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Neumonía adquirida en la comunidad en niños: tratamiento

ambulatorio
Autor: William J. Barson, MD
Editores de secciones: Morven S Edwards, MD, George B Mallory, MD
Editor Adjunto: Mary M Torchia, MD

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

Revisión de literatura vigente hasta mayo de 2019. | Este tema se actualizó por última vez el 1 de octubre de 2018.

INTRODUCCIÓN

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

La Pediatric Infectious Diseases Society / Infectious Diseases Society of America y la British Thoracic
Society han desarrollado guías de práctica clínica para la evaluación y el tratamiento de la PAC en
niños [ 1,2 ].

El tratamiento ambulatorio de la PAC en bebés y niños se revisará aquí. La neumonía neonatal y el

tratamiento hospitalario de la neumonía se analizan por separado, al igual que la epidemiología,
etiología, características clínicas y diagnóstico. (Consulte "Neumonía neonatal" y "Neumonía en
niños: Tratamiento hospitalario" y "Neumonía en niños: epidemiología, patogenia y etiología" y
"Neumonía adquirida en la comunidad en niños: características clínicas y diagnóstico" .)

INDICACIONES PARA LA HOSPITALIZACIÓN

La decisión de hospitalizar a un niño con NAC se individualiza en función de la edad, los problemas
médicos subyacentes y los factores clínicos, incluida la gravedad de la enfermedad ( tabla 1 ) [ 1-3 ].
En general, la hospitalización está justificada para los bebés menores de tres a seis meses de edad,
a menos que se sospeche una etiología viral o Chlamydia trachomatis y sean normoxémicas y
relativamente asintomáticas. La hospitalización también está garantizada para un niño de cualquier
edad cuya familia no pueda brindar atención adecuada y garantizar el cumplimiento del régimen
terapéutico. Las indicaciones adicionales para la hospitalización incluyen [ 1,2 ]:

● Hipoxemia (saturación de oxígeno <90 por ciento en el aire de la habitación al nivel del mar)

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

● Dificultad respiratoria de moderada a grave: frecuencia respiratoria> 70 respiraciones por minuto

para bebés menores de 12 meses y> 50 respiraciones por minuto para niños mayores; dificultad
para respirar (gruñidos, enrojecimiento nasal, retracciones); apnea

● Apariencia tóxica (más común en la neumonía bacteriana y puede sugerir un curso más grave) [
4]

● Las condiciones subyacentes que pueden predisponer a un curso más grave de neumonía (p.
Ej., Enfermedad cardiopulmonar, síndromes genéticos, trastornos neurocognitivos), pueden
empeorar por neumonía, incluso neumonía viral (p. Ej., Trastorno metabólico) o pueden afectar
adversamente la respuesta al tratamiento (p. Ej., , huésped inmunocomprometido)

● Complicaciones (p. Ej., Derrame / empiema) (ver "Epidemiología; presentación clínica; y

evaluación del derrame y empiema paraneumónicos en niños" y "Manejo y pronóstico del
derrame y empiema paraneumónicos en niños" )

● Sospecha o confirmación de que la PAC se debe a un patógeno con mayor virulencia, como
Staphylococcus aureus o Streptococcus del grupo A

● Fracaso de la terapia ambulatoria (empeoramiento o falta de respuesta en 48 a 72 horas)

(consulte "Fracaso del tratamiento" a continuación)

TERAPIA EMPIRICA

Descripción general : los niños con NAC que reciben tratamiento en el ámbito ambulatorio
generalmente reciben tratamiento empírico; las pruebas para identificar una etiología microbiológica
no se recomiendan para la mayoría de los niños que están lo suficientemente bien como para ser
tratados en un entorno ambulatorio [ 1,2 ]. Las decisiones con respecto a la terapia empírica se
complican por la superposición sustancial en la presentación clínica de las neumonías bacterianas y
no bacterianas [ 2,5,6 ]. Las decisiones de tratamiento generalmente se basan en algoritmos que
incluyen la edad del paciente, la información epidemiológica y clínica, y el laboratorio de diagnóstico
y los estudios de imagen (si se obtuvieron dichos estudios) ( tabla 2 y tabla 3 ) [ 4]. La consulta con
un especialista en enfermedades infecciosas puede ser útil en niños con alergias a medicamentos o
condiciones comórbidas. (Consulte "Neumonía adquirida en la comunidad en niños: características
clínicas y diagnóstico" y "Neumonía en niños: epidemiología, patogenia y etiología", sección sobre
"Agentes etiológicos" .)

Hay pocos ensayos controlados aleatorios para guiar la elección de antibióticos empíricos en niños
con NAC. Los factores que deben considerarse incluyen el espectro de probables patógenos,
susceptibilidad antimicrobiana, simplicidad, tolerabilidad, palatabilidad, seguridad y costo [ 7 ]. Las
recomendaciones de la mayoría de las guías se basan en observaciones sobre la susceptibilidad del
patógeno o patógenos más probables, en lugar de en la evidencia de la superioridad de un
antibiótico sobre otro [ 1,2 ]. La respuesta clínica a los antimicrobianos más utilizados parece ser
similar, independientemente de la etiología [ 8-10]]. La respuesta dentro de las primeras 48 a 72
horas de la terapia empírica (o la falta de terapia si la etiología viral es más probable) ayuda a
determinar si es necesaria una evaluación adicional o cambios en la terapia. (Ver 'Respuesta de
monitoreo' a continuación.)

Niños <5 años

Neonatos : el tratamiento de la neumonía neonatal se discute por separado. (Ver "Neumonía

neonatal" .)

De uno a seis meses : los bebés menores de tres a seis meses de edad con sospecha de NAC
bacteriana o que son hipoxémicos (saturación de oxígeno <90 por ciento en el aire de la habitación
al nivel del mar) deben ser ingresados en el hospital para recibir tratamiento empírico. (Consulte
"Neumonía en los niños: tratamiento hospitalario", sección sobre 'Tratamiento empírico' .)

En lactantes afebriles de uno a cuatro meses de edad con NAC, el patógeno bacteriano más
probable es C. trachomatis (es decir, "neumonía afebril de la infancia") [ 4,11 ]. Los bebés que se
cree tienen neumonía por afebril en la infancia pueden recibir tratamiento ambulatorio si no son
hipoxémicos y siguen siendo afebrile [ 4 ]. (Consulte "Infecciones por Chlamydia trachomatis en el
recién nacido", sección "Tratamiento" ).

Bordetella pertussis es una causa menos frecuente, pero más grave, de neumonía en bebés
pequeños; la fiebre puede o no estar presente. Al igual que C. trachomatis , B. pertussis es
susceptible a los macrólidos [ 4 ]. Sin embargo, los bebés pequeños que se cree que tienen
neumonía asociada a B. pertussis deben ser ingresados en el hospital porque tienen riesgo de
complicaciones (p. Ej., Hipoxia, apnea, hipertensión pulmonar, etc.). (Consulte "Infección por tos
ferina en bebés y niños: características clínicas y diagnóstico", sección "Infantes" e "Infección por tos
ferina en bebés y niños: Tratamiento y prevención", sección sobre "Hospitalización" .)

Seis meses a cinco años

Sospecha de etiología viral - etiologías virales predominan durante la primera infancia. La

neumonía viral (sugerida por un inicio gradual, que precede a los síntomas del tracto respiratorio
superior, hallazgos difusos en la auscultación, falta de apariencia tóxica ( tabla 3 )) no debe tratarse
con antibióticos. Los agentes antivirales generalmente no se usan para la neumonía viral en el
contexto ambulatorio, con la excepción de los inhibidores de la neuraminidasa para la neumonía por
influenza. (Consulte "Neumonía adquirida en la comunidad en niños: características clínicas y
diagnóstico", sección "Claves de la etiología" y "Neumonía en niños: epidemiología, patogenia y
etiología", sección sobre "Agentes etiológicos" y"Influenza de temporada en niños: prevención y
tratamiento con medicamentos antivirales", sección "Terapia antiviral" .

Los bebés y niños pequeños con enfermedad crónica conocida o sospechada (p. Ej., Enfermedad
cardiopulmonar, enfermedad neuromuscular, etc.) tienen un mayor riesgo de infección viral grave o
complicada del tracto respiratorio inferior (LRTI). Si tales niños no son admitidos en el hospital,
merecen una estrecha vigilancia en el ámbito ambulatorio.

● Sospecha de influenza : en los niños con sospecha de influenza que tienen un mayor riesgo de
complicaciones ( tabla 4 ), se recomienda iniciar el tratamiento antiviral lo antes posible; La
confirmación de laboratorio no debe retrasar el inicio de la terapia antiviral. El diagnóstico y
tratamiento de la influenza en niños se discuten por separado. (Consulte "Influenza de
temporada en niños: Prevención y tratamiento con medicamentos antivirales", sección "Terapia
antiviral" y "Influenza de temporada en niños: características clínicas y diagnóstico", sección
"Características clínicas" ).

Sospecha de etiología bacteriana : Streptococcus pneumoniae es la causa más frecuente

de neumonía bacteriana "típica" en niños de todas las edades [ 1,2 ]. La neumonía bacteriana en los
niños en edad preescolar generalmente causa una infección más grave, con una aparición abrupta y
dificultad respiratoria moderada a grave, que puede requerir tratamiento hospitalario. (Consulte
'Indicaciones para la hospitalización' más arriba y "Neumonía en niños: Tratamiento hospitalario",
sección sobre 'Tratamiento empírico' ).

Para los niños sanos de menos de cinco años inmunizados apropiadamente que se cree que tienen
una PAC bacteriana basada en la presentación clínica, los hallazgos del examen y los datos
radiográficos o de laboratorio de apoyo, si se obtienen (por ejemplo, consolidación lobar en la
radiografía, recuento de glóbulos blancos > 15,000 / microL, Proteína C reactiva> 35 a 60 mg / L [3.5
a 6 mg / dL] ( tabla 3 )), pero no requiere tratamiento hospitalario, la amoxicilina generalmente se
considera el fármaco de elección [ 1,2,12 ]. Sugerimos dosis altas de amoxicilina (90 a 100 mg / kg
por día divididas en dos o tres dosis; dosis máxima de 4 g / día) ( tabla 2 ).

Se prefiere la amoxicilina porque es efectiva contra la mayoría de los patógenos bacterianos para la
PAC en este grupo de edad, es bien tolerada y es barata [ 1,2 ]. La amoxicilina es más activa in vitro
que cualquiera de las cefalosporinas orales contra estos aislamientos.

The higher dose of amoxicillin is suggested because of the concern for antibiotic-resistant S.
pneumoniae isolated from patients with community-acquired respiratory tract infections [13,14],
although this is less of a concern following universal infant immunization with the pneumococcal
conjugate vaccine. (See "Impact of universal infant immunization with pneumococcal conjugate
vaccines in the United States", section on 'Antibiotic resistance' and "Resistance of Streptococcus
pneumoniae to beta-lactam antibiotics".)

Universal infant immunization with the 7-valent pneumococcal conjugate vaccine (PCV7) resulted in a
decreased prevalence of penicillin-resistant pneumococci. However, it was associated with the
emergence of antibiotic-resistant invasive serotypes, some of which are included in the 13-valent
pneumococcal conjugate vaccine (PCV13) (eg, serotype 19A), which replaced PCV7 in 2010 [1].
Surveillance after the introduction of PCV13 suggests further reduction of pneumococcal resistance
to penicillin and ceftriaxone. In a study of pneumococcal pneumonia from eight children's hospitals in
the United States, the proportion of isolates resistant to penicillin declined after the introduction of
PCV13 (from 8 to 3 percent); after 2010, only 1 percent of isolates were resistant to ceftriaxone [15].
Pending additional information and continued surveillance to determine whether high-dose amoxicillin
is necessary for S. pneumoniae pneumonia, we continue to suggest the high dose rather than
standard dose (ie, 40 to 45 mg/kg per day) when amoxicillin is used for empiric treatment of CAP in
children. (See "Impact of universal infant immunization with pneumococcal conjugate vaccines in the
United States", section on 'Antibiotic resistance' and "Resistance of Streptococcus pneumoniae to
beta-lactam antibiotics".)

Although there are prospective, comparative data supporting the efficacy of twice daily dosing of
amoxicillin for the treatment of acute otitis media [16-18], similar data are not available for
documented pneumococcal pneumonia in children. Unless the etiologic agent is identified as a S.
pneumoniae isolate with a minimum inhibitory concentration (MIC) of <2 mcg/mL, dividing the total
daily 90 to 100 mg/kg dose of amoxicillin into three doses may be warranted. Twice daily dosing for
pneumonia due to a S. pneumoniae isolate with an MIC of 2 mcg/mL is predicted to achieve a clinical
and microbiologic cure in only 65 percent of children, whereas the same total daily dose divided in
three equal portions is predicted to achieve a cure in 90 percent [19].
For children with non-type 1 hypersensitivity reactions to penicillin (table 5), a second- or third-
generation cephalosporin (eg, cefdinir) is an acceptable alternative to amoxicillin [1]. For children with
type 1 hypersensitivity reactions (table 5) to penicillin, clindamycin or a macrolide may be used [1,2].
However, if local resistance rates are high for clindamycin and macrolides, levofloxacin or linezolid
may be preferable. Doses are provided in the table (table 2).

For the infant or child who is suspected to have bacterial CAP and is unable to tolerate liquids at the
time of presentation, a single initial dose of ceftriaxone (50 to 75 mg/kg) may be administered
intramuscularly or intravenously before starting oral antibiotics [20,21]. Administration of
intramuscular ceftriaxone to children with uncomplicated CAP who are able to tolerate liquids is
expensive and provides no benefit over oral antibiotics.

Suspected atypical pneumonia — Mycoplasma pneumoniae and Chlamydia pneumoniae are

less common than S. pneumoniae in children younger than five years with CAP [5]. However, they
can occur in this age group and should be considered in children without a pneumonia-associated
complication who fail to improve after 48 to 72 hours of empiric therapy for S. pneumoniae (eg,
amoxicillin), at which time a macrolide could be added or substituted (table 2). (See 'Treatment failure'
below.)

Children ≥5 years

Suspected typical or atypical bacterial etiology — S. pneumoniae is the most frequent cause of
"typical" bacterial pneumonia in children of all ages [1,2]. However, in otherwise healthy children five
years and older with CAP who are not ill enough to require hospitalization, M. pneumoniae and C.
pneumoniae are the most likely pathogens [4,11,22].

We suggest macrolide antibiotics for initial empiric therapy for suspected atypical CAP (table 3) in
children older than five years who are treated as outpatients (table 2). Macrolide antibiotics provide
coverage for atypical pathogens and some coverage for S. pneumoniae, although macrolide
resistance exists among both M. pneumoniae and S. pneumoniae. For children ≥5 years with clinical
features strongly suggestive of typical bacterial or S. pneumoniae pneumonia (table 3), amoxicillin
remains the drug of choice (table 2) [1]. (See 'Suspected bacterial etiology' above.)

The prevalence of macrolide-resistant M. pneumoniae is increasing in some geographic regions,

including Asia, Europe, Israel, and the United States [23-31]. The reported prevalence of resistance
among M. pneumoniae isolates ranges from approximately 10 percent in the United States to 90
percent in China and some parts of Japan [25,28,32,33]. Alternative agents include levofloxacin and
doxycycline [1]. The long-held concern for enamel staining associated with doxycycline in children
younger than eight years use is unfounded [34,35].
Among the macrolide antibiotics, clarithromycin and azithromycin have a more convenient dosing
schedule and fewer side effects than erythromycin, but erythromycin is less expensive [8,36,37].
Macrolide antibiotics may provide coverage for S. pneumoniae, which is the most frequent typical
bacterial pathogen for all age groups [38-40]. However, approximately 40 to 50 percent of S.
pneumoniae isolates are resistant to macrolides. Failure to respond to macrolide therapy may
indicate the development of a complication, a macrolide-resistant pathogen, and/or the need to alter
therapy to provide better pneumococcal coverage. (See 'Treatment failure' below.)

Given the significant resistance of S. pneumoniae to macrolides, fluoroquinolones (eg, levofloxacin,

moxifloxacin) are another reasonable alternative for the outpatient treatment of CAP in the older child
when typical pneumonia is also a consideration based on clinical findings (table 3). In addition to their
excellent gram-negative spectrum, the fluoroquinolones are active against a number of the pathogens
responsible for CAP, including beta-lactam-susceptible and nonsusceptible S. pneumoniae, M.
pneumoniae, and C. pneumoniae [41]. However, S. pneumoniae resistant to levofloxacin has been
identified [42].

The British Thoracic Society clinical practice guideline suggests amoxicillin as the first-line therapy for
children of all ages [1,2].

Suspected influenza — Initiation of antiviral treatment for influenza (eg, oseltamivir) as soon as
possible is recommended for children with suspected influenza who are at high risk for complications
of influenza pneumonia (table 4); laboratory confirmation should not delay initiation of antiviral
therapy. The diagnosis and treatment of influenza in children are discussed separately. (See
"Seasonal influenza in children: Prevention and treatment with antiviral drugs", section on 'Antiviral
therapy'.)

Suspected aspiration pneumonia — Community-acquired aspiration pneumonia is usually treated

with amoxicillin-clavulanate. Clindamycin is an alternative for patients allergic to penicillin. Doses are
provided in the table (table 2). In neurologically compromised adolescents who may be prone to
aspiration events, empiric treatment with moxifloxacin (400 mg once per day) is an alternative.
Moxifloxacin is active against anaerobic bacteria, as well as the usual treatable causes of CAP: S.
pneumoniae, M. pneumoniae, and C. pneumoniae. Fluoroquinolone antibiotics generally are not
recommended for children younger than 18 years of age when there is a safe and effective
alternative. (See "Fluoroquinolones", section on 'Children'.)

Duration — Few randomized controlled trials have been performed to determine the appropriate
duration of antimicrobial therapy in radiographically confirmed childhood pneumonia [2,43]. Current
practice in the developed world determines the duration of therapy based upon the age of the host,
likely causative agent, and severity of disease:
 ● We suggest that infants ≥4 months and children with uncomplicated pneumonia suspected or
confirmed to be caused by routine pathogens (ie, S. pneumoniae, M. pneumoniae, C.
pneumoniae) be treated for 7 to 10 days; the course of azithromycin is five days [1,8]

● The duration of treatment for C. trachomatis pneumonia in young infants is discussed separately
(see "Chlamydia trachomatis infections in the newborn", section on 'Treatment')

A meta-analysis found three days of oral antimicrobial therapy to be as effective as five days for
nonsevere CAP in children aged 2 to 59 months [44]. However, the studies included in the meta-
analysis were performed in developing countries, where it is not feasible to perform radiographs or
evaluation for a microbiologic etiology; pneumonia was diagnosed by the World Health Organization
(WHO) criteria, which are based on clinical findings and respiratory rate thresholds. In another study,
only 14 percent of children diagnosed with nonsevere pneumonia by the WHO criteria had
radiographic evidence of pneumonia [45]. Many of the children in the meta-analysis probably had viral
pneumonia, for which antibiotic therapy is not warranted. This is supported by a subsequent
randomized trial in which the clinical outcomes did not differ for children aged 2 to 59 months who
were diagnosed with nonsevere pneumonia by the WHO criteria and treated for three days with
amoxicillin versus placebo [46].

In a subsequent randomized trial in a developed country, 4 of 10 children who received three days of
outpatient treatment (amoxicillin 80 mg/kg per day divided in three doses) for radiologically confirmed
CAP required rescue therapy or hospitalization versus none of 12 children treated for 10 days [47]. In
the second stage of the trial, five days of treatment (amoxicillin 80 mg/kg per day divided in three
doses) was as effective as 10 days in preventing the need for rescue therapy or hospitalization, but
with fewer than 60 patients in each arm, the study may have been underpowered to detect a
difference. Additional, larger studies are necessary to confirm these results before we suggest five
days of therapy for uncomplicated CAP.

Monitoring response — Children with CAP who are treated as outpatients (including those who
were not initially treated with antibiotics) should have follow-up within 24 to 48 hours [1,2]. Follow-up
may be performed by phone. Children with CAP who are appropriately treated generally show signs
of improvement within 48 to 72 hours.

Treatment failure — Among patients who do not improve as anticipated, the following possibilities
must be considered [1,2,14,48]:

● Alternative or coincident diagnoses (eg, foreign body aspiration) (see "Community-acquired

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

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

Worsened condition — Patients whose condition has worsened require additional evaluation
and hospitalization. They also should undergo radiologic evaluation to look for the development of
complications. Laboratory tests should be performed to try to establish a microbiologic diagnosis.
(See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on
'Laboratory evaluation' and "Pneumonia in children: Inpatient treatment", section on 'Hospitalization'.)

Failure to improve — In patients who fail to improve but have not worsened, it may be
reasonable to add or strengthen coverage for S. pneumoniae or atypical bacteria if these organisms
were not covered in the initial therapy (table 2) [1,4]. It is also important to consider underlying or
comorbid conditions (eg, immunodeficiency, anatomic abnormality). (See "Community-acquired
pneumonia in children: Clinical features and diagnosis", section on 'Differential diagnosis'.)

● Patients initially treated with beta-lactam antibiotics – Failure to improve while being treated
with a beta-lactam antibiotic (amoxicillin or cephalosporin) may indicate infection caused by
penicillin-resistant S. pneumoniae or S. aureus (either methicillin-susceptible or -resistant) [49]. If
penicillin-resistant S. pneumoniae is suspected, a change in antibiotic therapy to clindamycin or
linezolid may be indicated. Levofloxacin is an option if there is a high rate of pneumococcal
resistance to clindamycin. Doses are provided in the table (table 2). If S. aureus is suspected
based upon a rapidly worsening clinical course with progressive radiographic findings that may
include multiple patchy alveolar infiltrates coalescing to form large consolidated areas in a young,
immunocompetent host often with a preceding viral illness, the child should be hospitalized given
the increased risk of complications (eg, necrosis, empyema, pneumatocele) and death. (See
"Pneumonia in children: Inpatient treatment".)

● Patients initially treated with macrolide antibiotics – Failure to improve while being treated
with a macrolide antibiotic may indicate the need to perform a diagnostic test (eg, polymerase
chain reaction) to confirm an M. pneumoniae etiologic diagnosis and/or alter therapy to provide
better coverage for S. pneumoniae or macrolide-resistant M. pneumoniae. (See "Mycoplasma
pneumoniae infection in children", section on 'Approach to laboratory confirmation'.)

For patients initially treated with macrolides, better pneumococcal coverage can be achieved by
the addition of high-dose amoxicillin, a cephalosporin (eg, cefdinir, cefpodoxime), or clindamycin.
Among these options, we prefer high-dose amoxicillin because it is well tolerated and
inexpensive. Amoxicillin and cephalosporins may provide coverage for other potential, albeit less
common causes, of bacterial pneumonia in older children (eg, Haemophilus influenzae type b,
 nontypeable H. influenzae, Moraxella catarrhalis, group A Streptococcus) [11]. Clindamycin
provides coverage for most S. aureus infections. For children who have type 1 hypersensitivity
(table 5) to penicillins, a fluoroquinolone (eg, levofloxacin, moxifloxacin) may be used.
Tetracyclines (eg, doxycycline) and fluoroquinolones can be used if macrolide-resistant M.
pneumoniae is suspected [50]. Fluoroquinolones also provide coverage for most typical bacterial
etiologies of CAP except S aureus. Doses are provided in the table (table 2). (See "Mycoplasma
pneumoniae infection in children", section on 'Treatment'.)

SUPPORTIVE CARE

The families of children who are managed as outpatients should be instructed regarding management
of fever and pain, maintaining adequate hydration, and identification of deterioration (eg, persistent
fever, increased retractions, use of accessory muscles, grunting, inability to feed) [2].

● Children with pneumonia usually have fever and may have pleuritic chest pain, which can lead to
shallow breathing and impaired ability to cough [2]. Administration of antipyretics and/or
analgesics can be used to keep the child comfortable. Adequate pain control may promote
coughing, which facilitates airway clearance. Antitussives should be avoided as none have been
found to be effective in pneumonia [51]. Symptomatic treatment of cough is discussed separately.
(See "The common cold in children: Management and prevention", section on 'Cough'.)

● Infants and young children with respiratory distress may be better able to maintain hydration if
fluids are provided in small volumes more frequently than in large volumes less often.

● Gentle suction of the nares may be helpful in infants and children whose nares are blocked by
nasal secretions.

FOLLOW-UP

Clinical course — Children who are appropriately treated for CAP gradually improve with time [52].
The symptoms associated with viral lower respiratory tract infections, particularly cough, usually
resolve in less than one month in healthy infants and children but may rarely last for up to three to
four months. Cough may 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 [52].

Radiographs — Follow-up radiographs are not necessary in asymptomatic children with

uncomplicated CAP. Follow-up radiographs two to three weeks after completion of therapy may be
helpful in assessing alternate diagnoses or coincident conditions in children with recurrent
pneumonia, persistent symptoms, severe atelectasis, unusually located infiltrates, or round
pneumonia (ie, pulmonary consolidation that appears to be spherical) [1,2,53]. 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 [53-57]. (See "Community-acquired pneumonia in children: Clinical features and
diagnosis", section on 'Differential diagnosis'.)

Several studies have evaluated the utility of follow-up radiographs in cohorts of children with acute
radiologically proven CAP [58-63]. Three of the studies included clinical as well as radiologic follow-
up at three to seven weeks after initial diagnosis [58-61]. In each of these studies, follow-up
radiographs were normal or improved in asymptomatic children. Residual findings, even when
present, did not result in additional therapy.

PROGNOSIS

Most otherwise healthy children who develop pneumonia recover without any long-term sequelae
[40]. Although some prospective studies suggest that pneumonia in childhood is associated with
subsequent symptoms of asthma that may persist into adulthood, it is not clear whether this is related
to unrecognized asthma at the time of presentation with pneumonia or a tendency to develop asthma
after CAP [64,65].

SOCIETY GUIDELINE LINKS

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

INFORMATION FOR PATIENTS

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subjects by searching on "patient info" and the keyword[s] of interest.)

● Basics topics (see "Patient education: Pneumonia in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary

parenchyma in a patient who has acquired the infection in the community. The clinical
manifestations and diagnosis of CAP are discussed separately. (See "Community-acquired
pneumonia in children: Clinical features and diagnosis".)

● The decision to hospitalize a child with pneumonia must be individualized and is based upon
age, underlying medical problems, and severity of illness (table 1). (See 'Indications for
hospitalization' above.)

● Children with CAP who are treated in the outpatient setting are treated empirically. It is not
necessary to identify a microbiologic etiology in children who are well enough to be treated as
outpatients. Decisions regarding empiric antimicrobial therapy for CAP in children are usually
based upon age unless there are other overriding epidemiologic or clinical factors to suggest a
specific etiologic agent. (See 'Overview' above.)

● Infants younger than three to six months of age with suspected bacterial CAP or who are
hypoxemic should be admitted to the hospital for management. Afebrile infants one to four
months of age who are thought to have afebrile pneumonia of infancy (eg, Chlamydia
trachomatis) can be treated in the outpatient setting if they are not hypoxemic and remain
afebrile. (See "Pneumonia in children: Inpatient treatment" and "Chlamydia trachomatis infections
in the newborn".)

● We recommend that empiric antibiotic therapy for CAP in children six months to five years of age
who are thought to have bacterial pneumonia (eg, abrupt onset, moderate to severe respiratory
distress, and supportive laboratory data if obtained (table 3)) include coverage for Streptococcus
pneumoniae (table 2) (Grade 1B). (See 'Children <5 years' above.)

● We initiate macrolide antibiotics for initial empiric therapy for suspected atypical CAP (table 3) in
children ≥5 years who are treated as outpatients. For children ≥5 years with clinical features
strongly suggestive of typical bacterial or S. pneumoniae pneumonia (table 3), amoxicillin
remains the drug of choice (table 2). (See 'Children ≥5 years' above.)
 ● In infants and children six months and older, the usual duration of antimicrobial therapy is five
days for azithromycin and 7 to 10 days for other agents. (See 'Duration' above.)

● Children who are treated for CAP as outpatients should have follow-up within 24 to 48 hours.
Those whose condition has worsened at follow-up should be evaluated for potential
complications and hospitalized. (See 'Monitoring response' above and "Pneumonia in children:
Inpatient treatment".)

● Children recovering from CAP may continue to cough for several weeks to four months,
depending upon the etiology. Those recovering from typical or atypical bacterial pneumonia may
have moderate dyspnea on exertion for two to three months. (See 'Clinical course' above.)

● Follow-up radiographs in children with uncomplicated CAP who remain asymptomatic are not
needed. Follow-up radiographs two to three weeks after completion of therapy may be helpful in
children with recurrent pneumonia, persistent symptoms, severe atelectasis, unusually located
infiltrates, or round pneumonia. (See 'Radiographs' above.)

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

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37. Chien SM, Pichotta P, Siepman N, Chan CK. Treatment of community-acquired pneumonia. A
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38. Pelton SI, Hammerschlag MR. Overcoming current obstacles in the management of bacterial
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course therapy of the same antibiotic for community-acquired pneumonia in adolescent and
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of community-acquired pneumonia. Respir Med 2004; 98:488.

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society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in
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antibiotics. Future Microbiol 2011; 6:423.

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52. Gaston B. Pneumonia. Pediatr Rev 2002; 23:132.

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56. Eggli KD, Newman B. Nodules, masses, and pseudomasses in the pediatric lung. Radiol Clin
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 57. Rose RW, Ward BH. Spherical pneumonias in children simulating pulmonary and mediastinal
masses. Radiology 1973; 106:179.

58. Grossman LK, Wald ER, Nair P, Papiez J. Roentgenographic follow-up of acute pneumonia in
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61. Heaton P, Arthur K. The utility of chest radiography in the follow-up of pneumonia. N Z Med J
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62. Wacogne I, Negrine RJ. Are follow up chest x ray examinations helpful in the management of
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63. Surén P, Try K, Eriksson J, et al. Radiographic follow-up of community-acquired pneumonia in

children. Acta Paediatr 2008; 97:46.

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up study. BMJ 2000; 320:1514.

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adults: a longitudinal study. Pediatrics 2015; 135:607.

Topic 5987 Version 41.0

GRAPHICS

Severity of community-acquired pneumonia in infants and children

Clinical features of mild pneumonia Clinical features of severe pneumonia

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

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

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

Normal color Cyanosis

Normal mental status Altered mental status

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

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

Normal heart rate Tachycardia

Capillary refill <2 seconds Capillary refill ≥2 seconds

RR: respiratory rate.

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

Graphic 72015 Version 4.0

Initial oral empiric antibiotics for outpatient treatment of pediatric community-
acquired pneumonia

Age group Empiric regimen

1 to 6 months

Bacterial (not Chlamydia Infants <3 to 6 months of age with suspected bacterial pneumonia should be
trachomatis) hospitalized

C. trachomatis Refer to UpToDate topic on C. trachomatis infections in the newborn

6 months to 5 years

Typical bacterial* Amoxicillin ¶ 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day), or

Amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin component in 2 or 3 divided

doses (MAX 4 g/day amoxicillin component), or

For patients with non-type 1 hypersensitivity to penicillins:

- Cefdinir 14 mg/kg per day in 2 divided doses (MAX 600 mg/day), or

For patients with type 1 hypersensitivity to penicillins:

- Levofloxacin Δ 16 to 20 mg/kg per day in 2 divided doses (MAX 750 mg/day), or

- Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 1.8 g/day), or

- Erythromycin 40 to 50 mg/kg per day in 4 divided doses (MAX 2 g/day as base, 3.2
g/day as ethylsuccinate), or

- Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (MAX
500 mg on day 1 and 250 mg thereafter), or

- Clarithromycin 15 mg/kg per day in 2 divided doses (MAX 1 g/day), or

In communities with a high rate of pneumococcal resistance to penicillin:

- Levofloxacin Δ 16 to 20 mg/kg per day in 2 divided doses (MAX 750 mg/day), or

- Linezolid 30 mg/kg per day in 3 divided doses (MAX 1800 mg/day)

≥5 years

Mycoplasma pneumoniae Erythromycin 40 to 50 mg/kg per day in 4 divided doses (MAX 2 g/day as base, 3.2
or Chlamydia g/day as ethylsuccinate), or
pneumoniae
Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (MAX 500
mg on day 1 and 250 mg thereafter), or

Clarithromycin 15 mg/kg per day in 2 divided doses (MAX 1 g/day), or

Doxycycline 4 mg/kg per day in 2 divided doses (MAX 200 mg/day), or

For patients ≥18 years:

- Levofloxacin Δ § 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 500

mg/day); 500 mg once per day for children for children ≥16 years, or

- Moxifloxacin Δ◊ 400 mg once per day

Typical bacterial* Amoxicillin ¶ 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day), or

For patients with non-type 1 hypersensitivity to penicillins:

- Cefdinir 14 mg/kg per day in 2 divided doses (MAX 600 mg/day), or

- Cefpodoxime 10 mg/kg per day in 2 divided doses (MAX 400 mg/day), or

For patients with type 1 hypersensitivity to penicillins:

- Levofloxacin Δ 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 750

mg/day); 750 mg once daily for children ≥16 years

- Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 1.8 g/day), or

 - Erythromycin 40 to 50 mg/kg per day in 4 divided doses (MAX 2 g/day as base, 3.2
g/day as ethyl succinate), or

- Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (MAX
500 mg on day 1 and 250 mg thereafter), or

- Clarithromycin 15 mg/kg per day in 2 divided doses (MAX 1 g/day), or

In communities with a high rate of pneumococcal resistance to penicillin:

- Levofloxacin Δ 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 750

mg/day); 750 mg once daily for children ≥16 years, or

- Linezolid 30 mg/kg per day divided in 3 doses (MAX 1800 mg/day) for children <12
years; 20 mg/kg per day divided in 2 doses (MAX 1200 mg/day) for children ≥12
years

Aspiration pneumonia

Community-acquired Amoxicillin-clavulanate 40 to 50 mg/kg per day in 2 or 3 divided doses (MAX 1750

mg/day amoxicillin component), or

For patients with type 1 hypersensitivity to beta-lactam antibiotics:

- Clindamycin 30 to 40 mg/kg per day, divided in 3 or 4 doses (MAX 1.8 g/day)

MAX: maximum.
* For the infant or child who is suspected to have bacterial community-acquired pneumonia and is unable to tolerate liquids at
the time of presentation, a single initial dose of ceftriaxone (50 to 75 mg/kg) may be administered intramuscularly or
intravenously before starting oral antibiotics.
¶ Preferred agent.
Δ In the United States, fluoroquinolones (eg, levofloxacin and moxifloxacin) are approved by the US Food and Drug
Administration for community-acquired pneumonia for patients ≥18 years of age. However, they may be used in younger
children if other antibiotics are inappropriate (eg, due to hypersensitivity or local antimicrobial resistance patterns).
◊ Also covers typical bacterial pathogens.

Data from:
1. McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
2. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children
older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious
Diseases Society of America. Clin Infect Dis 2011; 53:e25.
3. American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2018 Report of the Committee on
Infectious Diseases, 31st ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics,
Itasca, IL 2018. p.914.

Graphic 80561 Version 25.0

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

Radiographic
Etiology Clinical features
features

Bacteria Children of all ages Alveolar infiltrates

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

Elevated acute phase reactants (if obtained) Lung abscess

Necrotizing pneumonia
Pneumatocele

Atypical bacterial
(Mycoplasma pneumoniae,
Chlamydia pneumoniae)
Children of all ages (most common in children >5 Interstitial infiltrates
years)
Abrupt onset with constitutional findings (malaise,
myalgia, headache, rash, conjunctivitis, photophobia,
sore throat, headache)
Gradually worsening nonproductive cough
Wheezing
Extrapulmonary manifestations or complications (eg,
Stevens-Johnson syndrome, hemolytic anemia,
hepatitis, etc)

Viral Usually children <5 years Interstitial infiltrates

Gradual onset
Preceding upper airway symptoms
Nontoxic appearing
Diffuse, bilateral auscultatory findings
Wheezing
May have associated rash (eg, measles, varicella)

Afebrile pneumonia of Usually in infants 2 weeks to 4 months Hyperinflation with

infancy (most commonly Insidious onset interstitial process
Chlamydia trachomatis) Rhinorrhea
Staccato cough pattern
Peripheral eosinophilia (if CBC obtained)

Fungal Appropriate geographic or environmental exposure Mediastinal or hilar

adenopathy

Mycobacterium tuberculosis Children of any age Mediastinal or hilar

Chronic cough adenopathy
Constitutional symptoms
Exposure history

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

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

Data from:
1. Bartlett JG, Mundy LM. Community-acquired pneumonia. N Engl J Med 1995; 333:1618.
 2. Boyer KM. Nonbacterial pneumonia. In: Textbook of Pediatric Infectious Diseases, 6 th ed, Feigin RD, Cherry JD,
Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009. p.289.
3. Broughton RA. Infections due to Mycoplasma pneumoniae in childhood. Pediatr Infect Dis 1986; 5:71.
4. McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.

Graphic 52021 Version 10.0

Groups at high risk for serious influenza complications

Children <5 years, but especially <2 years*

Adults ≥65 years of age

Women who are pregnant or up to two weeks postpartum

Residents of nursing homes and long-term care facilities

Native Americans and Alaska Natives

People with medical conditions including:

Asthma
Neurologic and neurodevelopmental conditions (including disorders of the brain, spinal cord, and peripheral nerve
and muscle such as cerebral palsy, epilepsy, stroke, intellectual disability [mental retardation], moderate to severe
developmental delay, muscular dystrophy, and spinal cord injury)
Chronic lung disease (eg, chronic obstructive pulmonary disease, cystic fibrosis)
Heart disease (eg, congenital heart disease, congestive heart failure, coronary artery disease)
Blood disorders (eg, sickle cell disease)
Endocrine disorders (eg, diabetes mellitus)
Kidney disorders
Liver disorders
Metabolic disorders (eg, inherited metabolic disorders and mitochondrial disorders)
Weakened immune system due to disease (eg, HIV, AIDS, cancer) or medication (eg, chronic glucocorticoids)
Children <19 years of age who are receiving long-term aspirin therapy
People with extreme obesity (body mass index [BMI] ≥40)

* In young children, rates of hospitalization and mortality are greatest among those <6 months of age.

Adapted from: Centers for Disease Control and Prevention. People at high risk of developing flu-related complications.
www.cdc.gov/flu/about/disease/high_risk.htm (Accessed on August 27, 2018).

Graphic 72029 Version 19.0

Gell and Coombs classification of immunologic drug reactions

Clinical
Type Description Mechanism
features

I IgE-mediated, Antigen exposure causes IgE-mediated Anaphylaxis

Immediate reaction immediate-type activation of mast cells and basophils, with Angioedema
(within one hour) hypersensitivity release of vasoactive substances, such as
Bronchospasm
histamine, prostaglandins, and leukotrienes.
Urticaria (hives)
Hypotension

II Antibody-dependent An antigen or hapten that is intimately Hemolytic anemia

cytotoxicity associated with a cell binds to antibody, Thrombocytopenia
leading to cell or tissue injury.
Neutropenia

III Immune complex Damage is caused by formation or deposition Serum sickness

disease of antigen-antibody complexes in vessels or Arthus reaction
tissue. Deposition of immune complexes
causes complement activation and/or
recruitment of neutrophils by interaction of
immune complexes with Fc IgG receptors.

IV Cell-mediated or Antigen exposure activates T cells, which then Contact dermatitis

delayed mediate tissue injury. Depending upon the Some morbilliform
hypersensitivity type of T cell activation and the other effector reactions
cells recruited, different subtypes can be
Severe exfoliative
differentiated (ie, types IVa to IVd).
dermatoses (eg,
SJS/TEN)
AGEP
DRESS/DiHS
Interstitial nephritis
Drug-induced
hepatitis
Other presentations

IgE: immunoglobulin E; Fc IgG: Fc portion of immunoglobulin G; SJS/TEN: Stevens-Johnson syndrome/toxic epidermal

necrolysis; AGEP: acute generalized exanthematous pustulosis; DRESS/DiHS: drug rash with eosinophilia and systemic
symptoms/drug-induced hypersensitivity syndrome.

Adapted from: Weiss ME, Adkinson NF. Immediate hypersensitivity reactions to penicillin and related antibiotics. Clin Allergy
1988; 18:515.

Graphic 80466 Version 18.0

Contributor Disclosures
William J Barson, MD Grant/Research/Clinical Trial Support: Pfizer [Pneumonia (United States pediatric
multicenter pneumococcal surveillance study group)]. Morven S Edwards, MD Grant/Research/Clinical Trial
Support: Pfizer [Group B Streptococcus]. George B Mallory, MD Grant/Research/Clinical Trial Support: TOPP-2
[pulmonary hypertension (patient registry)]. Mary M Torchia, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.

Política de conflicto de intereses.