillin or other b-lactam agents owing to a serum half-life in pathogen in CAP. Nontypeable H. influenzae is not usually
infants as short as 30–40 min. considered a pathogen in pediatric pneumonia except in chronic
Alternatively, therapy can be provided with ceftriaxone or lung disease or if chronic obstruction develops. When it is iso-
cefotaxime in standard, nonmeningitis dosages, as has been lated and thought to be a true pathogen in pediatric CAP, oral
documented to be effective in adults with CAP caused by strains amoxicillin should be effective therapy for mild to moderate
previously considered resistant to ceftriaxone [198]. Ceftriaxone infections caused by b-lactamase–negative strains. For b-lacta-
and cefotaxime are substantially more active in vitro against mase–producing organisms causing LRTI, amoxicillin clav-
penicillin-resistant strains than penicillin G. Microbiologic ulanate or second-generation (cefuroxime), or third-generation
failures of ceftriaxone have not been reported in children for (cefdinir, cefixime, cefpodoxime, or ceftibuten) oral cepha-
pneumococcal pneumonia for organisms demonstrating a cef- losporins should all be effective therapy. Fluoroquinolones are
triaxone MIC ,4.0 lg/mL; published data in adults support the usually not needed for treatment of H. influenzae infection in
use of ceftriaxone for organisms with MICs for ceftriaxone of up children, except in those who are severely allergic to all oral
to 4 lg/mL [198]. Caution should be exercised when treating b-lactam agents. For inpatient therapy, ampicillin is active
resistant pneumococci with other parenteral cephalosporins, as against virtually all b-lactamase–negative strains in North
few prospectively collected data exist to document efficacy. Al- America, whereas second-generation (cefuroxime) or third-
though no prospective evaluations of intravenous ampicillin or generation (ceftriaxone, cefotaxime) cephalosporins are active
amoxicillin compared with ceftriaxone have been conducted in against both b-lactamase–negative and –positive strains.
children, limited data in adults suggest that intravenous amox- Group A Streptococcus
icillin, as amoxicillin clavulanate (not available in the United Streptococcus pyogenes (group A streptococcus) remains an
States), is as effective as ceftriaxone for strains demonstrating an infrequent cause of pediatric CAP but may cause severe necro-
amoxicillin MIC of up to 2 lg/mL [199]. tizing pneumonia. Penicillin or cephalosporin resistance has not
Costs for penicillin and ampicillin are less than for other antimi- been described in this pathogen. Clindamycin resistance is rare
crobial agents, but utilization of hospital resources and overall costs and in most geographic areas is ,2%. For inpatients, penicillin
for administration of agents given every 4–6 hours may be greater G may be used to treat disease at a dosage of 100 000–200 000 U/
than those for agents given once or twice daily. The lower costs of kg/day in 4–6 divided doses, although dosages as high as
hospital care, however, need to be balanced by the increased 200 000–250 000 U/kg/day are well-tolerated and may be used
possibility of alteration of the normal microbiome and the emer- for more severe disease. Macrolides are not considered anti-
gence of resistance that may occur with any agent that has greater microbials of choice for treatment of streptococcal infections,
broad-spectrum activity than penicillin G. For children initially because compared with b-lactams, antibiotic resistance for all
treated with broad-spectrum antimicrobials but in whom adequate macrolides is greater, and for erythromycin, tissue concen-
cultures are either not obtained or are obtained after antimicrobial trations and tolerability are lower. For children with manifes-
treatment has begun and do not document a pathogen, transition tations of toxin-mediated disease (toxic shock–like syndrome),
to oral therapy with amoxicillin is still appropriate. some experts recommend combination therapy with a b-lactam

and clindamycin to decrease the severity of symptoms believed with linezolid, although this antibiotic has a relatively high ad-
to be caused by streptococcal toxins [201]. verse effect profile. Platelet and neutrophil suppression, and
Staphylococcus aureus peripheral nerve injury occur more frequently than documented
Pneumonia suspected to be caused by S. aureus is most often for b-lactam antibiotics, although most adverse effects do not
treated initially in the inpatient setting. Multiple strains or occur until the end of the second week of therapy.
clones of S. aureus with differing susceptibility patterns currently Atypical Pneumonia
circulate in the United States. For inpatients with infection Mycoplasma pneumoniae
caused by methicillin-susceptible S. aureus (MSSA), single drug Symptomatic LRTI has been associated with this pathogen, best
intravenous therapy with a b-lactamase–stable penicillin described in school-aged children and adults. However, no pro-
(oxacillin or nafcillin) or a first-generation cephalosporin spective, randomized, blinded, placebo-controlled clinical trials
(cefazolin) should be adequate. Combination therapy with an have been performed specifically for Mycoplasma LRTI in chil-
aminoglycoside (gentamicin) is not well studied, although for dren. Most studies of CAP in children that collected information
more severe infections, the combination is used by some experts, on Mycoplasma were retrospective or were prospective but en-

particularly for the first days of therapy until a clinical response rolled insufficient numbers of children with infection docu-
is achieved. Similarly, combination therapy with a b-lactam and mented to be caused by Mycoplasma to allow statistically valid
rifampin, supported in part by in vitro data for many, but not conclusions regarding the benefit of antibiotics [205]. The recent
all, strains [202], may be used for more severe infections. emergence of macrolide-resistant M. pneumoniae in Japan pro-
However, as with aminoglycosides, no prospectively collected, vided an opportunity to compare clinical outcomes in children
well-controlled clinical data exist for combination therapy with treated with macrolides who were noted, retrospectively, to be
rifampin. infected with either macrolide-susceptible (MS) strains (n 5 47;
CA-MRSA is an increasing problem in many areas of the mean age, 7.5 years) or macrolide-resistant (MR) strains (n 5 22;
United States and comprises .50%–70% of clinical isolates in mean age 7.7 years) based on organisms that were cultured and
some regions [203, 204]. Virtually all strains of CA-MRSA assessed for resistance by both microdilution techniques and PCR
isolated from children are susceptible to vancomycin, a bac- identification of mutations previously linked to macrolide re-
tericidal agent, which is considered the drug of choice for sistance. In this retrospective analysis, comparing children in-
serious infections. Intravenous clindamycin is an alternative fected with MS versus MR strains, days of fever (1.5 vs 4.0 days)
agent for both MSSA and MRSA for susceptible strains. and cough (7.0 vs 11.4 days) were both significantly decreased in
Knowledge of local resistance rates and laboratory docu- those infected with MS strains (P , .01) [206].
mentation of susceptibility should guide therapy of serious Data extrapolated from adult studies suggests a modest ben-
infections. Inducible resistance to clindamycin may be present efit of therapy with tetracyclines and macrolides for illness of
in staphylococci (ie, they may be D-test positive); for these mild to moderate severity [207, 208]. It is likely that children
strains, clindamycin should not be used in high-inoculum with moderate to severe disease will benefit from treatment with
infections such as empyema, for which the risk of the presence macrolides or tetracyclines (for children .7 years). Therapy
organisms that constitutively produce methylase is high. with the respiratory fluoroquinolones has demonstrated treat-
Some experts use clindamycin or other ribosomal-targeted ment outcomes for adults that are not inferior to macrolides and
antibiotics when manifestations of toxin-mediated infection tetracyclines [27, 209]. Of note, for preschool children with
are present, but no data from prospective, controlled studies Mycoplasma LRTI documented serologically, amoxicillin clav-
have been collected to date [201]. Some experts use genta- ulanate demonstrated clinical outcomes equivalent to those for
micin, clindamycin, or rifampin in combination with van- levofloxacin when evaluated for the primary end point of clinical
comycin for treatment of life-threatening infections caused by cure at the test-of-cure visit, 10–17 days after the last dose of the
CA-MRSA, although no prospectively collected data exist to study drug. These results suggest a high rate of spontaneous
support this practice. Virtually all strains of CA-MRSA are clinical resolution in Mycoplasma infection without need for
also susceptible to linezolid, a bacteriostatic agent currently antimicrobial therapy in this younger age group, although lack
considered second-line therapy. Linezolid may be advanta- of benefit may have resulted from analysis at the test-of-cure
geous if the patient has preexisting renal dysfunction or is visit, without an additional analysis for benefit at much earlier
receiving other nephrotoxic agents. Daptomycin is inactivated time points into therapy [210].
by pulmonary surfactant and is not indicated for the treat- Chlamydia trachomatis and C. pneumoniae
ment of staphylococcal pneumonia, despite a laboratory re- Chlamydia trachomatis is most often identified as a cause of
port that may document susceptibility. afebrile LRTI in very young infants 2–12 weeks of age, born to
Children with severe type 1 hypersensitivity to b-lactam drugs mothers with genital infection, whereas C. pneumoniae is be-
who do not tolerate vancomycin or clindamycin can be treated lieved to cause atypical pneumonia in school-aged children and

adolescents [211]. Antimicrobial treatment effects in C. still be important in a child with a serious viral LRTI, and em-
pneumoniae LRTI in older children have been difficult to define. piric therapy for bacterial agents may also be necessary.
Serologic methods of diagnosis have not been well standardized, Respiratory Syncytial Virus
and a correlation between culture positivity and serologic pos- Controversy exists regarding the efficacy of inhaled ribavirin
itivity has been poor [212]. For children with cultures who are for treatment of RSV CAP in infants. Ribavirin has in vitro
treated with macrolides, eradication rates are 70%–80%, but activity against RSV, but use of this drug for RSV infection is not
similar rates of clinical improvement occurred in those who routinely recommended in the management of lower respiratory
were persistently culture positive and in those demonstrating an tract disease owing to considerations of cost, aerosol adminis-
apparent microbiologic cure [118, 120]. tration, potential toxic effects among exposed healthcare pro-
Viral Pathogens in CAP viders, and efficacy. Effective prophylaxis for RSV infection is
Influenza available in palivizumab (Synagis), a humanized murine
Antiviral therapy exists for susceptible strains of influenza monoclonal antibody administered intramuscularly. Recom-
A with adamantanes and neuraminidase inhibitors and for mendations for target populations for prophylaxis, dosage, and

susceptible strains of influenza B with neuraminidase inhibitors. duration of prophylaxis are available through the AAP [220].
Because substantial genetic variation occurs in influenza from Investigational monoclonal antibodies against RSV that are
year to year, resistance of influenza virus strains to either class of more potent than palivizumab have shown promise in the
antiviral agents may develop and spread quickly. The majority of prophylaxis of RSV infection [221].
strains of influenza A virus isolated since the 2005–2006 season Parainfluenza Virus, Adenovirus, Metapneumovirus, Rhinovi-
have been adamantine resistant; resistance to adamantanes is rus, Coronavirus, and Bocavirus
intrinsic to all influenza B strains. The WHO and CDC track and There no data from prospective, controlled studies for anti-
report resistance as strains are analyzed during the influenza viral therapy against these viruses that are associated with
season. Dosages of antiviral agents that are currently recom- pediatric CAP.
mended for seasonal influenza were developed for fully sus- VI. How Can Resistance to Antimicrobials Be Minimized?
ceptible strains and were evaluated in clinical trials that Recommendations
mandated treatment within 48 hours of onset of symptoms.
Although earlier treatment will result in the most benefit [213], 50. Antibiotic exposure selects for antibiotic resistance;
patients with serious illness or those with ongoing clinical de- therefore, limiting exposure to any antibiotic, whenever
possible, is preferred. (strong recommendation; moderate-
terioration after 48 hours of symptoms are still likely to benefit
quality evidence)
from therapy [214–217]. The degree of benefit has not been
51. Limiting the spectrum of activity of antimicrobials to
defined in these situations.
that specifically required to treat the identified pathogen is
The optimal dose of oseltamivir is not known for patients
preferred. (strong recommendation; low-quality evidence)
with severe illness, those with highly pathogenic avian influenza
52. Using the proper dosage of antimicrobial to be able to
A (H5N1) infection, those receiving extracorporeal membrane
achieve a minimal effective concentration at the site of infection
oxygenation [218] or for those with severe immune deficiency,
is important to decrease the development of resistance. (strong
such as transplant recipients. Some experts have suggested
higher doses (eg, 150 mg administered orally every 12 hours for
53. Treatment for the shortest effective duration will
persons .40 kg). However, no prospectively controlled data
minimize exposure of both pathogens and normal microbiota
exist on which to base higher dosages or a duration of therapy
to antimicrobials, and minimize the selection for resistance.
beyond the standard 5-day treatment course. Investigational
(strong recommendation; low-quality evidence)
neuroaminidase inhibitors that can be administered in-
travenously were available for treatment of documented H1N1 Evidence Summary
infections during the H1N1 pandemic, but adequate data on the Evidence to support the impact of decreased antibiotic use on the
safety and efficacy of these antiviral agents, particularly for emergence of multidrug resistant organisms in hospitals is
children, are not yet available. More complete information on available from a number of recent reviews of antimicrobial
antiviral therapy is available in the IDSA Guidelines for In- stewardship programs [215–219]. Although many inpatient
fluenza [219]. programs have demonstrated that antibiotic use can be decreased,
As noted throughout these guidelines, bacterial-viral co- few have shown that decreased use of a specific antibiotic can lead
infections have been well-documented to occur with influenza to a decrease in the isolation of organisms resistant to that par-
virus, most often documented for S. pneumoniae, S. aureus (both ticular antibiotic in the institution. Furthermore, most of the
methicillin-susceptible and methicillin-resistant strains) and analyses have not assessed the reduction in the actual number of
group A streptococcus. Investigation of bacterial infection may patient infections caused by organisms resistant to a specific

antibiotic, after a reduction in the use of that specific antibiotic. the rapidity of improvement. Improvement in fever, cough,
Even fewer high-quality data are available for pediatric infections tachypnea, and supplemental oxygen dependency and in-
treated on an outpatient basis [222]. Evidence to support the use creased activity and appetite, supported by a reduction in
of the lowest effective antimicrobial drug exposure (dose and peripheral leukocyte counts and/or CRP or other acute-phase
duration) required to prevent the emergence of resistance and reactants, are used by many clinicians to aid in decisions re-
subsequent infection by antibiotic resistant organisms has not yet garding transition to oral therapy. In the absence of bacter-
been evaluated and published. emia, or in children with bacteremia in whom secondary foci
of infection have not been found, transition to oral therapy
VII. What Is the Appropriate Duration of Antimicrobial Therapy can take place as early as 2–3 days after the start of parenteral
for CAP? therapy, although data to support this recommendation are
Recommendations primarily retrospective [225].
In addition to amoxicillin, other oral antibiotic options are
54. Treatment courses of 10 days have been best studied,
available for the allergic child, depending on the antimicrobial
although shorter courses may be just as effective, particularly

susceptibility of the pathogen. Certain antimicrobial drugs
for more mild disease managed on an outpatient basis. (strong
recommendation; moderate-quality evidence) demonstrate excellent absorption from the gastrointestinal tract
55. Infections caused by certain pathogens, notably CA-MRSA, and, if deemed to be appropriate therapy, are likely to be as
may require longer treatment than those caused by S. pneumoniae. effective by mouth as by parenteral route for the convalescing
(strong recommendation; moderate-quality evidence) child in a compliant family. Such antimicrobials include fluo-
roquinolones, linezolid, clindamycin, trimethoprim-sulfame-
Evidence Summary thoxazole, and azithromycin.
The duration of antimicrobial therapy in children in the de- Infections caused by certain pathogens, notably CA-MRSA,
veloped world has primarily been studied in the context of an- may require longer treatment than those caused by S. pneu-
tibiotic registration trials, comparing newer agents with those moniae [226]. Complicated infections that result in para-
having a standard treatment course of 10 days (5 days for azi- pneumonic effusions, empyema, or lung abscess may also
thromycin, which has distinctly different tissue-site pharmaco- require therapy for .10 days, but prospective, randomized
kinetics compared with b-lactam antibiotics) in these protocols trials that define duration based on attributes of the pathogen
[13]. Short-course (3-day) therapy has been studied in the de- and the characteristics of the pneumonia have not been per-
veloping world, but the clinical, laboratory, and radiographic formed. Some experts would treat an appropriately drained
description of these study patients is less definitive than in de- effusion or empyema 7–10 days after resolution of fever,
veloped countries, and documentation of a bacterial pathogen is whereas others recommend therapy for up to 4–6 weeks. Lung
infrequent [223]. Similar prospective, comparative studies of abscesses are varied in size and microbial etiology; therapy
short-course therapy with intensive investigation for etiology of should be individualized based on the clinical, laboratory, and
pneumonia have not been performed in the developed world. imaging response to antimicrobial treatment.
Although the total course of therapy is often 10 days, transition to
oral therapy has been often used to allow discharge from an VIII. How Should the Clinician Follow the Child With CAP for the
inpatient setting, providing decreased risks from intravenous Expected Response to Therapy?
administration of therapy and exposure to nosocomial pathogens. Recommendation
Although no data from prospective, controlled studies are avail-
56. Children receiving adequate therapy should demonstrate
able, retrospective reviews suggest that this practice is effective.
clinical and laboratory signs of improvement within 48–72 hours.
Transition from intravenous to daily intramuscular therapy with
For children whose condition deteriorates after admission and
long-acting antibiotics, particularly b-lactams such as ceftriaxone
initiation of antimicrobial therapy or who show no improvement
or ertapenem, may provide another option for hospital discharge
within 48–72 hours, further investigation should be performed.
for the child who no longer requires supplemental oxygen and
skilled nursing care but may still require parenteral therapy. In
areas with skilled pediatric outpatient nursing resources, for Evidence Summary
children who may require longer duration of parenteral therapy, Clinical signs and symptoms, including fever, respiratory rate, and
outpatient intravenous therapy through an indwelling central oxygenation (as measured by pulse oximetry and supplemental
catheter, with daily skilled pediatric home nursing visits, provides oxygen requirement), should demonstrate improvement within
another option for out-of-hospital care [224]. 48–72 hours, based on data originally collected .50 years ago in
The duration of parenteral therapy before transition to oral placebo-controlled trials when antimicrobial therapy first became
therapy is based on the severity of the initial presentation and available [227]. Clinical findings of response to therapy may be

supported by laboratory markers of inflammation (certain acute- versus parenchymal opacification, then further imaging with
phase reactants such as procalcitonin or CRP), although these chest ultrasound or CT scan is warranted. Chest ultrasound is
laboratory tests have not been routinely incorporated into clinical considered a safer imaging procedure than CT, owing to lack of
trial design and have not been adequately evaluated or validated ionizing radiation.
[228]. Further discussion on management of these children is
provided in the Evidence Summary for Recommendation 71.
X. What Factors Are Important in Determining Whether Drainage
of the Parapneumonic Effusion Is Required?
ADJUNCTIVE SURGICAL AND NON– Recommendations
ANTI-INFECTIVE THERAPY FOR PEDIATRIC CAP 58. The size of the effusion is an important factor that
determines management (Table 8, Figure 1). (strong
IX. How Should a Parapneumonic Effusion Be Identified? recommendation; moderate-quality evidence).
Recommendation 59. The child’s degree of respiratory compromise is an

57. History and physical examination findings may be important factor that determines management of
suggestive of parapneumonic effusion in children suspected parapneumonic effusions (Table 8, Figure 1) (strong
of having CAP, but chest radiography should be used to recommendation; moderate-quality evidence).
confirm the presence of pleural fluid. If the chest radiograph
Evidence Summary Drainage of a parapneumonic effusion
is not conclusive, then further imaging with chest ultrasound
may be required for several reasons. The most common cause of
or CT is recommended. (strong recommendation; high-quality
parapneumonic effusion in children is infection. If there is
evidence)
doubt about the infectious etiology of the effusion or if malig-
Evidence Summary nancy is suspected, thoracentesis may be performed for cytologic
Parapneumonic effusion is defined as a collection of fluid in the examination. When an empyema is present, drainage of puru-
pleural space associated with underlying pneumonia. In a large lent material is usually required for adequate treatment of the
study of patients with CAP in Canada, parapneumonic effusions infection. Drainage of infected pleural fluid may result in de-
were observed in 9% of adult patients [229]. In children, creased fever, inflammation, and hospital stay [240, 241]. Fi-
prospective studies of CAP in Europe and the Americas have nally, the size of the effusion and the degree of respiratory
demonstrated parapneumonic effusions in 2%–12% [230–233]. compromise are important factors to be considered when de-
Parapneumonic effusions may occur in up to 20% of pneu- termining the management plan. Small effusions (see Table 8)
monias due to M. pneumoniae and may also be seen in 10% of
often respond well to antibiotic therapy and usually require no
viral pneumonias [17, 234], but these effusions are rarely large
further intervention. Moderate to large effusions are more likely
enough to require intervention. Parapneumonic effusions occur
to cause respiratory compromise, not resolve quickly and benefit
most frequently with bacterial pneumonia, occurring in 50%
from drainage, as outlined in Figure 1.
of cases due to typical bacteria including S. pneumoniae,
Although the classification of effusion size is both qualitative
S. pyogenes, and S. aureus in countries where H. influenzae
and arbitrary, the effusion size classification criteria used in this
type b vaccine is in general use [17].
guideline are similar to those recommended for adult patients
Parapneumonic empyema is a collection of pus in the pleural
[242, 243], and they have also been used in at least 2 recent
space associated with an underlying pneumonia. Pus may be
investigations [244, 245]. Small effusions (,10 mm rim of fluid
defined by gross appearance, WBC count (.50 000 WBCs/lL)
on lateral decubitus or less than one-fourth of the hemithorax
[235], or positive bacterial culture. Hospitalization rates for
parapneumonic empyema are increasing in the United States opacified on an upright chest radiograph) are likely to resolve on
[45, 89, 236–238]. their own and usually do not require drainage. Reporting their
In children with CAP, parapneumonic effusion may be sus- 12-year, single-institution, retrospective experience with pneu-
pected based on history and physical examination. In children monia and parapneumonic effusions, Carter et al noted that no
with CAP, prolonged fever, chest pain, and abdominal pain have small pleural effusion required drainage; all patients with small
all been associated with parapneumonic effusion [89, 239]. effusions recovered uneventfully with antibiotic therapy alone
Physical examination may reveal signs of pleural fluid, including [245]. In the absence of mediastinal shift, only 27% of patients
dullness to percussion, diminished breath sounds, and a change (23 of 84) with moderate pleural effusions required drainage.
in the quality of breath sounds and transmitted speech over the Carter et al also noted that of 94 children with large effusions
effusion. Chest radiography, including lateral decubitus views, (more than half of the hemithorax opacified), 62 (66%) ulti-
should be used to confirm the presence of pleural fluid in mately required pleural drainage. In adults, Ferguson et al noted
children with CAP. If there is still a question of pleural fluid that simple aspiration and drainage were likely to fail in

effusions occupying .40% of the hemithorax [246]. This was Evidence Summary
also the consensus in the British Thoracic Society guidelines for Gram stain and bacterial culture of pleural fluid are positive
children [241] and the adult-based American College of Chest in up to 49% of cases of pneumonia complicated by para-
Physicians consensus statement [243]. There are few data con- pneumonic effusion, with most investigators reporting posi-
tive cultures in ,25% [89, 249–254]. When positive, pleural
cerning moderate effusions, although Carter et al noted that the
fluid culture can direct antibiotic therapy. Unfortunately, the
majority of children with moderate effusions were successfully
majority of parapneumonic effusions, although thought to be
managed without pleural drainage; only 1 child treated initially
caused by pathogenic bacteria, are culture negative. Using
with antibiotics alone required readmission for pleural fluid
nucleic acid or antigen detection methods, several studies
drainage [245]. However, further prospective studies are needed
in the United States and Europe have demonstrated
in this area.
that culture-negative empyema is caused primarily by
In effusions large enough warrant consideration of drain-
S. pneumoniae, often nonvaccine serotypes that are susceptible
age, the presence of loculated or ‘‘organizing’’ fluid influences
to penicillin [226, 249, 250, 255–258]. These methods

treatment decisions, because drainage by chest thoracostomy
have greater sensitivity than traditional culture-based meth-
tube alone may not be effective and adjunctive therapy may be
ods, identifying bacterial pathogens in 42%–80% of samples,
required. The choice of adjunctive therapy is discussed below.
especially in patients pretreated with antibiotics [226, 259,
The imaging study of choice to assess for pleural fluid
260] Antigen and nucleic acid assays for the diagnosis of
loculations is chest ultrasound, although lateral decubitus
pathogens responsible for parapneumonic empyema, in-
radiography and CT of the chest can also be used. There is
cluding S. pneumoniae and S. aureus, are still in development,
some evidence that loculated parapneumonic effusions are
but these tests may be helpful in centers where they are
associated with more complicated hospital courses. Ramnath
available. Most of these tests are not currently FDA-approved,
et al found that children with loculated parapneumonic ef-
but many developers may not wish to seek full FDA approval
fusions treated with antibiotics alone, either with or without
for use in neonates, infants and children based on economic,
chest tube placement, had longer lengths of stay and more
medical and ethical concerns.
complicated courses than those with simple (nonloculated)
Biochemical tests of pleural fluid are often performed in
effusions that were treated similarly [247]. Himelman et al
adults to distinguish exudative from transudative effusions and
noted that adults with loculated parapneumonic effusions had
to help guide clinical management [235]. In children, the
larger effusions and longer hospital stays and underwent
overwhelming majority of parapneumonic effusions are due to
thoracostomy procedures more frequently than those with
infection. Biochemical tests are rarely required to help establish
nonloculated effusions [248]. However, Carter et al found that
the etiology (eg, infection vs malignancy or other cause) of the
pleural fluid loculations were not associated with the need for
effusion and have rarely been associated with changes in patient
pleural drainage [245].
management. In adult patients, a meta-analysis demonstrated
that pH had the highest diagnostic accuracy for identifying
XI. What Laboratory Testing Should Be Performed on Pleural complicated parapneumonic effusions requiring pleural fluid
Fluid? drainage with an area under the receiver operating characteristic
Recommendation (ROC) curve of 0.92, compared with 0.84 for pleural fluid
60. Gram stain and bacterial culture of pleural fluid should glucose and 0.82 for lactate dehydrogenase. Even after exclusion
be performed whenever a pleural fluid specimen is obtained. of pleural fluid that was grossly purulent, pH retained a high
(strong recommendation; high-quality evidence) diagnostic accuracy (area under the ROC curve, 0.89) with de-
61. Antigen testing or nucleic acid amplification through cision thresholds at pH cutoff values between 7.21–7.29 [261].
PCR increase the detection of pathogens in pleural fluid and In children, pH values ,7.2 have been associated with need for
may be useful for management. (strong recommendation; pleural fluid drainage [262]. Biochemical testing of pleural fluid
moderate-quality evidence) in children with parapneumonic effusions associated with
62. Analysis of pleural fluid parameters, such as pH, glucose, pneumonia is not required. However, some experts believe that
protein, and lactate dehydrogenase, rarely changes patient measurement of pleural fluid pH, obtained at the time of initial
management and is not recommended. (weak recommendation; drainage, may help guide decisions regarding need for pleural
very weak-quality evidence) fluid drainage.
63. Analysis of the pleural fluid WBC count, with cell WBC counts with differential analysis have been conven-
differential analysis, is recommended primarily to help tionally been performed in pleural fluid, but the value of this
differentiate bacterial from mycobacterial, fungal, or malignancy analysis in demonstrating bacterial etiology is being replaced by
etiologies. (weak recommendation; moderate-quality evidence) molecular analysis. The value of the pleural fluid cell count in

Table 9. Summary of Published Fibrinolysis Regimens
Published Total no. of

source, year Fibrinolytic agent Concentration Regimen doses
St Peter et al, Tissue plasminogen 4 mg mixed in 40 mL of First dose at time of chest tube placement 3
2009 [92] activator normal saline with 1-hour dwell time,a after which chest
tube is placed on continuous suction
(–20 cm H2O); repeat every 24 hours
Hawkins et al, Tissue plasminogen 0.1 mg/kg with a First dose after placement of pigtail catheter 9
2004 [266] activator maximum of 3 mg with 45–60-minute dwell time,a after which
mixed in 10–30 mL chest tube is placed on continuous suction
of normal saline (–20 to –25 cm H2O); repeat every 8 hours
Sonnappa et al, Urokinase 10 000 U in 10 mL of First dose at placement of chest tube with 6
2006 [267] normal saline for 4-hour dwell time,a after which chest tube
children ,1 year old; is placed on continuous suction
40 000 U in 40 mL of (–10 to –20 cm H2O); repeat every 12 hours

normal saline for
children .1 year old
a
Chest drain remains clamped during ‘‘dwell time.’’
predicting morbidity and outcome does not justify a strong VATS have been advocated as effective treatment measures
recommendation [263]. However, clues to the origin of pleural for pediatric parapneumonic effusions [92, 266–269]. Either
fluid caused by less common etiologies, such as tuberculosis and chest tube drainage with fibrinolysis or VATS is preferred
malignancy, may be found in the cell count, differential analysis, (over chest tube drainage alone) for complicated, loculated
and cytologic findings for the fluid [264, 265]. effusions; currently available data are not adequate to de-
termine that one procedure is clearly preferred over the other.
See Table 9 for fibrinolytic regimens used with children
XII. What Are the Drainage Options for Parapneumonic [92, 266, 267]. Both interventions have been reported to have
Effusions? improved patient outcomes, including resolution of infection
Recommendations and decreased length of hospital stay, when compared with
64. Small, uncomplicated parapneumonic effusions should conservative treatment with chest tube drainage and anti-
not routinely be drained and can be treated with antibiotic therapy biotics [92, 266–268, 270]. Two single-center randomized
alone. (strong recommendation: moderate-quality evidence) controlled trials compared fibrinolytic therapy with VATS.
65. Moderate parapneumonic effusions associated with Although different strategies for fibrinolysis were used by Son-
respiratory distress, large parapneumonic effusions, or nappa et al (30 patients treated with urokinase, 30 with VATS)
documented purulent effusions should be drained. (strong and St Peter et al (18 patients treated with alteplase, 18 treated
recommendation; moderate-quality evidence) with VATS), both studies demonstrated similar patient out-
66. Both chest thoracostomy tube drainage with the addition comes, including length of hospital stay, and both also demon-
of fibrinolytic agents and VATS have been demonstrated to be strated a decreased cost for treatment of parapneumonic
effective methods of treatment. The choice of drainage procedure empyema with fibrinolytic agents compared with VATS
depends on local expertise. Both of these methods are associated [92, 267]. A randomized trial by Kurt et al (10 patients treated
with decreased morbidity rates compared with chest tube with VATS, 8 treated with conventional tube thoracostomy with
drainage alone. However, in patients with moderate to large reteplase fibrinolysis solely as rescue therapy) documented
effusions that are free flowing (no loculations), placement of shorter length of stay among patients undergoing initial VATS
a chest tube without fibrinolytic agents is a reasonable first [271]. Based on the currently available data, both chest tube with
option. (strong recommendation; high-quality evidence) fibrinolysis and VATS are considered acceptable initial drainage
Evidence Summary strategies.
The choice of drainage procedure depends on local or regional
expertise and experience. In patients with pleural fluid that is XIII. When Should VATS or Open Decortication Be Considered in
not loculated, initial drainage with a chest tube alone is an Patients Who Have Had Chest Tube Drainage With or Without
option, though proceeding directly to adjunctive therapy is Fibrinolytic Therapy?
also reasonable. Loculated effusions cannot be drained with Recommendation
a chest tube alone and thus require adjunctive therapy. Both 67. VATS should be performed when there is persistence
chest tube drainage with the instillation of fibrinolytic agents, of moderate to large effusions and ongoing respiratory
including urokinase or tissue plasminogen activator, and compromise, despite 2–3 days of management with a chest

tube and completion of fibrinolytic therapy. Open chest 71. The duration of antibiotic treatment depends on the
débridement with decortication represents another option adequacy of drainage and on the clinical response
for management of these children but is associated with higher demonstrated for each patient. In most children, antibiotic
morbidity rates. (strong recommendation; low-quality evidence) treatment for 2–4 weeks is adequate (strong recommendation;
low-quality evidence).
Evidence Summary
Approximately 17% [92, 266, 267] of children with para- Evidence Summary
pneumonic effusions treated with fibrinolytic agents via The antibiotic treatment of parapneumonic effusion or empy-
a chest tube will require further intervention to complete ema is similar to that for CAP without effusion. The bacterial
drainage of the pleural space. Children who require further pathogens responsible for CAP and for parapneumonic effusion
intervention with VATS or open thoracotomy or de- or empyema are also similar, with S. pneumoniae the most
cortication are those who have persistence of moderate or commonly isolated pathogen in most studies [236, 237, 242–
large effusions and ongoing respiratory compromise despite 246], though S. aureus remains an important cause of empyema
but a less common cause of uncomplicated CAP. Whenever

2–3 days of management with a chest tube and fibrinolytic
agents. Persistence of fever alone is not an indication of possible, antibiotic therapy should be pathogen directed, based
treatment failure. Chest CT should be performed to evaluate on results of bacterial culture of either blood or pleural fluid.
the adequacy of pleural fluid drainage and to determine Unfortunately, pleural fluid cultures are often negative owing to
whether loculated fluid collections or necrotizing parenchy- the high frequency of antibiotic treatment initiated before fluid
mal disease are present. After failure of chest tube with is obtained for culture. In these circumstances, treatment is
fibrinolytic agents, drainage of the pleural space is most often based on regional epidemiology and selected to provide coverage
accomplished by VATS; rarely, children will require open for the most common pathogens (see Evidence Summary for
decortication. It is not routinely necessary to obtain chest Recommendations 46–49). When molecular testing is used,
radiographs serially after VATS or chest tube placement. culture-negative empyema is most often found to be due to
S. pneumoniae that had been partially treated before bacterial
XIV. When Should a Chest Tube Be Removed After Either Primary cultures were obtained and has rarely been found to be due to
Drainage or VATS? S. aureus [226, 250, 256–258]. Empyema caused by S. aureus,
especially CA-MRSA, results in positive bacterial culture more
68. A chest tube can be removed in the absence of an often than empyema caused by pneumococcus. In a single-
intrathoracic air leak and when pleural fluid drainage is center study of 63 pleural fluid specimens tested by bacterial
,1 ml/kg/24 h, usually calculated over the last 12 hours.
culture and PCR, all cases of CA-MRSA were demonstrated
(strong recommendation; very low-quality evidence)
by both culture and PCR. No cases of MRSA were demonstrated
Evidence Summary by PCR in culture negative pleural fluid [226], although this
Once a chest tube is placed, either as primary treatment or after finding should be verified in settings with higher incidences of
VATS, criteria for removal include the absence of an air leak and CA-MRSA.
,1 mL/kg/24 h of pleural fluid drainage, usually calculated over The optimal duration of antibiotic treatment for para-
the last 12 hours, or 25–60 mL total in a 24-hour period [92, pneumonic effusion or empyema is dependent on the adequacy
266, 267]. This can often be accomplished within 48–72 hours of the drainage procedure and may vary by pathogen, but it has
after the operation or completion of fibrinolysis. not been determined through randomized controlled trials.
Treatment for 2–4 weeks is commonly recommended; some
experts treat the infection for 10 days after resolution of fever.
XV. What Antibiotic Therapy and Duration Is Indicated for the
Treatment of Parapneumonic Effusion or Empyema?
Recommendations MANAGEMENT OF THE CHILD NOT
RESPONDING TO TREATMENT
69. When the blood or pleural fluid bacterial culture identifies
a pathogenic isolate, antibiotic susceptibility should be used to XVI. What Is the Appropriate Management of a Child Who Is Not
determine the antibiotic regimen. (strong recommendation; high- Responding to Treatment for CAP?
quality evidence) Recommendation
70. In the case of culture-negative parapneumonic effusions,
72. Children who are not responding to initial therapy after
antibiotic selection should be based on the treatment
48–72 hours should be managed by one or more of the following:
recommendations for patients hospitalized with CAP (see
Evidence Summary for Recommendations 46–49). (strong a. Clinical and laboratory assessment to determine the current
recommendation; moderate-quality evidence) severity of their illnesses and anticipated progression in order

to determine whether higher levels of care or support are 3. Persisting increased heart rate
required. (strong recommendation; low-quality evidence) 4. Oxygen saturation ,90% with room air, need for
b. Imaging evaluation to assess the extent and progression of supplemental oxygen or ventilation
the pneumonic or parapneumonic process. (weak recommen-
B. Systemic or focal symptoms or signs
dation; low-quality evidence)
c. Further investigation to identify whether the original 1. Clinically defined ‘‘toxicity’’ based on clinical judgment or
pathogen persists, whether it has developed resistance to the change in mental status 2. Chest pain, splinting of the chest
agent used, or whether there is a new secondary infecting agent. 3. Inability to maintain oral intake and hydration
(weak recommendation; low-quality evidence) 4. Extent of abnormal or absent breath sounds at
auscultation or dullness in response to percussion
73. A BAL (BAL) specimen should be obtained for Gram
stain and culture for the mechanically ventilated child. (strong C. Laboratory and/or radiologic results
recommendation; moderate-quality evidence) 1. Peripheral WBC count, taking into account the total count
74. A percutaneous lung aspirate should be obtained for Gram

and percentage of immature forms of neutrophils
stain and culture in the persistently and seriously ill child for 2. Levels of inflammatory markers (eg, procalcitonin, CRP)
whom previous investigations have not yielded a microbiologic 3. Isolation of a pathogen by culture; nonresponsive pathogens
diagnosis. (weak recommendation; low-quality evidence) include either those with antimicrobial resistance to current
75. An open lung biopsy for Gram stain and culture should therapy or those susceptible to current therapy but with
be obtained in the persistently and critically ill, mechanically inadequate drug exposure in infected tissues, inadequate drainage
ventilated child for whom previous investigations have not of empyema or abscess, or inadequate duration of therapy.
yielded a microbiologic diagnosis. (weak recommendation; low- 4. Increased degree of parenchymal involvement, presence of
quality evidence) or increase in pleural fluid, or development of pulmonary
Evidence Summary abscess or necrotizing pneumonia, as documented by imaging
The decision to consider a patient as a nonresponder during with chest radiography, ultrasound, or CT.
therapy for bacterial or viral CAP is based on the clinician’s in- Children with nonresponding CAP should have the clinical
terpretation of the patient’s clinical course and, at times, labora- severity of their condition repeatedly assessed to determine
tory data relative to the patient’s condition at the onset of therapy. whether they require higher levels of care, for example, ad-
In general, the clinician should consider a patient a nonresponder mission to the hospital from the outpatient setting, skilled
if there is a lack of improvement within 48–72 hours or significant transport from a community hospital to a tertiary pediatric
worsening at any time after initiation of therapy. care center, or transfer to the ICU from a hospital ward. The
The frequency of nonresponse in pediatric pneumonia is evaluation should include monitoring for the expected im-
not well described but has been estimated overall at between
provements in presenting findings that may include fever,
5% and 15% in hospitalized children [272]. This is similar
respiratory rate, respiratory distress (chest retractions,
to findings of a meta-analysis of prospective randomized trials
grunting), and hypoxemia (with pulse oximetry). Children
in adults investigating treatment failure, in which persistent fever
should also be monitored for their global response in terms of
and deterioration of the patient’s condition requiring a change in
activity, appetite, and hydration status. Some outpatient
prescribed antibiotics was seen in 16% of patients [273].
‘‘nonresponders’’ will require hospitalization (see Evidence
Clinical judgment is paramount in defining nonresponse, but
Summary for Recommendation 1) if they are unable to
the determination of nonresponse is also influenced by labora-
maintain adequate oxygenation or hydration or show signs of
tory and/or imaging results. The relative weights of these factors
increased work of breathing or toxicity. Children treated
in the decision to consider a patient a nonresponder vary by age,
initially with oral antibiotic therapy for presumed bacterial or
the setting (outpatient vs inpatient vs ICU), the severity of the
atypical pneumonia as outpatients may actually be infected by
presentation, and finally the rate of clinical deterioration or
duration of the lack of improvement. pathogens not susceptible to initial therapy, and may require
The following factors influence the decision to consider the alternative or additional antibacterial or antiviral therapy.
patient a nonresponder at 48–72 hours: Children with nonresponding CAP that is moderate to severe
should undergo radiographic imaging, particularly if clinical
A. Vital signs and oxygen saturation [45] evidence suggests increased respiratory effort, increased areas of
1. Persistence or increase in the general fever pattern abnormal lung sounds, or dullness to percussion in areas where it
2. Increased respiratory rate, grunting, chest retractions, was not detected previously. For outpatients, the preferred im-
cyanosis aging study is chest radiography including posteroanterior and

lateral views. If a moderate to large pleural effusion is suspected, adequate oxygenation or perfusion, such as mechanical venti-
then a lateral decubitus chest radiograph or a chest ultrasound is lation, cardiovascular support, or extracorporeal membrane
indicated (see Evidence Summary for Recommendation 57). If oxygenation support, should be transferred to a unit capable of
a chest mass, pulmonary abscess, or necrotizing pneumonia is providing intensive care.
suspected, chest CT should be performed. When nonresponding CAP is suspected to be either viral in
Children with complications of pneumonia, including moder- origin or a result of coinfection with bacterial and viral patho-
ate to large pleural effusions, require consultation with those gens, confirming a viral pathogen can be beneficial. Rapid an-
services in the institution that have expertise in obtaining pleural tigen testing and PCR have the advantage of rapid turnaround
fluid specimens and providing drainage, fibrinolytic agents, and/or times, but the availability and expense of PCR testing can be
VATS (see Evidence Summary for Recommendations 58 and 59). a limiting factor. As the accessibility of molecular-based tech-
Reassessment for bacterial pathogens may include sputum for nologies such as PCR increases, and costs decrease, these tests
culture in children who can cough and expectorate. In children may replace many antigen-based tests, because they generally
with parapneumonic effusions who are not responding to anti- have improved test performance characteristics and can identify

microbial therapy alone, pleural fluid samples should be obtained an increasing number of viral pathogens.
for culture, Gram stain, and, if available, either PCR [258, 259] or A nonresponding child with CAP may have influenza virus
antigen testing [274]; samples should also be evaluated for my- infection alone that is resistant to empiric antiviral treatment with
cobacteria and fungi with appropriate stains and cultures, in the oseltamivir. In such patients, testing for oseltamivir resistance
context of a clinically relevant exposure and clinical presentation. should be pursued through public health laboratories, and
Children should also be considered for drainage or removal of the treatment should be initiated with an alternative antiviral agent,
effusion. In seriously ill children requiring mechanical ventilation, such as zanamivir, or an investigational antiviral agent that may
cultures obtained by bronchoscopy using BAL, tracheal aspirate, retain activity against the influenza strain. For children ,7 years
or bronchial brush may be helpful. old, or for those who require intravenous antiviral therapy, in-
Although rare pathogens can present as CAP, CAP in children vestigational antiviral therapy may be required, usually through
is usually caused by the traditional respiratory tract pathogens (see the drug manufacturer. Children with worsening CAP and a viral
Etiology). When CAP is not responding to initial empiric anti- pathogen should receive antiviral treatment if available and
microbial therapy, particularly if an attempt to discover a patho- should undergo further testing aimed at identifying previously
gen was initially not considered necessary, there should be a more undetected bacterial pathogens (see Evidence Summary for
aggressive approach to pathogen identification. Furthermore, the Recommendations 28, 29, 39, and 40).
patient should be reassessed to consider whether more resistant Children who present with initially confirmed viral CAP oc-
common bacterial or viral pathogens or unusual pathogens, in- casionally develop secondary bacterial infection. Secondary
cluding fungal, mycobacterial, or parasitic organisms, may be bacterial infection in infants and children with viral disease
responsible for worsening signs and symptoms. Secondary bac- occurs most frequently in hospitalized children, especially those
terial infection from an airway obstructed from either intrinsic or with influenza [276–278] or RSV infection requiring intensive
extrinsic mechanisms should also be considered. care [117, 279–282]. If secondary bacterial infection is suspected
Inpatients who fail to respond to initial therapy may require with clinical deterioration supported by laboratory evidence of
expansion of antimicrobial therapy for pathogens that are not increased systemic inflammation, then investigation for bacterial
included in the spectrum of the initial antibiotic choice or that pathogens is warranted, and antibacterial therapy should be
subsequently display resistance to the initial agent by means of expanded to provide coverage for common bacterial pathogens,
induction of resistance mechanisms, mutation, or selection of keeping in mind the local resistance patterns. Occasionally, in
a small subpopulation of the pathogen that is intrinsically re- children $3–5 years old, testing for Mycoplasma or C. pneu-
sistant to the agent but not detected on initial cultures. For moniae is warranted, particularly if pulmonary infiltrates are
example, a patient initially treated with intravenous ampicillin perihilar and bilateral and wheezing is present. If test results
should have coverage broadened with either nafcillin-oxacillin require several days, clinicians should start empiric therapy with
or cefazolin for MSSA or with clindamycin (moderately ill pa- the addition of a macrolide, tetracycline, or fluoroquinolone
tients) or vancomycin (patients with severe or life-threatening (see Evidence Summary for Recommendations 44 and 48).
conditions) for MRSA. Another example is represented by pa-
tients receiving long-term treatment with vancomycin for XVII. How Should Nonresponders With Pulmonary Abscess or
infection caused by CA-MRSA in whom selection for ‘‘hetero- Necrotizing Pneumonia Be Managed?
resistance’’ to vancomycin occurs, with increasing MICs that Recommendation
require an increasing dosage of vancomycin to achieve cure 76. A pulmonary abscess or necrotizing pneumonia identified
[275]. Patients who require significant intervention to maintain in a nonresponding patient can be initially treated with

intravenous antibiotics. Well-defined peripheral abscesses 81. Patients should have documentation that they can
without connection to the bronchial tree may be drained tolerate their home anti-infective regimen, whether oral or
under imaging-guided procedures either by aspiration or with intravenous, and home oxygen regimen, if applicable, before
a drainage catheter that remains in place, but most will drain hospital discharge. (strong recommendation; low-quality
through the bronchial tree and heal without surgical or invasive evidence)
intervention. (weak recommendation; very low-quality evidence) 82. For infants or young children requiring outpatient oral
antibiotic therapy, clinicians should demonstrate that parents
Evidence Summary
are able to administer and children are able to adequately
Most pulmonary abscesses arise in previously normal lung as
comply with taking those antibiotics before discharge. (weak
a result of an initial pneumonia. The abscess and/or lung
recommendation, very low-quality evidence)
necrosis may lead to a lack of clinical response. The non-
83. For children who have had a chest tube and meet the
responding patient who has a lesion on chest radiograph
requirements listed above, hospital discharge is appropriate
suggestive of abscess or necrotizing pneumonia should
after the chest tube has been removed for 12–24 hours, with
undergo CT of the chest with contrast medium enhancement

either no clinical evidence of deterioration since removal,
to help confirm or rule out these processes. In general, surgical
or if a chest radiograph was obtained for clinical concerns,
intervention should be avoided, because most abscesses re-
radiographic evidence of no significant reaccumulation of
solve with antibiotics alone [283, 284]. However, if the abscess
a parapneumonic effusion or pneumothorax. (strong
is peripheral and not associated with airway connection, then
recommendation; very low-quality evidence)
CT-guided drainage or catheter placement is a reasonable
84. In infants and children with barriers to care, including
option [285–287]. Retrospective data suggest that drainage
concern about careful observation at home, inability to
shortens hospital stays and facilitates earlier recovery [288].
comply with therapy, or inability to be followed up, these
Specimens obtained at drainage should be methodically
issues should be identified and addressed before discharge.
investigated for potential pathogens.
Patients with a secondary abscess due to an underlying pul- (weak recommendation; very low-quality evidence)
monary anomaly or lesion (eg, congenital cystic adenomatoid Evidence Summary
malformation, pulmonary sequestration) require surgical con- There are no studies that clearly determine the best criteria for
sultation for evaluation of long-term management of the lesion, hospital discharge. However, the following criteria are commonly
and to determine whether surgical resection is required. Nec- used: (1) the child has decreasing fever, (2) no supplemental
rotizing pneumonia should be treated medically because surgical oxygen is required, (3) the child has been taking foods and liquids
intervention and/or placement of chest tubes via trocar may adequately for at least 12–24 hours, and (4) if a chest tube was
increase the risk for bronchopleural fistula [286]. placed, the child is free of intrathoracic air leak for at least 12–24
hours after the tube is removed. In adults, improvement of
pneumonia has been primarily determined by improved fever
Discharge Criteria
course, resolution of tachycardia and tachypnea, improved sys-
XVIII. When Can a Hospitalized Child With CAP Be Safely tolic blood pressure, and resolution of a need for supplemental
Discharged? oxygen as assessed by pulse oximetry [289]. In children, criteria
Recommendations for stability in the course of treatment of pneumonia are far less
77. Patients are eligible for discharge when they have well defined.
documented overall clinical improvement, including level of Fever is extremely common in pneumonia, and may persist
activity, appetite, and decreased fever for at least 12–24 hours. for several days despite adequate therapy, particularly for
(strong recommendation; very low-quality evidence) children with complicated pneumonia [290, 291]. In a study
78. Patients are eligible for discharge when they demonstrate of adults, lowering of a threshold of what is considered
consistent pulse oximetry measurements .90% in room air for a ‘‘stable’’ temperature does not alter time to discharge from
at least 12–24 hours. (strong recommendation; moderate-quality the hospital, implying that, at least in that group, temperature
evidence) stability is not the prime consideration for discharge [289].
79. Patients are eligible for discharge only if they Because resolution of fever is a sign of adequate therapy for
demonstrate stable and/or baseline mental status. (strong bacterial pneumonia, an improving fever curve can be used
recommendation; very low-quality evidence) to document the adequacy of therapy in the absence of a de-
80. Patients are not eligible for discharge if they have finitive organism and sensitivities.
substantially increased work of breathing or sustained tachypnea There is wide variability in practice among physicians as to
or tachycardia (strong recommendation; high-quality evidence) what is considered a safe pulse oximetry level for discharged

patients with pneumonia [49]. However, the use of 90% as families with incomes below the federal poverty threshhold
a cutoff for oxygen supplementation is recommended for represented 11% of children whose hospitalizations were con-
viral respiratory illness [292]. As pulse oximetry measurements sidered avoidable [58].
fall below 90% (acid-base status, temperature, and other con-
siderations notwithstanding), further decreases in oxygenation XIX. When Is Parenteral Outpatient Therapy Indicated, in
result in a faster decline in saturation rates, as determined by the Contrast to Oral Step-Down Therapy?
oxygen-dissociation curve of hemoglobin. Recommendations
Infants and children given unpleasant-tasting antibiotics 85. Outpatient parenteral antibiotic therapy should be
are more likely to spit out their dose [293, 294]. It has been offered to families of children no longer requiring skilled
suggested that for infants and children taking liquid medi- nursing care in an acute care facility but having a demonstrated
cations, taste has more of an impact on adherence with need for ongoing parenteral therapy. (weak recommendation;
a prescribed therapy than interval or duration of dosing [295]. moderate-quality evidence)
A trial of oral antimicrobial therapy before discharge is im- 86. Outpatient parenteral antibiotic therapy should be

portant, particularly for agents such as liquid clindamycin, offered through a skilled pediatric home nursing program or
which is known to have an unpalatable taste. Ways to improve through daily intramuscular injections at an appropriate
the palatability of certain antibiotic suspensions exist, in- pediatric outpatient facility. (weak recommendation; low-
cluding both flavorings available in the home and flavorings quality evidence)
that can be added at the time the antibiotic is reconstituted in 87. Conversion to oral outpatient step-down therapy, when
a pharmacy. Close follow-up with the primary care practi- possible, is preferred to parenteral outpatient therapy. (strong
tioner is important to make sure that the child continues to recommendation; low-quality evidence)
tolerate oral antimicrobial therapy.
Children with complicated pneumonia often have surgical Evidence Summary
procedures to drain accumulation of pleural fluid. Up to Outpatient parenteral antimicrobial therapy has been used suc-
a third of patients who have primary chest tube placement cessfully for .2 decades in both children and adults for treatment
may require a second surgical procedure for further fluid of a wide variety of infections, including pneumonia, leading to
drainage [270]. Length of stay and likelihood of re- the creation of IDSA practice guidelines for outpatient parenteral
accumulation of fluid will be significantly reduced, but not antimicrobial therapy [224, 299]. With use of a set of clinical
eliminated, by VATS or fibrinolytic therapy via chest tube parameters that document no further need for skilled nursing care
[270, 298] (see Evidence Summary for Recommendations 64 and with the creation of an outpatient management team—
and 65). However, care must be taken that patients do not consisting of a pediatrician, skilled pediatric nurse, and pediatric
have ongoing accumulation of pleural fluid before discharge, pharmacist—outpatient parenteral therapy for CAP can be suc-
which may necessitate a more conservative approach to cessful with a variety of antimicrobial agents [224]. Examples of
discharge criteria. For patients who do not receive fibrinolytic infants and children who may require ongoing parenteral therapy
therapy or VATS, a longer period of observation for accu- include those who may have ongoing disease requiring a high
mulation may be warranted. serum antibiotic concentration in order to achieve sufficient an-
It is prudent to take into consideration both economic and tibiotic exposure in infected tissues, including those with exten-
social conditions that will impact compliance with care and sive parenchymal disease, parapneumonic effusions, or lung
safety of discharge in these patients. Although the effect of abscess. Specific criteria to identify children with a need for
cost of outpatient medication on adherence has not been prolonged parenteral therapy have not been well defined.
studied in pediatric pneumonia, low-income parents are less No randomized trials have examined the appropriateness of
likely to comply with prescribed medicines for a variety of oral compared with parenteral outpatient antibiotic therapy in
medical illnesses [297, 298]. For children with pneumonia children with CAP. Selection of oral antimicrobial therapy that
who are being discharged, it is reasonable to verify that a pa- is well tolerated and well absorbed, achieving the required an-
tient’s prescribed regimen as well as follow-up outpatient timicrobial exposure at the site of infection, is essential for on-
services and care will not incur a cost that will reduce the going outpatient treatment in a compliant family. The risks of
likelihood of compliance. adverse events from oral therapy are less than those of in-
In one large Canadian study, children with pneumonia were travenous therapy [300].
more likely to be hospitalized simply because they were of lower Early retrospective studies documented the efficacy of oral
socioeconomic status, presumably because of poor timely access step-down therapy in children, including children with CAP
to adequate outpatient services [59]. In another study in the [225]. More recent studies of oral step-down therapy of osteo-
United States, children hospitalized with CAP who came from myelitis, with some prospectively collected data on treated

Table 10. Areas for Future Research in Pediatric Community- complications of peripherally inserted central venous catheters
Acquired Pneumonia (CAP) [300], suggesting that parenteral outpatient therapy should be
reserved for children who are unable to tolerate (either unable to
1. Define the epidemiology of community acquired pneumonia
caused by specific bacteria, viruses, atypical bacteria, and take or unable to absorb) appropriate oral antibiotics and those
disease caused by combinations of $1 virus and bacteria for with infections caused by resistant bacteria for which appro-
all pediatric age groups, in countries with universal use of
protein-conjugate vaccines for Streptococcus pneumoniae and
priate oral antibiotics are unavailable.
Haemophilus influenzae type b
2. Define risk factors (epidemiologic, clinical and laboratory) for PREVENTION
respiratory failure and hospitalization in the developed world
3. Define mild, moderate, and severe pneumonia for children in
the developed world using clinical, laboratory, and oximetry XX. Can Pediatric CAP Be Prevented?
parameters that will enable reliable assessment of the outcome Recommendations
of interventions for each set of children
4. Develop diagnostic tests (on respiratory tract secretions, blood, or 88. Children should be immunized with vaccines for
respiratory tract tissue) that are noninvasive yet sensitive and bacterial pathogens including S. pneumoniae, H. influenzae

specific in documenting clinical disease caused by single
pathogens or combinations of pathogens type b and pertussis to prevent CAP. (strong recommendation;
5. Develop and validate for universal use interpretive criteria for chest high-quality evidence)
radiographs in the diagnosis of pediatric CAP 89. All children and adolescents $6 months of age should
6. Enhance the ability to track antimicrobial resistance on local, be immunized annually with vaccines for influenza virus to
regional, and national levels and communicate these data in
ways that can affect local decisions on selecting the most prevent CAP. (strong recommendation; high-quality evidence)
appropriate antimicrobial at the most appropriate dosage 90. Parents and caretakers of infants ,6 months of age,
7. Develop diagnostic tests, such as acute-phase reactants, that can including pregnant adolescents, should be immunized with
validate a clinical impression of severity of disease and can be
used to assess appropriate response to therapy vaccines for influenza virus and pertussis to protect the
8. Collect and publish data on the expected response of CAP, by infants from exposure. (strong recommendation; weak-quality
pathogen, to appropriately active antimicrobial agents evidence)
9. Conduct more studies on the impact of viral testing on patient
outcomes and antibiotic prescribing behavior to potentially limit
91. Pneumococcal CAP after influenza virus infection is
the use of inappropriate antibiotic treatment decreased by immunization against influenza virus. (strong
10. Assess the role of antimicrobial therapy for atypical bacterial recommendation; weak-quality evidence)
pathogens in pediatrics, particularly for children ,5 years of age
92. High-risk infants should be provided immune
11. Develop clinical trial designs that can provide information on the
lowest effective antimicrobial dose for the shortest duration of prophylaxis with RSV-specific monoclonal antibody to decrease
therapy to decrease the development of antimicrobial resistance the risk of severe pneumonia and hospitalization caused by RSV.
and the risk of antimicrobial toxicity
12. Develop clinical trial designs that assess the value of combination
antimicrobial therapy for severe pneumonia, including
combinations that are designed to decrease toxin production in Evidence Summary
certain pathogens while also inhibiting growth Infections with S. pneumoniae and H. influenzae type b are
13. Analyze the cost-effectiveness of each diagnostic and therapeutic among the most common causes of pediatric CAP worldwide
intervention for children in the developed world
14. Determine the best imaging techniques for parapneumonic [303, 304]. These 2 pathogens account for approximately half
effusions that provide high-quality diagnostic information with of pneumonia deaths globally in children ,5 years old [305].
minimal radiation exposure
Infection with both of these pathogens is preventable through
15. Determine which children with parapneumonic effusions require
drainage procedures and which procedures are most appropriate immunization. In the United States, pneumococcal conjugate
for children with complicated effusions and H. influenzae type b conjugate vaccines have been rec-
16. Standardize management of thoracostomy catheters with ommended for infants and children as part of the routine
creation of standard criteria for removal of catheters
infant immunization schedule and have reduced rates of
17. Determine appropriate duration of antimicrobial therapy in
children with complicated parapneumonic effusions morbidity and mortality from pneumococcal and H. influ-
18. Determine the criteria required for hospital discharge for children enzae type b pneumonia [306–308]. In 2010, the US Food and
who continue to need antibiotics administered intravenously, Drug Administration approved the 13-valent pneumococcal
intramuscularly, or orally
19. Identify and address barriers to medical care for children with
conjugate vaccine, and the CDC Advisory Committee on
CAP Immunization Practices has issued guidelines for the use of
this immunization in children [98, 309]. The 13-valent vaccine
(PCV13) contains antigen for the 7 serotypes in the PCV7 vac-
children, have demonstrated the safety and effectiveness of oral cine (serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F) and for 6
outpatient therapy for serious bacterial infections [301, 302]. additional serotypes (1, 3, 5, 6A, 7F, and 19A). Some of these
Studies have also highlighted the relatively high frequency of additional serotypes have been reported in North America,

South America, and Europe and are often implicated in pneu- ambulatory setting and to guide the admission, management,
monia, especially pneumonia complicated by empyema or ne- and discharge decisions for hospitalized patients. Outcomes that
crosis [89, 236, 250, 258, 310–316]. The licensure of PCV13 may can be standardized, measured, and compared will allow us to
decrease complicated pediatric pneumonia and empyema. establish benchmarks for the care of children with CAP, with an
Influenza virus LRTIs in children may be associated with understanding of the variability in the clinical course between
bacterial pneumonia, with or without empyema [260, 317–320]. pathogens (bacterial, viral, fungal, tuberculosis, and co-
Immunization with the inactivated trivalent vaccines provides infections), between age groups, between socioeconomic groups,
an average vaccine efficacy of 86% (95% confidence interval, and between those with genetic differences in immune re-
29%–97%) [321], and live, cold-adapted, attenuated vaccine, sponse). In addition, defined outcome measures with current
provides even greater efficacy in young children 6–59 months of standards of care will enable subsequent documentation of the
age [322], compared with inactivated trivalent vaccine. The benefits of new therapeutic interventions.
highest rates of protection were documented for years in which Relevant outcomes to be considered in the evaluation of
the vaccines strains were well matched for circulating strains of children hospitalized with pneumonia include time to resolution

influenza in the community, particularly for the inactivated of observed clinical and vital sign abnormalities (including fever,
trivalent vaccines. work of breathing, respiratory rate, tachycardia, need for paren-
In children, bacterial pneumonia, particularly pneumococcal teral fluid administration, need for surgical intervention, de-
pneumonia and, more recently, CA-MRSA pneumonia, has been velopment of pneumonia-associated local, metastatic, or systemic
associated with preceding seasonal influenza virus infection [277, complications, and mortality). Additional outcomes that can
323, 324]. Complicated pneumonia and empyema have also been be measured to assess the effectiveness of interventions include
associated with historical influenza pandemics [63, 325–327] and the requirement for hospitalization, length of hospitalization,
the 2009 H1N1 pandemic [259]. The CDC Advisory Committee readmission after discharge, and costs of care. Few of these out-
on Immunization Practices and the AAP currently recommend comes have been considered in studies of childhood CAP. Sev-
universal annual influenza immunization for infants and children eral, such as the requirement for hospitalization and length of
aged $6 months [328]. Universal influenza immunization can hospitalization, are subjective and may be related to important
decrease pediatric CAP in the United States. nonclinical factors, including psychosocial or behavioral consid-
Respiratory syncytial virus is the most common viral etiology erations, socioeconomic considerations, potential for non-
of hospitalization for CAP in infants [329]. Studies have docu- adherence to prescribed therapy, and barriers to follow-up
mented the ability of palivizumab (Synagis) to decrease the risk medical care. Others, such as persistence of clinical symptoms,
of hospitalization due to RSV disease in otherwise healthy, may be related to nonbacterial causes of pneumonia.
premature young infants and those with medical conditions that Many randomized trials of adults hospitalized with CAP use
place them at greater risk of hospitalization from infection, in- mortality as the primary outcome measure. Among children,
cluding chronic lung disease of prematurity, congenital abnor- mortality attributable to CAP has decreased by 97% over the
malities of the airway, and neuromuscular disease [330]. past 50 years to ,5% of children hospitalized with CAP [331].
Guidelines for the use of palivizumab have been published by In a large cohort of children hospitalized with CAP at 38 tertiary
the AAP and focus on those most likely to benefit from pro- care children’s hospitals, only 156 of 20,703 children (0.75%)
phylaxis during the RSV season: the most premature infants and hospitalized with CAP died [332]. Mortality rates should be
those with comorbid conditions, including underlying lung examined in all studies of childhood pneumonia, though the
pathology or congenital abnormalities of the airways, hemody- infrequency of deaths precludes the use of mortality as a primary
namically significant congenital heart disease, and neuromus- outcome measure in the United States and other developed
cular diseases [220]. countries.
Directly related to the issue of outcome measures for child-
hood CAP is the selection of the initial site of care, whether
AREAS FOR FUTURE RESEARCH
outpatient or in the hospital. This decision is important, because
Throughout these guidelines, it has been noted that high-quality it directly affects the intensity of subsequent testing and therapy.
evidence to support recommendations is often lacking. Areas The wide variation in CAP-related admission rates between
that have been specifically highlighted in the guidelines are neighboring geographic regions [333] suggests that physicians
summarized in Table 10. do not use consistent criteria to make site-of-care decisions.
Unnecessary hospitalization has disadvantages, including nos-
Objective Outcome Measures ocomial infection, exposure to ionizing radiation, and increased
Objective outcome measures are needed to guide decisions healthcare costs. However, outpatient management of high-risk
surrounding initial site of care for patients evaluated in the patients may increase CAP-associated morbidity rates. As is the

case for CAP in adults [32–35, 38], triage decisions might be years ago had evidence of only mild obstructive lung disease,
facilitated by the creation of clinical prediction rules that identify whereas no lung function abnormalities were reported among 13
patients at high or low risk of clinical deterioration and pneu- patients studied by Satish et al [340] just 7 years ago. The impact
monia-associated complications. of the improved quality of care provided by pediatric hospital
medicine specialists and pediatric critical care specialists during
Cost Analysis the past 3 decades is likely to be substantial but remains poorly
The medical costs of caring for a child with CAP are $1464 per defined.
episode (in 1997 dollars) [334]. The mean costs for the subset
of patients requiring hospitalization are $12 000 per episode
[335]. Contributing to the family burden are parental days of Notes
work loss, ranging from 2 days for CAP treated in the am- Acknowledgments. The members of the panel wish to express their
bulatory setting to 4 days for CAP requiring hospitalization, gratitude to Drs Joseph St Geme, Richard L. Hodinka, Michael Light, and
Karen L. McGowan for their thoughtful review of earlier drafts of the
and family stress, leading to repercussions for parents’ health

manuscript. In addition, the panel is greatly indebted to Jennifer Padberg,
and family morale [336]. Cost is not considered a primary MPH (IDSA), and Christy Phillips, MSA (PIDS), for exceptional organiza-
outcome for childhood pneumonia. However, cost may be in tional skills in coordinating meetings, conference calls and several drafts of
the guidelines manuscript conforming to the new GRADE (Grades of Rec-
important factor in choosing among therapies with similar
ommendation, Assessment, Development, and Evaluation) method of as-
efficacy. Therefore, studies examining the comparative effec- signing a strength to the recommendations and the quality of the evidence.
tiveness of different treatment strategies for uncomplicated The recommendations in this report do not represent an official doc-
pneumonia and severe pneumonia complicated by para- ument of the Centers for Disease Control and Prevention. It is important
to realize that guidelines cannot always account for individual variation
pneumonic effusions, empyema, abscesses or necrosis should among patients. They are not intended to supplant physician judgment
examine cost as a secondary outcome measure. Cost analyses with respect to particular patients or special clinical situations. IDSA
may also include nonmedical costs, such as lost parental in- considers adherence to the guidelines listed below to be voluntary, with the
ultimate determination regarding their application to be made by the
come. physician in the light of each patient’s individual circumstances.
Financial support. This work was supported by the IDSA.
Long-Term Disability Potential conflicts of interest. J. S. B. has received no pharmaceutical
funding or support during the past 36 months for management of pedi-
Few studies have examined long-term outcomes of children with
atric CAP. C. L. B. served as principal investigator on Wyeth/Pfizer
pneumonia. Several longitudinal studies suggest that children clinical trials of PCV13; the funding was to her employer, the University of
with LRTIs in childhood are at higher risk of subsequently de- Utah. C. H. has received honoraria from Sanofi Pasteur, and his employer
veloping obstructive lung disease; most of these studies, however, has received grant funds for research performed by C. H. from Johnson &
Johnson Pharmaceuticals, Cubist, Merck, Sanofi Pasteur, Astellas, and
did not confirm the diagnosis of pneumonia with chest radi- GlaxoSmithKline. S. L. K. has served as a consultant for Pfizer, Glax-
ography, and whether the respiratory tract infection was the oSmithKline, and Novartis. S. E. M. has served as principal investigator on
cause or consequence of airway hyperreactivity is unclear. a Gebauer clinical trial for vapocoolant and a clinical site investigator for
a multicenter Baxter Hylenex clinical trial, the funding for both trials was
Among children with pneumonia complicated by para- to her employer, the Cleveland Clinic; she has also served as consultant for
pneumonic effusion or empyema, scoliosis, though uncommon, Baxter Health Care, Halozyme Therapeutics, Pricara (Ortho-McNeil-
may occur but is usually transient. Abnormalities in lung func- Janssen), Rox-888, and Venasite. J. A. S. has given expert testimony for
Finley, Alt, Smith, and Schamberg. S. S. S. receives research support from
tion are common, but no consistent pattern of abnormalities the National Institutes of Health and the Robert Wood Johnson Foun-
exists, and the sample sizes are too small to enable meaningful dation. He received past research support from Wyeth Pharmaceuticals
comparisons between drainage procedure and lung function (completed September 2009); the funding was to his employer. All other
authors:No reported conflicts.
abnormalities. Furthermore, because these children were not All authors have submitted the ICMJE Form for Disclosure of Potential
evaluated for lung function before the diagnosis of pneumonia, it Conflicts of Interest. Conflicts that the editors consider relevant to the
also possible that premorbid conditions involving lung function content of the manuscript have been disclosed.
existed before pneumonia but were assumed by investigators to
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IDSA GUIDELINES

The Management of Community-Acquired

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Strength of recommendation Clarity of balance between Methodologic quality of supporting

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Signs of Respiratory Distress

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46. Ampicillin or penicillin G should be administered to the

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Oral therapy (step-down therapy

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Alternatives: ceftriaxone (50–100 mg/kg/day every Alternative: oral clindamycina

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Alternatives: intravenous erythromycin lactobionate Alternatives: clarithromycin

Alternatives: intravenous erythromycin lactobionate Alternatives: clarithromycin

Doses for oral therapy should not exceed adult doses.

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Risk of poor Tube drainage with or

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Yes, if the patient has respiratory

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76. A pulmonary abscess or necrotizing pneumonia identified

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