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Pneumonia in children: Inpatient treatment

Author:

William J Barson, MD

Section Editors:

Morven S Edwards, MD

George B Mallory, MD

Deputy Editor:

Mary M Torchia, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Sep 2016. | This topic last updated: Jul 05, 2016.

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

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

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

HOSPITALIZATION

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

●Hypoxemia (oxygen saturation [SpO2] 70 breaths/minute for infants 50 breaths per minute for older children; retractions; nasal flaring; difficulty breathing; apnea; grunting

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

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

●Complications (eg, effusion/empyema)

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

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

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

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

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

●Recurrent apnea or slow irregular respirations

●Cardiovascular compromise with progressive tachycardia and/or hypotension that requires or is refractory to fluid management

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

●Respiratory rate >70 breaths/minute for infants 50 breaths/minute for older children

●Apnea

●Increased work of breathing (retractions, dyspnea, nasal flaring, grunting)

●PaO2/FiO2 ratio 6 [5]

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

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

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

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

●Adenovirus – Contact and droplet precautions

●Methicillin-resistant S. aureus and other multidrug resistant organisms – Special organism precautions; contact and droplet precautions and dedicated patient equipment

These precautions are discussed separately (see "General principles of infection control"). Guidelines for hand hygiene in healthcare settings can be accessed through the Centers for Disease Control and Prevention.

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

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

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

We suggest that children with oxygen saturation [SpO2] 92 percent) [2]. Gentle bulb suction of the nares may be helpful in infants and children whose nares are blocked with secretions. Minimal handling seems to reduce oxygen requirements. (See "Continuous oxygen delivery systems for infants, children, and adults".)

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

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

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

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

Adjunctive glucocorticoid therapy — We do not routinely provide adjunctive glucocorticoid therapy to children hospitalized with pneumonia. Although a systematic review and meta-analysis of randomized trials in adult patients hospitalized with CAP found that corticosteroid therapy may be beneficial in reducing the development of acute respiratory distress syndrome, need for mechanical ventilation, and the duration of hospitalization [18], additional studies in children are necessary. A retrospective study evaluating adjunctive glucocorticoid therapy for children being treated for CAP in the outpatient setting found an association between adjunctive glucocorticoid therapy and treatment failure in children without underlying asthma [19].

EMPIRIC THERAPY

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

The recommendations of most guidelines are based on in vitro susceptibilities of the most likely pathogen or pathogens, rather than evidence of the superiority of one antibiotic over another. Clinical response to empiric therapy and results of microbiologic studies, when available, help to determine whether additional evaluation or changes in therapy are necessary [1,2]. (See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Microbiology' and 'Specific therapy' below and 'Response to therapy' below.)

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

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

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

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

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

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

Influenza pneumonia — Initiation of antiviral treatment for influenza (eg, oseltamivir) as soon as possible is recommended for children hospitalized with presumed influenza pneumonia; laboratory confirmation should not delay initiation of antiviral therapy. The diagnosis and treatment of influenza in children are discussed separately. (See "Seasonal influenza in children: Prevention and treatment with antiviral drugs", section on 'Antiviral therapy' and "Seasonal influenza in children: Clinical features and diagnosis", section on 'Diagnosis'.)

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

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

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

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

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

Ampicillin or penicillin G generally provides adequate coverage for the fully immunized child (table 4) in communities without substantial prevalence of penicillin-resistant S. pneumoniae [1,34,35]. We suggest a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) for children younger than 12 months and those who are not fully immunized because third-generation cephalosporins provide coverage for the beta-lactamase producing pathogens (eg, H. influenzae and M. catarrhalis) that may occur in these children. We also suggest third-generation cephalosporins for children with more severe illness (table 1) because third-generation cephalosporins provide coverage for a broader range of pathogens, including penicillin-resistant S. pneumoniae, than ampicillin [1,36,37]. The fifth-generation parenteral cephalosporin, ceftaroline, is approved by the US Food and Drug Administration (FDA) for treatment of community-acquired bacterial pneumonia due to S. pneumoniae, methicillin-susceptible S. aureus (MSSA), and H. influenzae in children ≥2 months of age. Although ceftaroline exhibits in vitro activity against MRSA, clinical experience is insufficient to suggest its use when MRSA is a consideration. In a randomized trial in children between 2 months and 35 to 60 mg/L [3.5 to 6 mg/dL], chills, no response to outpatient therapy with a macrolide or doxycycline) [4,40].

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

Severe CAP

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

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

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

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

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

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

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

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

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

When treating with vancomycin, renal function and serum trough levels or dosing to achieve an area under thecurve/minimum inhibitory concentration (AUC/MIC) ratio >400 should be monitored in an attempt to assure therapeutic efficacy and limit toxicity. In adults, vancomycin trough levels between 15 and 20 microgram/mLhave been suggested to improve clinical outcomes for complicated infections due to S. aureus [45-47]. Similar trough levels may not be needed in children to achieve an AUC/MIC >400 and further studies are needed to evaluate the clinical effectiveness and safety of these dosing recommendations in children [47-52].

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

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

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

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

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

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

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

●Parapneumonic effusion/empyema – The treatment of parapneumonic effusion and empyema is discussed in detail separately. (See "Management and prognosis of parapneumonic effusion and empyema in children".)

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

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

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

●Pneumatocele – Most pneumatoceles involute spontaneously [61-63]. However, on occasion, pneumatoceles result in pneumothorax [64].

Hospital-acquired pneumonia — Empiric treatment of hospital-acquired pneumonia should include coverage for S. aureus, Enterobacteriaceae, Pseudomonas aeruginosa, and anaerobes. Acceptable broad spectrum regimens usually include an aminoglycoside (for gram-negative pathogens) and another agent to address gram-positive pathogens and anaerobes (table 2):

●Aminoglycoside (usually gentamicin; amikacin if extended spectrum or Amp C beta-lactamase producing gram-negative rods are possible etiologies) plus one of the following:

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

•Meropenem 60 mg/kg per day IV in three divided doses, up to a maximum of 6 g/day if extended-spectrum or Amp C beta-lactamase-producing gram-negative rods are possible etiologies, or

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

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

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

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

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

Aspiration pneumonia — Empiric antibiotic regimens for community-acquired aspiration pneumonia must cover oral anaerobes. Appropriate antibiotic regimens for hospitalized children include [53]:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

●Methicillin-susceptible S. aureus – Methicillin-susceptible S. aureus pneumonia may be treated withoxacillin, nafcillin, or cefazolin [1,4]

●Methicillin-resistant S. aureus (MRSA) (see "Methicillin-resistant Staphylococcus aureus in children: Treatment of invasive infections", section on 'Definitive therapy')

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

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

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

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

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

DURATION OF TREATMENT

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

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

Uncomplicated cases — The usual duration of combined parenteral and oral therapy for uncomplicated pneumonia is 7 to 10 days [1,2]. Some authorities suggest continuing oral therapy at least one week beyond resolution of fever; others suggest treating until the erythrocyte sedimentation rate falls below 20 mm/hour. Some data from trials in adults suggest that a shorter course may be equivalent to a 7- to 10-day course, but additional controlled studies are necessary before this practice can be recommended routinely for children [53,66,67].

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

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

●Temperature

●Respiratory rate

●Heart rate

●Oxygen saturation (SpO2)

●Work of breathing (eg, retractions, nasal flaring, grunting)

●Chest examination (extent of abnormal or absent breath sounds; extent of dullness to percussion)

●Mental status

●Ability to maintain oral intake and hydration

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

The respiratory status of children with community-acquired pneumonia (CAP) who are appropriately treated should improve within 48 to 72 hours [1]. However, fevers may persist for several days after initiation of appropriate therapy [53].

Treatment failure — In children who fail to improve as anticipated, the following possibilities must be considered [1,2,68,69]:

●Alternative or coincident diagnoses (eg, foreign body aspiration) (see "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Differential diagnosis')

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

●Development of complications (see "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Complications')

●Underlying immunodeficiency condition

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

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

Depending upon the severity of illness, more aggressive attempts may need to be made to establish a microbiologic diagnosis (eg, induced sputum [70], bronchoscopy with bronchoalveolar lavage, percutaneous needle aspiration, or lung biopsy). In children with lung abscess whose condition fails to improve or worsens after 72 hours of antibiotic therapy, needle aspiration or percutaneous catheter drainage may provide diagnostic information and therapeutic benefit [53,54,58,59]. (See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Invasive studies'.)

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

●Improvement of vital signs

●Ability to maintain adequate fluid and nutrition orally

●Ability to maintain oxygen saturation ≥90 percent in room air

●Improvement in respiratory status

●Overall clinical improvement including level of activity, appetite, and decreased fever for at least 12 to 24 hours

●Stable and/or baseline mental status

●Parents' ability to administer and child's ability to comply with home antibiotic regimen

●Safe and compliant home environment

Outpatient parenteral antibiotic therapy — Outpatient parenteral antimicrobial therapy (OPAT) is an option for selected patients who require prolonged treatment (usually for complicated CAP that for some reason cannot be treated with an oral antibiotic) and have stabilized clinically [53,71,72]. Eligibility for OPAT requires a suitable home environment and a pharmacologic agent with a reasonable dosing schedule [73]. Decisions regarding OPAT should involve the caregivers, an infectious disease specialist (or clinician knowledgeable about the use of antimicrobial agents in OPAT), a hospital pharmacist, and the primary care provider. The services of a visiting nurse may be required for home visits, education and observation of caregiver administration, and/or obtaining blood samples for therapeutic monitoring.

FOLLOW-UP

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

Children who are appropriately treated for pneumonia should gradually improve with time. Cough may persist for as long as three to four months after viral pneumonia or pertussis. Children who are recovering from typical or atypical bacterial pneumonia may continue to cough for several weeks and have moderate dyspnea on exertion for two to three months [74]. Symptomatic treatment of cough is discussed separately. (See "The common cold in children: Management and prevention", section on 'Cough'.)

Radiographs — Follow-up radiographs are not necessary in asymptomatic children with uncomplicated community-acquired pneumonia (CAP). However, in children with complicated CAP or CAP that required intervention, follow-up radiographs help to ensure resolution [2,75]. Follow-up radiographs also may be helpful in children with recurrent pneumonia, persistent symptoms, severe atelectasis, unusually located infiltrates, or round pneumonia (ie, pulmonary consolidation that appears to be spherical) [2,53,76]. Conditions that must be considered if a round pneumonia fails to resolve on follow-up imaging include congenital lung sequestration, metastatic Wilms tumor, cavitary necrosis, pleural pseudocyst, and primary lung carcinoma [76-80]. When follow-up radiographs are indicated, they should be obtained two to three weeks after hospital discharge [53,81].

Several studies have evaluated the utility of follow-up radiographs in cohorts of children with acute radiologically proven CAP [82-87]. Three of the studies included clinical as well as radiologic follow-up at three to seven weeks after initial diagnosis [82-85]. In each of these studies, follow-up radiographs were normal or improved in asymptomatic children. Residual findings, even when present, did not result in additional therapy.

PROGNOSIS — Most otherwise healthy children with pneumonia recover without sequelae, even if the pneumonia is complicated [53,55,56,88]. In a multicenter cohort study, approximately 3 percent of 82,566 children hospitalized with pneumonia were readmitted with pneumonia within 30 days of discharge; 8 percent were readmitted for any reason. Readmission was more common among children younger than one year and children with chronic medical conditions [89].

Although some data suggest that nearly one-half of children who are hospitalized for viral pneumonia have symptoms of asthma five years after hospitalization, it is not clear whether this is related to unrecognized asthma at the time of presentation with pneumonia or a tendency to develop asthma after community-acquired viral pneumonia [90,91].

The overall pneumonia mortality rate in developed countries is ................
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