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Community-Acquired Pneumonia in Children (Older Than 3 Months)
Synopsis
Key Points
- Community-acquired pneumonia is an acute infection of the pulmonary parenchyma that occurs in a child who has not resided in a hospital or health care facility in the preceding 14 days
- Patient presents with fever, cough, and tachypnea. In the setting of fever, tachypnea is the most sensitive finding suggesting pneumonia in young children
- Most of the pediatric pneumonia cases are viral; the most common bacterial cause is Streptococcus pneumoniae
- When diagnosis of SARS-CoV-2 is suspected or probable, implement COVID-19 transmission-based precautions and confirm with nucleic acid amplification test or antigen test performed on respiratory specimen
- Chest radiography, cultures, and other diagnostic testing are not routinely recommended but are indicated when the child is sick enough to require admission
- For outpatient treatment, amoxicillin is the first line therapy for a previously well, appropriately immunized child with pneumonia. Macrolide antibiotics are first line therapy for a child with probable atypical pneumonia
- For inpatient treatment, ampicillin or penicillin G is recommended for fully immunized children unless there is evidence of local high-level penicillin resistance. Otherwise, give a third-generation parenteral cephalosporin (eg, ceftriaxone, cefotaxime)
- Empiric combination therapy with a macrolide (oral or parenteral) and a β-lactam antibiotic are indicated when Mycoplasma pneumoniae and Chlamydia pneumoniae are significant considerations for a hospitalized child
- Treat children with community-acquired pneumonia and probable influenza with influenza antiviral therapy
- Treatment of COVID-19 pneumonia includes strict infection-control measures and routine supportive care; treatment may include use of remdesivir and dexamethasone, when indicated
- Supportive care includes oxygen for a pulse oximetry reading lower than 90%, IV fluids for dehydration, and antipyretics for a fever r1
- Routine childhood vaccinations are recommended to prevent acquisition of many pathogens responsible for community-acquired pneumonia (eg, Streptococcus pneumoniae, Haemophilus influenzae type b, pertussis, influenza, varicella, measles)
- Vaccination against COVID-19 is recommended for children aged 5 years or older
Urgent Action
- Administer supplemental oxygen for oxygen saturation lower than 90% r1
- Consider noninvasive positive pressure ventilation for patients with greater than 50% FiO₂ requirement or other signs of significant respiratory distress
- Administer antibiotics as soon as possible to any ill-appearing patient or patients suspected of having bacterial pneumonia
Pitfalls
- Consider a foreign body in a child with recurrent pneumonia
Terminology
Clinical Clarification
- Community-acquired pneumonia is an acute infection of the pulmonary parenchyma that occurs in a child who has not resided in a hospital or health care facility in the preceding 14 days
Classification
- By cause
- Typical
- Caused by Streptococcus pneumoniae
- Atypical
- Caused by Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella species, and respiratory viruses
- Typical
- By severity level (and site of care)
- Pneumonia that can be managed as an outpatient r1
- Moderate to severe community-acquired pneumonia, as defined by respiratory distress and/or hypoxemia, that should be managed with general ward admission r1
- Respiratory distress
- Tachypnea, retractions, grunting, and nasal flaring
- Apnea
- Altered mental status
- Hypoxemia
- Pulse oximetry measurement less than 90% on room air
- Respiratory distress
- Severe pneumonia that meets at least 1 major or 2 minor severity criteria that require ICU admission r1
- Major criteria
- Need for invasive mechanical ventilation
- Fluid refractory shock
- Acute need for noninvasive positive pressure ventilation
- Hypoxemia requiring FiO₂ greater than inspired concentration or flow feasible in general care area
- Minor criteria
- Respiratory rate higher than WHO classification for age
- Apnea
- Increased work of breathing (eg, retractions, dyspnea, nasal flaring, grunting)
- PaO₂ to FiO₂ ratio less than 250
- Multilobar infiltrates
- Pediatric Early Warning score (bedside nursing assessment tool based on vital signs and neurologic examination) greater than 6 r2
- Altered mental status
- Hypotension
- Presence of effusion
- Comorbid conditions (eg, sickle cell anemia, immunosuppression, immunodeficiency)
- Unexplained metabolic acidosis
- Major criteria
Diagnosis
Clinical Presentation
History
Physical examination
- Fever
- Tachypnea alone is a sensitive sign of pneumonia r6c12
- Nasal flaring, retractions, and reduced oxygen saturation increase likelihood of pneumonia diagnosis c13c14c15
- Abnormal lung examination
- Localized rales on auscultation in younger children c16
- Rales, bronchial breathing, and pleural rub on auscultation in older children c17c18c19c20c21c22
- Wheezing more commonly associated with atypical or viral pneumonia c23
- Absent breath sounds and dull percussion raise concern for an effusion r5c24c25
Causes and Risk Factors
Causes
- Most common, by age group
- Neonatal
- Children older than 1 month
- Viral (up to 70% of cases) r7
- Human respiratory syncytial virus (more common among children younger than 5 years) r8c30c31
- Parainfluenza virus 1, 2, and 3 c32
- Influenza A and B virus c33c34
- SARS-CoV-2 d1
- Limited data suggest that SARS-CoV-2 is responsible for up to 20% of community-acquired pneumonia cases among children requiring hospital admission during pandemic conditions r3
- Human adenovirus (more common among children younger than 5 years) r8c35c36
- Human rhinovirus c37
- Human herpesvirus 1 and 2 c38
- Human metapneumovirus (more common among children younger than 5 years) r8c39c40
- Human enterovirus c41
- Bacterial r7
- Streptococcus pneumoniae (routine childhood vaccination has led to reduced incidence) c42
- Haemophilus influenzae type b (routine childhood vaccination has led to reduced incidence) c43
- Moraxella catarrhalisc44
- Staphylococcus aureusc45
- Mycoplasma pneumoniae (more common among older children and adolescents) c46
- Chlamydia pneumoniae (more common among older children and adolescents) c47
- Viral (up to 70% of cases) r7
Risk factors and/or associations
Age
Sex
Other risk factors/associations
- Chronic respiratory conditions leading to infection (eg, cystic fibrosis, bronchiectasis) c54c55c56
- Immune deficiency c57
- Chronic lung disease of prematurity c58
- Congenital heart disease c59
- Use of gastric acid inhibitors r10c60
- Risk factors in developing countries: r11
- Definite risk factors
- Likely risk factors
Diagnostic Procedures
Primary diagnostic tools
- History and physical examination are the primary diagnostic tools c72
- Suspected or probable infection with SARS-CoV-2
- Implement early and strict transmission-based precautions using contact, respiratory droplet, and airborne precautions during aerosol-generating procedures
- Note that chest imaging is not usually necessary in most children with lower respiratory tract infection with SARS-CoV-2 because imaging does not often change clinical management and poses a risk to infection-control measures r12
- Confirm Sars-CoV-2 infection with nucleic acid amplification test or antigen test performed on respiratory specimen r13
- Additional testing for patients admitted to the hospital (those meeting requirements for moderate to severe pneumonia)
Laboratory
- Blood cultures c83
- Obtain if child has probable bacterial pneumonia that is moderate to severe, associated with complications, or requires admission r1
- Not routinely needed in children with community-acquired pneumonia who have nontoxic appearance, are fully immunized, and are being treated in the outpatient setting r1
- Obtain if child deteriorates or symptoms get worse after antibiotics are started r1
- Sputum culture c84
- Tracheal aspirates r1
- Obtain if child requires endotracheal intubation c86
- Gram stain and culture
- Viral pathogens, including influenza virus
- Obtain if child requires endotracheal intubation c86
- Viral pathogen testing c87
- Obtain select studies for specific pathogens in hospitalized patients as clinically indicated for isolation measures and when treatment may be affected for certain pathogens such as influenzar14 viruses and SARS-CoV-2r13
- Use sensitive and specific tests for the rapid diagnosis of influenza virus, SARS-CoV-2, and other respiratory viruses
- Influenza viruses
- SARS-CoV-2
- Confirm infection with detection of either viral nucleic acid (nucleic acid amplification test) or protein (antigen test) on respiratory specimen r13
- Atypical bacterial testing
- CBC c89
- Obtain in hospitalized patients r1
- Acute phase reactants (eg, erythrocyte sedimentation rate, C-reactive protein concentration, serum procalcitonin concentration) c90c91c92
- No need to measure routinely in fully immunized children with community-acquired pneumonia who will be treated as outpatients, but may be helpful to measure in children with more serious disease or complications r1
- May help in monitoring response to therapy and course of disease
- May help distinguish between bacterial and viral disease but should not be the sole criteria used r1
- Elevated levels of procalcitonin are associated with greater likelihood of bacterial cause for pneumonia; however, predictive thresholds are not well established r16
- No need to measure routinely in fully immunized children with community-acquired pneumonia who will be treated as outpatients, but may be helpful to measure in children with more serious disease or complications r1
Imaging
- Chest radiography c93
- Not necessary for patients with suspected community-acquired pneumonia with mild symptoms who do not require admission r1r17
- Use posteroanterior and lateral radiographic views for patients with hypoxemia, respiratory distress, or other indications for hospitalization and for patients who do not respond to initial outpatient antibiotic therapy r1r17
- British Thoracic Society guidelines do not advocate for routine lateral films r5
- Lobar consolidation is typically seen in pneumococcal pneumonia
- Hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing is seen in most instances of viral pneumonia
- Findings in patients with COVID-19 pneumonia
- Repeat chest radiography in children who do not improve, have worsening of symptoms, or have clinical deterioration within 48 to 72 hours of starting antibiotic therapy
- Lung ultrasonography c94
- Indicated as first line imaging in patients with complicated pneumonia r17r19
- Valuable for diagnosis and assessment of pleural effusions
- Evidence supports lung ultrasonography (which does not require radiation exposure) as an alternative to chest radiography for initial diagnosis of pneumonia in children r20r21r22
- Indicated as first line imaging in patients with complicated pneumonia r17r19
- Chest CT c95
Functional testing
Differential Diagnosis
Most common
- Bronchitis c97d2
- Occurs in older adolescents; acute bronchitis is not usually diagnosed in young children
- Afebrile or low-grade fever (lower than 38 °C), malaise, chest pain, and protracted dry, hacking cough (which may be productive) lasting for 1 to 3 weeks
- Chest radiographs are usually normal or may have increased bronchial markings
- Absence of tachycardia, tachypnea, and high fever helps to differentiate from pneumonia
- Bronchiolitis c98d3
- Acute infection of the lower respiratory tract resulting in small airway obstruction
- Respiratory syncytial virus is the most common cause of bronchiolitis in children younger than 2 years and can be confirmed with rapid viral antigen or polymerase chain reaction, but the diagnosis is clinical
- Commonly occurs in infants aged 1 to 3 months, with peak incidence during winter and early spring
- Usually starts with sneezing and clear rhinorrhea; fine crackles or overt wheezes with prolongation of the expiratory phase of breathing can be heard on auscultation
- Chest radiographs may show hyperinflated lungs with patchy atelectasis
- COVID-19 c99d1
- Spectrum of illness caused by SARS-CoV-2 is quite variable
- Most children exhibit either asymptomatic or mild disease; when symptomatic, the most common manifestations are fever, cough, and sore throat
- Common presenting syndromes include acute respiratory tract infection; asthma exacerbation; influenzalike illness; isolated fever, gastroenteritis, and vomiting; and community-acquired pneumonia
- Up to about 40% of children develop moderate disease (eg, evidence of lower airway disease by clinical assessment or imaging without hypoxia), about 2% develop severe illness (eg, lower airway disease with hypoxia), and about 0.7% devleop critical illness (eg, shock, respiratory failure, multiple organ failure) r23r24
- May have known exposure to confirmed case (typically within own household)
- Infection with respiratory pathogens other than SARS-CoV-2 (eg, influenza, respiratory syncytial virus, Mycoplasma pneumoniae) does not exclude diagnosis because coinfection with additional respiratory pathogens occurs in up to 6% r25
- Findings may be present on chest imaging before symptoms manifest; approximately 44% of children with COVID-19 in 1 systematic review data set show evidence of radiographic abnormalities on chest radiograph or chest CT r26
- Chest imaging r18
- May reveal unilateral or bilateral pulmonary infiltrates
- Pleural effusions are rare
- Findings frequently noted in other lower viral respiratory tract infections are uncommon (eg, increased peribranchial markings, hyperinflation)
- Chest imaging r18
- Diagnosis is confirmed by rapid antigen or polymerase chain reaction for SARS-CoV-2 on specimens from upper respiratory tract r27d4
- Spectrum of illness caused by SARS-CoV-2 is quite variable
- Pertussis c100d5
- Symptoms occur in 3 phases:
- Catarrhal
- Low-grade fever, upper respiratory tract infection symptoms, and cough
- Apnea may occur
- Paroxysmal
- Coughing episodes; whoop occurs in older children
- Vomiting
- Infants typically do not produce a whoop but have paroxysmal cough and/or apnea with color change
- Convalescent
- Persistent cough
- Catarrhal
- Differentiate by cough history and polymerase chain reaction
- Symptoms occur in 3 phases:
- Asthma c101d6
- Symptoms include episodic dry cough, expiratory wheezing, chest tightness, feeling of discomfort in the chest, and shortness of breath in response to physical exertion or airway irritants
- Severe exacerbations are associated with inspiratory and expiratory wheezing, retractions, nasal flaring, and use of accessory respiratory muscles
- Dyspnea is present, but signs of infection are usually absent
- Airway obstruction reversible with bronchodilators in the setting of a clear chest radiograph is diagnostic
- Tuberculosis c102d7
- Suspect when child is from an endemic area or has had contact with persons who are at high risk of having the disease, including those who are urban homeless, are incarcerated, and have HIV infection
- Presents subacutely with anorexia, weight loss, and night sweats
- Differentiate based on history of either being from an endemic area or having exposure to high-risk people
- Acute respiratory distress syndrome c103d8
- Mild respiratory distress with tachypnea, dyspnea, and increased oxygen requirement progresses rapidly to severe hypoxia accompanied by carbon dioxide retention and respiratory failure
- Chest radiograph may reveal interstitial and alveolar pulmonary edema
- Patients with a measured PaO₂ to percentage of the FiO₂ ratio of less than 200 are considered to have severe hypoxia and are classified as having acute respiratory distress syndrome
Treatment
Goals
- Improve respiratory symptoms
- Eradicate infection with antimicrobials, if indicated
- Prevent complications
Disposition
Admission criteria
Respiratory distress r1
- Tachypnea
- Aged 0 to 2 months: more than 60 breaths per minute
- Aged 2 to 12 months: more than 50 breaths per minute
- Aged 1 to 5 years: more than 40 breaths per minute
- Older than 5 years: more than 20 breaths per minute
- Retractions (ie, suprasternal, intercostals, subcostal)
- Grunting
- Nasal flaring
- Apnea
- Altered mental status
Hypoxemia (defined by pediatric pneumonia guidelines as sustained saturation less than 90% on room air) r1
Age younger than 3 to 6 months and suspected bacterial community-acquired pneumonia r1
Suspected or documented community-acquired pneumonia caused by a potentially virulent pathogen, such as community-associated MRSA r1
Moderate (clinical or radiographic evidence of lower airway disease without hypoxia) or severe COVID-19 disease (hypoxia, greater than 50% lung infiltrates, significant tachypnea, or severe respiratory distress) r28d1
Concern about observation at home, inability to comply with therapy, or unavailability for follow-up r1
Criteria for ICU admission
- Need for noninvasive positive pressure ventilation or endotracheal intubation r1
- Impending respiratory failure r1
- Sustained tachycardia, hypotension, or need for pharmacologic support of blood pressure or perfusion r1
- Inspired oxygen greater than 50% results in a pulse oximetry measurement of 92% or less r1
- Altered mental status due to hypercarbia or hypoxemia resulting from pneumonia r1
- Do not use severity of illness scores as the only criteria for ICU admission; use them in the context of other clinical, laboratory, and radiologic findings r1
Recommendations for specialist referral
- Refer to a pediatric infectious disease specialist for:
- Age younger than 6 months
- No improvement on antibiotics
- Recurrent or complicated pneumonia
- Refer to a pediatric surgeon for:
- Pleural effusion
Treatment Options
Empiric antibiotic therapy r1
- Prescribe empiric antibiotic therapy according to age and care setting; typical duration is 7 to 10 days r7
- Outpatient r1
- Older than 3 months to younger than 5 years
- Antimicrobial therapy not routinely required for preschool-aged children with community-acquired pneumonia because the majority of cases are viral
- Amoxicillin is first line therapy for appropriately immunized infants or preschool-aged children with suspected typical bacterial community-acquired pneumonia
- Azithromycin is the first line therapy for children with community-acquired pneumonia suspected to be caused by atypical organisms
- Aged 5 to 17 years
- Amoxicillin is first line therapy for appropriately immunized school-aged children and adolescents with suspected typical bacterial community-acquired pneumonia
- Combination therapy with a macrolide in addition to a β-lactam antibiotic can be prescribed if there are no features to distinguish bacterial from atypical pneumonia
- Azithromycin is first line therapy for children with community-acquired pneumonia suspected to be caused by atypical organisms
- Amoxicillin is first line therapy for appropriately immunized school-aged children and adolescents with suspected typical bacterial community-acquired pneumonia
- Older than 3 months to younger than 5 years
- Inpatient (older than 3 months) r1
- Ampicillin or penicillin G is first line therapy for fully immunized infant or school-aged child admitted to a hospital ward with community-acquired pneumonia when there is no local substantial high-level penicillin resistance for invasive Streptococcus pneumoniae
- A third-generation parenteral cephalosporin (eg, ceftriaxone, cefotaxime) is first line therapy for hospitalized infants and children who are not fully immunized, in regions where invasive pneumococcal strains show high-level penicillin resistance (minimum inhibitory concentrations 4.0 mcg/mL or higher), and for infants and children with life-threatening infection, including those with empyema
- Add antistaphylococcal coverage (eg, clindamycin or vancomycin) if methicillin-resistant Staphylococcus aureus is suspected
- Add a macrolide (oral or parenteral) in addition to a β-lactam antibiotic if atypical organisms are significant considerations
- However, empirical macrolide combination therapy conferred no benefit over β-lactam monotherapy for children hospitalized with community-acquired pneumonia in prospective study, including a subset of children with confirmed atypical bacteria r29
Pathogen-directed therapy r1
- Adjust antibiotic therapy, if necessary, based on culture results r1
- Recommended antibiotic regimens for specific pathogens are available in Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America r1
Influenza antiviral therapy r1
- Indicated for children of any age hospitalized with suspected or confirmed influenza-induced community-acquired pneumonia regardless of duration of symptoms r30
- Also offer to outpatients with severe, complicated, or progressively worsening illness attributable to influenza and those at high risk of complications due to influenza r30
- Start treatment as soon as possible; however, even after 48 hours of symptomatic infection treatment, may still provide clinical benefit to those with more severe disease r1
- Do not delay treatment in case of positive influenza test results r1
- Oral oseltamivir is the drug of choice in children older than 2 weeks; zanamivir, peramivir, and baloxavir are alternatives r30
- Consult CDC Influenza Surveillance Report for recent drug resistance information to aid drug selection r31
SARS-CoV-2 therapy d1
- Treat in accordance with hospital isolation policy and standard transmission-based precautions; minimum includes strict contact, respiratory droplet, and airborne precautions during aerosol-generating procedures
- Remdesivir
- FDA approved for use in hospitalized patients aged 12 years and older and weighing 40 kg or more; available through emergency use authorization for hospitalized children younger than 12 years weighing at least 3.5 kg
- Recommended for the following hospitalized patients with COVID-19: r23
- Children aged 12 years and older with risk factors for severe disease and an emergent or increasing supplemental oxygen requirement
- Children aged 16 years or older with an emergent or increasing supplemental oxygen requirement regardless of risk factors for severe disease
- Consider using (in consultation with an infectious disease specialist) in hospitalized pediatric patients of any age with COVID-19 who have emergent or increasing supplemental oxygen requirement r23
- Dexamethasone
- Recommended for hospitalized pediatric patients with COVID-19 who require any of the following: r23
- High-flow oxygen
- Noninvasive or invasive ventilation
- Extracorporeal membrane oxygenation
- Recommended for hospitalized pediatric patients with COVID-19 who require any of the following: r23
- Children with mild to moderate manifestations at high risk of progression to severe disease r32
- May be eligible for early treatment with certain pharmacotherapeutics (eg, nirmatrelvir-ritonavir, sotrovimab, remdesivir) in consultation with infectious disease specialist r33
Drug therapy
- Penicillins c104
- Amoxicillin c105
- Amoxicillin Trihydrate Oral suspension; Infants and Children 4 months to 12 years: 90 mg/kg/day (Max: 4 g/day) PO in divided doses every 12 hours for 5 to 7 days.
- Amoxicillin Trihydrate Oral capsule; Adolescents: 90 mg/kg/day (Max: 4 g/day) PO divided every 8 to 12 hours for 5 to 7 days.
- Ampicillin c106
- Ampicillin Sodium Solution for injection; Infants 4 to 11 months, Children, and Adolescents: 150 to 400 mg/kg/day IV/IM in divided doses every 6 hours for 10 days.
- Dosages of 300 to 400 mg/kg/day IV/IM in divided doses every 6 hours are used as an alternative to ceftriaxone for resistant strains of Streptococcus pneumoniae.
- Penicillin G c107
- Penicillin G Sodium Solution for injection; Infants, Children, and Adolescents 4 months to 17 years: 100,000 to 250,000 units/kg/day IV/IM divided every 4 to 6 hours for 10 days.
- Amoxicillin c105
- Macrolides c108
- Azithromycin c109
- Oral
- Azithromycin Oral suspension; Infants 3 to 5 months†: 10 mg/kg/dose PO for 1 day, followed by 5 mg/kg/dose PO once daily for 4 days.
- Azithromycin Oral suspension; Infants and Children 6 months to 12 years: 10 mg/kg/dose (Max: 500 mg/dose) PO for 1 day, followed by 5 mg/kg/dose (Max: 250 mg/dose) PO once daily for 4 days.
- Azithromycin Oral suspension; Adolescents: 10 mg/kg/dose (Max: 500 mg/dose) PO for 1 day, followed by 5 mg/kg/dose (Max: 250 mg/dose) PO once daily for 4 days.
- Intravenous
- Azithromycin Solution for injection; Infants, Children, and Adolescents 3 months to 15 years†: 10 mg/kg/dose (Max: 500 mg/dose) IV once daily for 2 days, followed by oral therapy to complete a 5-day treatment course.
- Azithromycin Solution for injection; Adolescents 16 to 17 years: 500 mg IV once daily for at least 2 days, followed by oral therapy to complete a 7- to 10-day treatment course
- Oral
- Clarithromycin c110
- Clarithromycin Oral suspension; Infants 3 to 5 months†: 7.5 mg/kg/dose PO every 12 hours for 10 days.
- Clarithromycin Oral suspension; Infants and Children 6 months to 12 years: 7.5 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 10 days.
- Clarithromycin Oral tablet; Adolescents: 7.5 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 5 to 10 days.
- Erythromycin c111
- Oral
- Erythromycin Ethylsuccinate Oral suspension; Infants 4 to 11 months, Children, and Adolescents: 40 mg/kg/day PO in 4 divided doses (Usual Max: 2 g/day) for 10 days.
- Intravenous
- Erythromycin Lactobionate Solution for injection; Infants 4 to 11 months, Children, and Adolescents: 20 mg/kg/day IV divided every 6 hours (Max: 4 g/day) for 10 days.
- Oral
- Azithromycin c109
- Cephalosporins c112
- Ceftriaxone c113
- Ceftriaxone Sodium Solution for injection; Infants and Children: 50 to 100 mg/kg/day IV divided every 12 to 24 hours (Max: 4 g/day) for up to 10 days.
- Ceftriaxone Sodium Solution for injection; Adolescents: 50 to 100 mg/kg/day IV divided every 12 to 24 hours (Max: 4 g/day) for 5 to 10 days.
- Cefotaxime c114
- Cefotaxime Sodium Solution for injection; Infants and Children: 150 mg/kg/day IV divided every 8 hours (Max: 6 g/day) for 10 days.
- Cefotaxime Sodium Solution for injection; Adolescents: 150 mg/kg/day IV divided every 8 hours (Max: 6 g/day) for 5 to 10 days.
- Ceftriaxone c113
- Vancomycin c115c116
- Vancomycin Hydrochloride Solution for injection; Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients.
- Vancomycin Hydrochloride Solution for injection; Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day for at least 7 days; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter.
- Vancomycin Hydrochloride Solution for injection; Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients.
- Vancomycin Hydrochloride Solution for injection; Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day) for at least 7 days; adjust dose based on target PK/PD parameter.
- Clindamycin c117c118
- Clindamycin Solution for injection; Infants 4 to 11 months and Children: 40 mg/kg/day IV divided every 6 to 8 hours (Max: 1,800 mg/day) for 10 days.
- Clindamycin Solution for injection; Adolescents: 40 mg/kg/day IV divided every 6 to 8 hours (Max: 1,800 mg/day) for 10 days.
- Antivirals c119
- Oseltamivir c120
- Oseltamivir Phosphate Oral suspension; Infants 1 to 8 months: 3 mg/kg/dose PO twice daily for 5 days.
- Oseltamivir Phosphate Oral suspension; Infants 9 to 11 months: 3.5 mg/kg/dose PO twice daily for 5 days.
- Oseltamivir Phosphate Oral suspension; Children weighing 15 kg or less: 30 mg PO twice daily for 5 days.
- Oseltamivir Phosphate Oral suspension; Children weighing 16 to 23 kg: 45 mg PO twice daily for 5 days.
- Oseltamivir Phosphate Oral suspension; Children weighing 24 to 40 kg: 60 mg PO twice daily for 5 days.
- Oseltamivir Phosphate Oral suspension; Children and Adolescents weighing more than 40 kg: 75 mg PO twice daily for 5 days.
- Zanamivir c121
- Zanamivir Inhalation powder; Children and Adolescents 7 to 17 years: 10 mg by oral inhalation every 12 hours for 5 days.
- Administer 2 doses on the first day provided there are at least 2 hours between doses.
- Peramivir c122
- For the treatment of uncomplicated acute influenza (eg, influenza A virus infection or influenza B virus infection)
- Peramivir Solution for injection; Infants and Children 6 months to 12 years: 12 mg/kg/dose (Max: 600 mg/dose) IV as a single dose.
- Peramivir Solution for injection; Adolescents: 600 mg IV as a single dose.
- For the treatment of novel influenza A viruses associated with severe human disease†, including avian influenza A virus infection†
- Peramivir Solution for injection; Infants 91 to 180 days: 10 mg/kg/dose IV once daily for 5 days as alternative in patients who are unable to tolerate or absorb oseltamivir. Consider longer courses (e.g., 10 days) for severely ill hospitalized patients or immunosuppressed patients.
- Peramivir Solution for injection; Infants older than 180 days and Children 1 to 5 years: 10 to 12 mg/kg/dose IV once daily for 5 days as alternative in patients who are unable to tolerate or absorb oseltamivir. Consider longer courses (e.g., 10 days) for severely ill hospitalized patients or immunosuppressed patients.
- Peramivir Solution for injection; Children and Adolescents 6 to 17 years: 10 mg/kg/dose IV once daily (Max: 600 mg/dose) for 5 days as alternative in patients who are unable to tolerate or absorb oseltamivir. Consider longer courses (e.g., 10 days) for severely ill hospitalized patients or immunosuppressed patients.
- For the treatment of uncomplicated acute influenza (eg, influenza A virus infection or influenza B virus infection)
- Baloxavir
- Baloxavir Marboxil Oral tablet; Children and Adolescents 12 to 17 years weighing less than 80 kg: 40 mg PO as a single dose.
- Baloxavir Marboxil Oral tablet; Children and Adolescents 12 to 17 years weighing 80 kg or more: 80 mg PO as a single dose.
- Remdesivir
- Remdesivir Solution for injection; Infants and Children 1 to 11 years weighing at least 3.5 kg NOT requiring invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO)†: 5 mg/kg/dose (Max: 200 mg/dose) IV once on day 1, followed by 2.5 mg/kg/dose (Max: 100 mg/dose) IV once daily for 4 days; may extend treatment for up to 5 additional days if no clinical improvement.
- Remdesivir Solution for injection; Children and Adolescents 12 to 17 years weighing less than 40 kg NOT requiring invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO)†: 5 mg/kg/dose IV once on day 1, followed by 2.5 mg/kg/dose IV once daily for 4 days; may extend treatment for up to 5 additional days if no clinical improvement.
- Remdesivir Solution for injection; Children and Adolescents weighing 40 kg or more NOT requiring invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO): 200 mg IV once on day 1, followed by 100 mg IV once daily for 4 days; may extend treatment for up to 5 additional days if no clinical improvement.
- Oseltamivir c120
Nondrug and supportive care
IV fluids c123
- Indicated for patients who are unable to tolerate oral fluids, have an oxygen requirement, or have moderate to severe disease
Supplemental oxygen c124
- Indicated for patients with pulse oximetry readings lower than 90% r1
Procedures
Noninvasive positive pressure ventilation c125
- Delivery of mechanical respiratory support without the use of endotracheal intubation r34
- Goal of ventilatory support is to unload work of respiratory muscles, increase ventilation, and thus reduce dyspnea and respiratory rate and improve gas exchange
- When FiO₂ greater than 0.5 is necessary to maintain adequate oxygenation
- Best predictive factors for noninvasive positive pressure ventilation failure within the setting of acute respiratory failure appear to be the level of FiO₂ (greater than 0.6) and higher PaCO₂ on admission or within the first hours after starting noninvasive positive pressure ventilation r34
Comorbidities
- Children with the following comorbidities require more careful evaluation for pneumonia (in addition to consultation with an appropriate subspecialist):
- There is a lower threshold for admission of patients with these comorbidities, and they should be monitored for possible worsening of disease
Monitoring
- Arrange clinical follow-up for outpatient-treated patients within 24 to 48 hours; consider hospitalization if condition has deteriorated
- Follow-up chest radiographs are not typically required for uncomplicated cases c131
- Monitoring of patients for discontinuation of COVID-19 isolation measures depends on disease severity and if the patient has significant immunocompromise r35d1
- Symptoms-based strategy is recommended for most immunocompetent children with mild or moderate disease severity
- Isolate for 5 days and if symptoms are resolving (without fever for 24 hours), then follow by 5 days of wearing a mask when around others
- Test-based strategy may be necessary in consultation with an infectious disease specialist for patients with severe to critical COVID-19 and patients with significant immunocompromise
- Patients may require up to 20 days after onset of first symptom and negative results from nucleic acid amplification testing for SARS-CoV-2 RNA
- Symptoms-based strategy is recommended for most immunocompetent children with mild or moderate disease severity
Complications and Prognosis
Complications
- Necrotizing pneumonia c132
- Rare complication; occurs most commonly in preschool-aged children r36
- Streptococcus pneumoniae most common cause r36
- May also occur with other common bacterial pathogens
- Patient develops parapneumonic effusion, pleural empyema, or bronchopleural fistula r36
- Predisposing conditions include congenital cysts, sequestrations, bronchiectasis, neurological disorders, and immunodeficiency r37
- Obtain infectious disease and surgical consultation; may require chest tube/surgical intervention
- Empyema and pleural effusions c133c134c135c136
- Uncommon in outpatients, but incidence increased in patients admitted to hospital r5
- Treatment options include therapeutic thoracentesis, drainage catheter placement, fibrinolytic therapy, pleurodesis, and surgery
- Bacteremia/sepsis c137c138
- More likely to occur in patients with pneumonia complicated by moderate to large pleural effusion, empyema, or bronchopleural fistula
- Blood cultures can guide need for antibiotic change
- Pneumatoceles c139
- Occurs in approximately 2% to 8% of hospitalized children with pneumonia r38
- Most commonly associated with Staphylococcus aureus and Streptococcus pneumoniae infections r39
- Thin-walled, air-filled intraparenchymal cysts develop secondary to localized bronchiolar and alveolar necrosis, allowing 1-way passage of air into the interstitial space
- With mechanical ventilation, patients have an increased risk for developing complications related to pneumatoceles r40
- Most pneumatoceles cases (more than 85%) resolve spontaneously, partially, or completely over weeks
- Recurrent pneumonia c140
- Most patients have an underlying condition, such as: r41
- Oropharyngeal in coordination with aspiration syndrome (respiratory symptoms with feeding in those with gastroesophageal reflux)
- Immune disorder (recurrent infections at other locations and failure to thrive)
- Foreign body (consider if pneumonia in same anatomic location)
- Most patients have an underlying condition, such as: r41
Prognosis
- Prognosis is good for children treated for community-acquired pneumonia on an outpatient basis
- Morbidity and mortality are higher in hospitalized children
- Pediatric pneumonia is the leading cause of mortality worldwide in children younger than 5 years r11
Screening and Prevention
Screening c141
Prevention
- Interventions to prevent community-acquired pneumonia include breastfeeding, frequent handwashing, and avoidance of exposure to tobacco smoke c142c143c144
- Immunizations
- Administer pneumococcal conjugate vaccine (Prevnar 13) to prevent invasive pneumococcal disease in children aged 6 weeks to younger than 6 years r42c145
- Administer influenza, Haemophilus influenzae type b, pertussis, varicella, and measles vaccines according to recommended schedules r43c146c147c148c149c150
- Vaccination against COVID-19 is recommended for children aged 5 years or older r44
