Pneumonia in Children - Inpatient Treatment - UpToDate

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Pneumonia in children: Inpatient treatment

Author: William J Barson, MD
Section Editor: Morven S Edwards, MD
Deputy Editor: Mary M Torchia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2023. | This topic last updated: Apr 25, 2022.
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. Our recommendations 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]. (See 'Society guideline links' below.)
The outpatient treatment of CAP; the epidemiology, etiology, clinical features, and diagnosis
of CAP in children; and the management of coronavirus disease 2019-related pneumonia are
discussed separately:
● (See "Community-acquired pneumonia in children: Outpatient treatment".)

● (See "Pneumonia in children: Epidemiology, pathogenesis, and etiology".)
● (See "Community-acquired pneumonia in children: Clinical features and diagnosis".)
● (See "COVID-19: Management in children".)
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
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and they are not hypoxemic and relatively asymptomatic. Hospitalization is also warranted
for a child of any age whose caregivers cannot provide appropriate care and assure
compliance with the management plan. Additional indications for hospitalization include
[1,2]:
● Hypoxemia (peripheral capillary oxygen saturation [SpO2] <90 percent in room air at
sea level)
● Dehydration, or inability to maintain hydration orally; inability to feed in an infant
● Moderate to severe respiratory distress: Respiratory rate >70 breaths/minute for

infants <12 months of age and >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, necrotizing process, abscess)
● Suspicion or confirmation that CAP is due to a pathogen with increased virulence, such
as Staphylococcus aureus or group A Streptococcus (GAS)
● 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 (ICU; eg, mechanical ventilation, noninvasive positive pressure
ventilation, failure to maintain SpO2 >92 percent in fraction of inspired oxygen [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 ICU also may be warranted for children with two or more of the following [1]:
● Respiratory rate >70 breaths/minute for infants <12 months of age and >50
breaths/minute for older children
● Apnea
● Increased work of breathing (retractions, dyspnea, nasal flaring, grunting)
● Partial pressure of oxygen in arterial blood (PaO2):FiO2 ratio <250
● Multilobar infiltrates
● Altered mental status
● Hypotension
● Pleural effusion
● Comorbid condition (eg, sickle cell disease, immune deficiency, immunosuppression)
● Unexplained metabolic acidosis
● Pediatric Early Warning Score >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
'Approach to microbiologic testing'.)
Hand washing is the single most important procedure to prevent the spread of infection.
Guidelines for hand hygiene in health care settings can be accessed through the Centers
for Disease Control and Prevention.
Additional infection control measures depend upon the likely pathogen(s), as follows [6,7]:
● Respiratory syncytial, parainfluenza, and human metapneumovirus – Gown and gloves

(ie, contact precautions)
● Influenza and rhinoviruses, GAS (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

Because isolation precautions are different for different pathogens, we favor simplifying the
approach for viral respiratory pathogens by placing all patients with suspected viral
respiratory tract infection on both contact and droplet precautions. These precautions are
discussed separately. (See "Infection prevention: Precautions for preventing transmission of
infection".)
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 antipyretics and/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] <95 percent in room air be treated
with supplemental oxygen to maintain oxygen saturation ≥95 percent while they are in
respiratory distress. Different thresholds for supplemental oxygen are suggested by other
experts (eg, the British Thoracic Society guidelines suggest supplemental oxygenation to
maintain oxygenation saturation >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 the
acute care of 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 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 (IV) fluid therapy.
Nasogastric tubes should be avoided if possible because they may compromise breathing; if

necessary, the smallest nasogastric tube possible should be used [2]. (See "Maintenance
intravenous 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, IV 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 intravenous
fluid therapy in 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 two small heterogeneous trials suggested that glucocorticoids reduce clinical
failure (defined as death from any cause, radiographic progression, or clinical instability at
day 5 to 8) and time to clinical cure, additional studies in children are necessary before
glucocorticoids can be routinely recommended [18-20]. 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 [21].
Adjunctive glucocorticoids for adults with pneumonia are discussed separately. (See
"Treatment of community-acquired pneumonia in adults who require hospitalization",
section on 'Adjunctive glucocorticoids'.)
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 2A-B). Factors that must be considered include the spectrum
of likely pathogens, antimicrobial susceptibility, simplicity, tolerability, palatability, safety,
and cost [22].
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 'Specific therapy' below and 'Response to therapy' below and
'Etiologic diagnosis'.)
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 [23-25].
Treatment decisions usually are based upon algorithms that include patient age,
epidemiologic and clinical information, and diagnostic laboratory and imaging studies
( table 2A-B) [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).
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 [RSV])
[26]. 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: Clinical
features and diagnosis", section on 'Clinical manifestations' and "Respiratory syncytial virus
infection: Treatment".)
No effective antivirals are available for most viral pneumonias, with a few important
exceptions, described below.
COVID-19 pneumonia — The management of coronavirus 2019 (COVID-19)-related

pneumonia is discussed separately. (See "COVID-19: Management in children", section on
'Management of hospitalized children'.)
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: Management", 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. (See "Staphylococcus aureus in children: Overview of treatment of invasive
infections", section on 'Empiric antimicrobial therapy'.)
Other viral pneumonias — Acyclovir can be used in the treatment of pneumonia due to
herpes simplex virus or varicella zoster virus. Ganciclovir can 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 RSV or parainfluenza and
cidofovir for adenovirus. Concomitant immunotherapy is an additional consideration:
palivizumab for RSV, CMV immune globulin for CMV, and intravenous immunoglobulin for
the other viral etiologies. (See "Diagnosis, treatment, and prevention of adenovirus
infection", section on 'Treatment' and "Respiratory syncytial virus infection: Treatment".)
Uncomplicated bacterial pneumonia — Streptococcus pneumoniae is the most common

bacterial cause of pneumonia in children of all ages [4,27]. Other potential bacterial
pathogens that may need to be included in empiric therapy for hospitalized children include
S. aureus, including MRSA, Streptococcus pyogenes (group A Streptococcus), Haemophilus
influenzae type b (Hib; if unimmunized), other typeable non-b and nontypeable H. influenzae,
and Moraxella catarrhalis [2,4,27-32].
The table provides several suggested parenteral empiric antibiotic regimens for
uncomplicated bacterial pneumonia in hospitalized children when S. aureus is not a
consideration ( table 2A-B) [4,33,34]. 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' 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 [1,35,36].
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 [1,37,38].
When community-associated-MRSA (CA-MRSA) is considered a potential pathogen for CAP in

children, we usually add clindamycin or vancomycin (depending upon local susceptibility
patterns). The fifth-generation cephalosporin, ceftaroline, is an alternative. In the United
States, ceftaroline is available for the treatment of pediatric CAP due to S. pneumoniae,
methicillin-susceptible S. aureus, and H. influenzae in children ≥2 months of age [39].
Although ceftaroline has good in vitro activity against MRSA isolates [40] and has been
effective in the treatment of pediatric CAP in randomized trials, few children included in the
trials had documented MRSA [41,42].
A macrolide may be added ( table 2A-B) if M. pneumoniae, Chlamydia pneumoniae, or

legionellosis is suspected, although the benefits of combination therapy are uncertain. In a
prospective population-based study of 1418 children hospitalized with radiographically
confirmed CAP, the addition of a macrolide to beta-lactam antimicrobial therapy was not
associated with decreased length of stay, intensive care admission, rehospitalization, or self-
reported recovery [43]. In subgroup analysis, combination therapy was not associated with
decreased length of stay in children in whom atypical bacteria were detected, children older
than five years, children admitted to the intensive care unit (ICU), or children with wheezing.
(See 'Atypical pneumonia' below.)
We suggest that children who require hospitalization for treatment of CAP be treated initially
with parenteral antibiotics. However, oral amoxicillin may be an alternative for infants and
children fully immunized against Hib and S. pneumoniae with uncomplicated pneumonia that
is not thought to be due to S. aureus [44]. In a multicenter randomized trial, treatment with
amoxicillin was equivalent to treatment with penicillin G in children with CAP who required
hospital admission but did not have wheezing, hypotension, chronic pulmonary conditions
(other than asthma), immunodeficiency, pleural effusion requiring drainage, or oxygen
saturations <85 percent in room air [45]. The British Thoracic Society guidelines suggest that
oral antibiotics are safe and effective even for children with severe pneumonia as long as
they are able to tolerate oral fluids, are not vomiting, and do not have signs of septicemia or
complicated pneumonia [2].
Atypical pneumonia — Atypical bacterial pathogens include C. trachomatis in afebrile

infants, and M. pneumoniae and C. pneumoniae in older children and adolescents. The table
provides several suggested empiric regimens for atypical bacterial pneumonia in
hospitalized children ( table 2A-B) [4,33].
For children older than four years with suspected atypical pneumonia, coverage for typical
bacterial pathogens (eg, ampicillin or a third-generation cephalosporin) may be added to
empiric coverage for atypical pathogens if there is strong evidence of a bacterial cause.
Strong evidence of a bacterial cause includes white blood cell count >15,000/microL, C-
reactive protein >35 to 60 mg/L (3.5 to 6 mg/dL), chills, or no response to outpatient therapy
with a macrolide or doxycycline [4,46].
Fluoroquinolones (eg, levofloxacin, moxifloxacin) may be reasonable empiric therapy for the
older child and adolescent with suspected atypical pneumonia who could possibly have
pneumococcal pneumonia. The fluoroquinolones also may be used in the older child or
adolescent who is unable to receive beta-lactam antibiotics (eg, history of immunoglobulin
[Ig]E-mediated reaction or serious delayed reaction ( table 5)). 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 (including macrolide-resistant M. pneumoniae), and C.
pneumoniae [47]. However, S. pneumoniae resistant to levofloxacin have been identified [48].
Severe CAP
Severe CAP not requiring ICU admission — Children with severe CAP who do not require
admission to the ICU ( table 1) may benefit from combination empiric therapy with a
macrolide and a beta-lactam antibiotic (eg, ampicillin or third-generation cephalosporin)
( table 2A-B). Combination therapy improves coverage for resistant organisms and mixed
bacterial/atypical bacterial infections.
If S. aureus is an etiologic consideration, options include:
● Adding either vancomycin or clindamycin (depending upon local susceptibility patterns)

to the combination macrolide and beta-lactam, or
● Switching from the combination macrolide and beta-lactam to ceftaroline plus

azithromycin

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 ICU for serious
or life-threatening infections require broad-spectrum empiric coverage that addresses
potential beta-lactam resistance and CA-MRSA. (See 'Indications for intensive care' above.)
A suggested regimen for such children may include ( table 2A-B) [49-51]:
● Vancomycin ( table 6), and
● A third-generation cephalosporin (cefotaxime 150 mg/kg per day IV in four divided

doses up to a maximum of 8 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 to 200 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: Management", section on 'Antiviral therapy')
This combination is necessary because of reports of treatment failure resulting from

treatment of nonsusceptible S. pneumoniae with beta-lactams, clindamycin resistance among
S. pneumoniae (which, however, is becoming less prevalent), and concern for MRSA [49].
Virtually all strains of MRSA are susceptible to vancomycin [50]. (See "Staphylococcus aureus
in children: Overview of treatment of invasive infections", section on 'MRSA infections'.)
When treating with vancomycin, renal function and serum trough levels or dosing to achieve
an area under the curve/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/mL have been suggested to
improve clinical outcomes for complicated infections due to S. aureus [51-53]. 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 [53-58].
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For children in whom S. aureus is likely, linezolid could be substituted for vancomycin and
nafcillin in the above regimen. Linezolid is an oxazolidinone antibiotic with activity against
gram-positive cocci, including beta-lactam-resistant S. pneumoniae and MRSA. However,
against S. aureus it is only bacteriostatic. Linezolid is dosed according to age as follows:
● Age <12 years – 10 mg/kg per dose IV every 8 hours (maximum 600 mg/dose)
● Age ≥12 years – 600 mg every 12 hours
An alternative non-vancomycin-containing regimen for children in whom S. aureus is a

consideration consists of:
● Ceftaroline
• Age ≥2 months and <2 years – 8 mg/kg per dose IV every 8 hours
• Age ≥2 years and <18 years:
- Weight ≤33 kg – 12 mg/kg per dose IV every 8 hours
- Weight >33 kg – 400 mg/dose IV every 8 hours or 600 mg/dose IV every 12
hours
• Age ≥18 years – 600 mg/dose IV every 12 hours
● Plus 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
● 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: Management", section on 'Antiviral therapy')
Complicated CAP — Complicated CAP (eg, parapneumonic effusion, necrotizing process,

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 including CA-MRSA. Coverage for anaerobes and gram-
negative organisms also may be necessary for children with lung abscess [59]. 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 [60]. Appropriate regimens may include [33]:
● Either ceftriaxone 100 mg/kg IV in two divided doses (maximum 4 g/day) or cefotaxime
150 mg/kg per day IV in four divided doses (maximum 8 g/day)

If S. aureus or anaerobes are a consideration, add clindamycin 30 to 40 mg/kg per day

IV in three or four divided doses (maximum 2.7 g/day).
Vancomycin ( table 6) 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, in an effort 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,
severity of illness, renal function and/or use of other nephrotoxic agents, and
turnaround time for susceptibilities. When treating with vancomycin, renal function
and serum trough levels or dosing to achieve an AUC:MIC ratio 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 [51-53]. 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 [53-58]. (See "Staphylococcus aureus in children: Overview
of treatment of invasive infections", section on 'MRSA infections'.)
● Monotherapy with ceftaroline is an alternative if S. aureus is a consideration:
• Age ≥2 months and <2 years – 8 mg/kg per dose IV every 8 hours
• Age ≥2 years and <18 years:
- Weight ≤33 kg – 12 mg/kg per dose IV every 8 hours
- Weight >33 kg – 400 mg/dose IV every 8 hours or 600 mg/dose IV every 12
hours
• Age ≥18 years – 600 mg/dose IV every 12 hours
In a multicenter randomized trial in 40 children with complicated community-acquired

bacterial pneumonia (only one had documented MRSA), clinical cure rates at the end of
treatment were similar with ceftaroline monotherapy and combination ceftriaxone and
vancomycin (approximately 80 percent) [42].
● For children with lung abscess that is thought to be secondary to aspiration, ampicillin-
sulbactam 150 to 200 mg/kg per day of the ampicillin component IV in four divided
doses (maximum 8 g/day for the ampicillin component) alone may be effective. (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 [59,61-63].
● Lung abscess – Treatment of lung abscess requires a prolonged course of antibiotic

therapy. The duration is determined by the clinical response and radiographic
resolution of the abscess or stabilization of a small lesion. The usual course is a total of
three to four weeks or two weeks after the patient is afebrile and has clinical
improvement [60]. The average duration of fever is four to eight days. Antibiotic
therapy can be changed from the parenteral to the oral route when the child is
improving clinically and is afebrile. Eighty to 90 percent of lung abscesses in children
resolve with antibiotic therapy alone and spontaneous drainage through the
tracheobronchial tree, provided that any bronchial obstruction is removed [64].
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
[59,61,65,66]. Percutaneous drainage may be warranted in children with lung abscess
whose condition fails to improve or worsens after 72 hours of antibiotic therapy [67]. At
least three weeks of IV antibiotic therapy should be delivered before lobectomy is
considered for treatment failure [68].
● Pneumatocele – Most pneumatoceles involute spontaneously [69-71]. However, on

occasion, pneumatoceles may result in pneumothorax [72].
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:
● 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, or
• Clindamycin 30 to 40 mg/kg per day in three or four divided doses; maximum 2.7
g/day (for patients unable to receive beta-lactam antibiotics [eg, history of IgE-
mediated reaction or severe delayed hypersensitivity reaction ( table 5)])
The combination of amikacin and meropenem should be used if extended-spectrum beta-

lactamase-producing gram-negative rods are a consideration. The combination of amikacin
and either meropenem or cefepime should be used if AmpC beta-lactamase-producing
gram-negative rods are a consideration.
The cephalosporin/aminoglycoside combination lacks anaerobic coverage, so it 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. An agent

other than piperacillin-tazobactam should be chosen as the second agent, if feasible, when
vancomycin is added because the combination of these two drugs has been associated with
increased risk of acute kidney injury [73,74]. Ceftaroline is an alternative to vancomycin 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 [67]:
● Ampicillin-sulbactam 150 to 200 mg/kg per day of the ampicillin component IV in four
divided doses; maximum 8 g/day of the ampicillin component, or
● Clindamycin 30 to 40 mg/kg per day IV in three or four divided doses to a maximum of

2.7 g/day if MRSA etiology is suspected or for patients unable to receive beta-lactam
antibiotics (eg, history of IgE-mediated reaction or severe delayed hypersensitivity
reaction ( table 5)).
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 health care-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 regimen if MRSA is a consideration. Meropenem

may be preferred for gram-negative coverage if vancomycin is added because the
combination of vancomycin and piperacillin-tazobactam has been associated with increased
risk of acute kidney injury [73,74]. However, this risk must be weighed against the
development of meropenem resistance, particularly in closed units. Ceftaroline is an
alternative to vancomycin if MRSA is a consideration.
Patients with contraindications to beta-lactam antibiotics (eg, history of IgE-mediated

reaction or severe delayed 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-sulfamethoxazole for 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 diagnostic studies. 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 diagnostic evaluation 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 antimicrobial and/or supportive
therapy for the pathogens that commonly cause community-acquired pneumonia (CAP) in
children is discussed in the topic reviews listed below.
● S. pneumoniae (see "Pneumococcal pneumonia in children", section on 'Specific

therapy')
● Group A Streptococcus – Penicillin G or ampicillin are the preferred parenteral agents for
pneumonia caused by group A Streptococcus; the doses are as follows [1]:
• Penicillin G 100,000 to 250,000 units/kg per day intravenously (IV) divided in four or
six doses
• Ampicillin 200 mg/kg per day IV divided in four doses
Alternative parenteral agents include cefazolin, ceftriaxone or cefotaxime, clindamycin

(if susceptible), and vancomycin (for children unable to receive beta-lactam antibiotics
[eg, history of IgE-mediated reaction or severe delayed hypersensitivity reaction
( table 5)]) [1].
Amoxicillin or penicillin V are the preferred oral agents; the doses are as follows [1]:
• Amoxicillin 50 to 75 mg/kg per day orally divided in two doses (maximum 4 g/day)
• Penicillin V 50 to 75 mg/kg per day orally divided in three doses (maximum 2 g/day)
Alternative oral agents include cephalexin 75 to 100 mg/kg per day in three or four
divided doses (maximum 4 g/day) or clindamycin (if susceptible) 40 mg/kg per day
orally divided in three doses (maximum 1.8 g/day) [1].
● Haemophilus influenzae (typeable or nontypeable) (see "Epidemiology, clinical

manifestations, diagnosis, and treatment of Haemophilus influenzae", section on
'Directed treatment')
● M. pneumoniae (see "Mycoplasma pneumoniae infection in children", section on

'Management')
● C. pneumoniae (see "Pneumonia caused by Chlamydia pneumoniae in children")
● Methicillin-susceptible S. aureus (MSSA) – MSSA pneumonia may be treated with

oxacillin, nafcillin, or cefazolin [1,4]

● Methicillin-resistant S. aureus (MRSA) (see "Staphylococcus aureus in children: Overview

of treatment of invasive infections", section on 'Definitive antimicrobial therapy')
● Respiratory syncytial virus (see "Respiratory syncytial virus infection: Treatment")
● Influenza (see "Seasonal influenza in children: Management", 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) [2,75]. 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 [76].
Total duration — There are few randomized controlled trials to guide decisions about the
appropriate duration of antimicrobial therapy for radiographically confirmed childhood
pneumonia [2]. Clinical practice assigns duration of therapy according to the host, causative
agent, and severity.
● Uncomplicated cases – For children hospitalized with uncomplicated pneumonia, we

generally treat with a seven-day course of combined parenteral and oral therapy,
although a course of five to seven days may also be effective.
Although evidence from randomized trials in children is lacking, there is some evidence
to support five to seven days of therapy. In a single-center observational study in
children ≥6 months of age who were hospitalized with uncomplicated community-
acquired pneumonia (CAP), rates of treatment failure were similar among those who
received antibiotic therapy for 5 to 7 days and 8 to 14 days (3 versus 6 percent, odds
ratio 0.48, 95% CI 0.18-1.20) [77]. Treatment failure was defined as a composite of
unanticipated emergency department or outpatient visits, readmission, or death within
30 days after completion of antibiotics. Randomized trials in adult patients with mild to
moderate CAP also suggest that outcomes in patients treated for less than seven days
are similar to those in patients treated longer. These trials are discussed separately.

(See "Treatment of community-acquired pneumonia in adults in the outpatient setting",

section on 'Duration of therapy'.)
● 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 three to four weeks or a total of two weeks after the patient is afebrile and has
improved clinically. Some infectious diseases specialists use an erythrocyte
sedimentation rate value of <20 mm/hour as a laboratory indicator that the duration of
therapy has been sufficient. (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
● Peripheral capillary 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 [67].
Treatment failure — In children who fail to improve as anticipated, the following

possibilities must be considered [1,2,78,79]:
● 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
'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 [80], 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 [61,65-67]. (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 [1,67]:
● 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
● Caregivers' 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 [67,81,82]. Eligibility for OPAT requires a suitable home environment and
a pharmacologic agent with a reasonable dosing schedule [83]. 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 [67]. 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
[84]. 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), including round pneumonia [85].
However, in children with complicated CAP or CAP that required intervention, follow-up
radiographs help to ensure resolution [2,86]. Follow-up radiographs also may be helpful in
children with recurrent pneumonia, persistent symptoms, severe atelectasis, or unusually
located infiltrates [2,67,87]. When follow-up radiographs are indicated, they should be
obtained two to three weeks after hospital discharge [67,88]. Other conditions that should
be considered if symptoms persist in children with round pneumonia include congenital
lung sequestration, pulmonary arteriovenous malformation, metastatic Wilms tumor,
cavitary necrosis, pleural pseudocyst, and primary lung carcinoma [85,87,89-92].
Several studies have evaluated the utility of follow-up radiographs in cohorts of children with
acute radiologically proven CAP [93-98]. Three of the studies included clinical as well as
radiologic follow-up at three to seven weeks after initial diagnosis [93-96]. In each of these
studies, follow-up radiographs were normal or improved in asymptomatic children. Residual
radiographic 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 [62,63,67,99]. 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 [100].
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 [101,102].
The overall pneumonia mortality rate in developed countries is <1 per 1000 per year
[26,103]. Pneumococcal pneumonia case fatality rates (not adjusted for comorbid conditions)
for children in the United States were estimated to be 4 percent in children younger than
two years and 2 percent in children 2 to 17 years before the introduction of pneumococcal
conjugate vaccines [104].
The introduction of pneumococcal conjugate vaccines has resulted in a dramatic reduction

(37 to 80 percent) in invasive disease and mortality rates in the countries in which they have
been introduced [105]. However, pneumococcal pneumonia mortality rates have not been
specifically examined. Data from the United States Pediatric Multicenter Pneumococcal
Surveillance Study Group demonstrated overall pneumococcal mortality rates of 1 percent
after the introduction of PCV7 (during 2006 to 2009) and 0 percent after the introduction of
PCV13 (during 2011 to 2014) [106]. In a study from eastern Gambia, introduction of a nine-
valent pneumococcal conjugate vaccine resulted in reduced all-cause mortality (25.2 versus
30.1 per 1000 child-years, a 16 percent reduction) [107]. (See "Pneumococcal vaccination in
children", section on 'Efficacy and effectiveness'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Pediatric
pneumonia".)

INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or email these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword[s] of interest.)
● Basics topic (see "Patient education: Pneumonia in children (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Hospitalization and supportive care – The decision to hospitalize a child with

community-acquired pneumonia (CAP) must be individualized and is based upon age,
underlying medical problems, and severity of illness ( table 1). (See 'Indications'
above.)
CAP can be caused by a variety of microbial agents, requiring a variety of infection-

control measures. (See 'Infection control' above.)
Supportive care for children hospitalized with pneumonia includes provision of

adequate respiratory support, hydration, antipyresis, and analgesia. (See 'Supportive
care' above.)
● Empiric antimicrobial therapy – Children with CAP who are hospitalized are treated
empirically until information from the microbiologic evaluation is available to direct
therapy toward a specific pathogen. 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 ( table 2A-B).
(See 'Overview' above and "Pneumonia in children: Epidemiology, pathogenesis, and
etiology", section on 'Etiologic agents'.)
• We recommend that empiric antibiotic therapy for presumed bacterial pneumonia

in hospitalized children include coverage for Streptococcus pneumoniae

( table 2A-B) (Grade 1B). (See 'Uncomplicated bacterial pneumonia' above.)
• Extended empiric coverage may be indicated for children with complicated or

severe pneumonia, particularly those who require admission to an intensive care
unit (ICU) ( table 2A-B). (See 'Complicated CAP' above and 'Severe CAP requiring
ICU admission' above.)
● Specific antimicrobial therapy – When results of microbiologic tests are available,

antibiotic therapy can be directed toward the specific pathogen recovered. (See
'Specific therapy' above.)
● Switch to oral therapy – Oral therapy typically is initiated when the patient has been
afebrile for 24 to 48 hours and can tolerate oral intake. The total duration of antibiotic
therapy is usually seven days for uncomplicated CAP, although a course of five to seven
days may also be effective. Up to four weeks of antimicrobial therapy may be necessary
for complicated CAP. (See 'Duration of treatment' above.)
● Treatment failure – The respiratory status of children receiving appropriate therapy

for CAP should improve within 48 to 72 hours. Children who fail to improve as
anticipated may be receiving inadequate antibiotic therapy, have developed
complications, or have an alternative or coincident diagnosis. (See 'Treatment failure'
above.)
● Clinical course and follow-up – Children recovering from CAP may continue to have
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 are not necessary in asymptomatic children with uncomplicated

CAP. However, in children with complicated CAP or CAP that required intervention,
follow-up radiographs help to ensure resolution. Follow-up radiographs two to three
weeks after completion of therapy may be helpful in children with recurrent
pneumonia, persistent symptoms, severe atelectasis, or unusually located infiltrates.
(See 'Radiographs' above.)
Most otherwise healthy children who develop pneumonia recover without any long-
term sequelae. (See 'Prognosis' above.)
Use of UpToDate is subject to the Terms of Use.
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52. Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in
adult patients: a consensus review of the American Society of Health-System
Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious
Diseases Pharmacists. Am J Health Syst Pharm 2009; 66:82.
53. McKamy S, Hernandez E, Jahng M, et al. Incidence and risk factors influencing the
development of vancomycin nephrotoxicity in children. J Pediatr 2011; 158:422.
54. Moffett BS, Kim S, Edwards M. Vancomycin nephrotoxicity may be overstated. J Pediatr
2011; 158:865.
55. Cies JJ, Shankar V. Nephrotoxicity in patients with vancomycin trough concentrations of
15-20 μg/ml in a pediatric intensive care unit. Pharmacotherapy 2013; 33:392.
56. Frymoyer A, Guglielmo BJ, Hersh AL. Desired vancomycin trough serum concentration
for treating invasive methicillin-resistant Staphylococcal infections. Pediatr Infect Dis J
2013; 32:1077.
57. Chhim RF, Arnold SR, Lee KR. Vancomycin Dosing Practices, Trough Concentrations, and
Predicted Area Under the Curve in Children With Suspected Invasive Staphylococcal
Infections. J Pediatric Infect Dis Soc 2013; 2:259.
58. Patel K, Crumby AS, Maples HD. Balancing vancomycin efficacy and nephrotoxicity:
should we be aiming for trough or AUC/MIC? Paediatr Drugs 2015; 17:97.
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65. Rice TW, Ginsberg RJ, Todd TR. Tube drainage of lung abscesses. Ann Thorac Surg 1987;
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66. Zuhdi MK, Spear RM, Worthen HM, Peterson BM. Percutaneous catheter drainage of
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68. Emanuel B, Shulman ST. Lung abscess in infants and children. Clin Pediatr (Phila) 1995;
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69. Kunyoshi V, Cataneo DC, Cataneo AJ. Complicated pneumonias with empyema and/or
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72. Amitai I, Mogle P, Godfrey S, Aviad I. Pneumatocele in infants and children. Report of 12
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73. Downes KJ, Cowden C, Laskin BL, et al. Association of Acute Kidney Injury With
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74. Cook KM, Gillon J, Grisso AG, et al. Incidence of Nephrotoxicity Among Pediatric Patients
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94. Virkki R, Juven T, Mertsola J, Ruuskanen O. Radiographic follow-up of pneumonia in

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96. Heaton P, Arthur K. The utility of chest radiography in the follow-up of pneumonia. N Z
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97. Wacogne I, Negrine RJ. Are follow up chest x ray examinations helpful in the
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98. Surén P, Try K, Eriksson J, et al. Radiographic follow-up of community-acquired
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99. Bruckheimer E, Dolberg S, Shlesinger Y, et al. Primary lung abscess in infancy. Pediatr
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100. Neuman MI, Hall M, Gay JC, et al. Readmissions among children previously hospitalized
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102. Eastham KM, Hammal DM, Parker L, Spencer DA. A follow-up study of children
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randomised, double-blind, placebo-controlled trial. Lancet 2005; 365:1139.
Topic 6054 Version 66.0

GRAPHICS
Severity of community-acquired pneumonia in infants and children
Clinical features of severe

Clinical features of mild pneumonia
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 RR >70 breaths/minute for infants; RR >50
that defines moderate to severe respiratory breaths/minute for older children
distress Moderate/severe suprasternal, intercostal,
Mild or absent retractions or subcostal retractions (<12 months)
No grunting Severe difficulty breathing (≥12 months)
No nasal flaring Grunting
No apnea Nasal flaring
Mild shortness of breath Apnea
Significant shortness of breath
Normal color Cyanosis
Normal mental status Altered mental status
Normoxemia (oxygen saturation ≥92 percent in Hypoxemia (sustained oxygen saturation <90
room air) 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

Parenteral empiric antibiotics for inpatient treatment of pediatric

community-acquired pneumonia [1,2]
Age group and Suggested parenteral

Comments
suspected pathogens empiric agent(s)
1 to 6 months
Bacterial (not Chlamydia One of the following: If CA-MRSA is suspected,

trachomatis or Ceftriaxone ADD one of the following:
Staphylococcus aureus) Cefotaxime Vancomycin or
clindamycin
Ceftaroline*
(alternative)
C. trachomatis Azithromycin
≥6 months
Uncomplicated bacterial One of the following: Cefotaxime and ceftriaxone

(not Mycoplasma Ampicillin or penicillin G are reserved for:
pneumoniae, Chlamydia (preferred) Children with
pneumoniae, or S. aureus) Cefotaxime incomplete Hib or
Ceftriaxone Streptococcus
pneumoniae
immunizations, or
Communities with
substantial prevalence
of penicillin-resistant S.
pneumoniae (eg, ≥25%)
M. pneumoniae or C. One of the following:

pneumoniae Azithromycin
Erythromycin
Levofloxacin
Clinical syndrome (any Suggested empiric

Comments
age) parenteral agent(s)
Severe pneumonia Combination therapy with one Children with severe

of the following: infection may benefit from
Ceftriaxone broad-spectrum therapy
Cefotaxime that addresses both typical
PLUS one of the following: and atypical pathogens
Azithromycin If S. aureus is a
consideration, either:
Erythromycin
ADD vancomycin or
Doxycycline
clindamycin, OR

Provide therapy with

ceftaroline* PLUS
azithromycin
Severe pneumonia requiring Combination therapy with: If S. aureus is likely:

ICU admission Vancomycin ADD nafcillin ¶ , OR
PLUS one of the following: SUBSTITUTE linezolid
Ceftriaxone for vancomycin and
Cefotaxime nafcillin, OR
PLUS: Use ceftaroline* PLUS
Azithromycin azithromycin PLUS
antiviral treatment for
PLUS:
influenza if the child is
Antiviral treatment for
hospitalized during
influenza if the child is
influenza season
hospitalized during
influenza season
Complicated pneumonia (eg, Combination therapy with one Potential pathogens

effusion/empyema, of the following: include S. pneumoniae, S.
necrotizing process, abscess Δ ) Ceftriaxone aureus, and Streptococcus
Cefotaxime pyogenes
PLUS: Vancomycin is an
Clindamycin if S. aureus alternative to clindamycin
or anaerobic infection is for children with allergy to
a consideration clindamycin or high
prevalence of clindamycin
resistance in the
community ◊
Monotherapy with
ceftaroline is an alternative
if S. aureus is a
consideration
This table is meant for use with UpToDate content on the treatment of CAP in children. Refer to
related UpToDate content for details regarding complete Hib and S. pneumoniae immunization,
criteria for severe pneumonia, and pneumonia requiring ICU admission. Consultation with a
specialist in infectious diseases for children is suggested for children with severe hypersensitivity
to beta-lactam antibiotics (eg, penicillins and cephalosporins).
CA-MRSA: community-associated methicillin-resistant S. aureus; Hib: Haemophilus influenzae type

b; ICU: intensive care unit; CAP: community-acquired pneumonia; MSSA: methicillin-susceptible S.
aureus; MRSA: methicillin-resistant S. aureus.
* Ceftaroline is a fifth-generation cephalosporin. It is available in the United States for the

treatment of pediatric CAP due to S. pneumoniae, MSSA, and H. influenzae in children ≥2 months
of age. Although ceftaroline has in vitro activity against MRSA, experience in children with
documented MRSA CAP is limited.

¶ Nafcillin is added if S. aureus is likely because MSSA is more rapidly killed by nafcillin than by
vancomycin.
Δ Ampicillin-sulbactam alone may be effective if lung abscess is thought to be secondary to

aspiration.
◊ The threshold prevalence of clindamycin-resistant MRSA (constitutive plus inducible) for

choosing vancomycin varies from center to center, usually ranging from 10 to 25%, in an effort 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.
Data from:

Doses for parenteral antibiotics for the empiric treatment of community-

acquired pneumonia in hospitalized children
Agent Regimen [1,2] Comments
Ampicillin 150 to 200 mg/kg per day

in 4 divided doses (MAX 12
g/day)
Azithromycin 10 mg/kg once per day on Transition to oral therapy at

days 1 and 2 of therapy 5 mg/kg per day as soon as
(MAX 500 mg/day) clinically appropriate
5 mg/kg once per day on
subsequent days of therapy
(MAX 250 mg/day)
Cefazolin 100 to 150 mg/kg per day Limited data on doses >100
in 3 divided doses (MAX 12 mg/kg per day
g/day)
Cefotaxime 150 mg/kg per day in 3 or 4 The 4-dose regimen should

divided doses (MAX 8 be used for severe infection
g/day) or substantial local
penicillin resistance
Ceftaroline Age ≥2 months and <2 Experience with ceftaroline

years: 8 mg/kg every 8 in children with
hours documented MRSA
Age ≥2 and <18 years: infection is limited
Weight ≤33 kg: 12
mg/kg every 8 hours
Weight >33 kg: 400 mg
every 8 hours or 600
mg every 12 hours
Age ≥18 years: 600 mg
every 12 hours
Ceftriaxone 50 to 100 mg/kg per day in The 100 mg/kg per day
1 or 2 divided doses (MAX 4 dose should be used only if
g/day) local rates of penicillin
resistance to Streptococcus
pneumoniae are substantial
(eg, ≥25%)
The 2-dose regimen should
be used for severe infection
or if local rates of penicillin
resistance to S. pneumoniae
are substantial (eg, ≥25%)

Clindamycin 30 to 40 mg/kg per day in 3

or 4 divided doses (MAX 2.7
g/day)
Doxycycline 4 mg/kg per day in 2 Transition to oral therapy

divided doses (MAX 200 as soon as clinically
mg/day) appropriate
Erythromycin 20 mg/kg per day in 4 Parenteral erythromycin is

divided doses (MAX 4 associated with phlebitis,
g/day) prokinetic, and cardiotoxic
effects (rare)
Levofloxacin Age 6 months and <5 years: Fluoroquinolones may

16 to 20 mg/kg per day in 2 prolong QTc interval; avoid
divided doses use in patients with: [3]
Age ≥5 to 16 years: 8 to 10 Long QT syndrome
mg/kg once per day (MAX Hypokalemia or
750 mg) hypomagnesemia
Organic heart disease
(eg, congestive heart
failure; requiring a class
Ia antiarrhythmic
drug*, particularly
quinidine)
Concurrent use of other
medications that
prolong the QTc interval
Linezolid Age <12 years: 10 mg/kg

every 8 hours (MAX 600
mg/dose)
Age ≥12 years: 600 mg
every 12 hours
Nafcillin 150 to 200 mg/kg per day

in 4 or 6 divided doses
(MAX 12 g/day)
Penicillin G For therapy: 200,000 to

250,000 units/kg per day in
4 or 6 divided doses (MAX
24 million units/day)
Vancomycin 40 to 60 mg/kg per day in 3

or 4 divided doses (MAX 4
g/day) ¶
This table is meant for use with UpToDate content on the treatment of community-acquired
pneumonia in children. Refer to related UpToDate content for details about choice of therapy.

Consultation with a specialist in pediatric infectious diseases is suggested for children with
severe hypersensitivity to beta-lactam antibiotics (eg, penicillins and cephalosporins). The
recommended doses are for children with normal renal function.
MAX: maximum dose; MRSA: methicillin-resistant Staphylococcus aureus.
* Class Ia antiarrhythmic drugs include quinidine, ajmaline, disopyramide, and procainamide.
¶ Alternative dosing is suggested for clinicians/institutions who follow AUC-guided therapeutic

monitoring for vancomycin for serious MRSA infections as suggested by consensus
guidelines [4] ; this strategy requires input from a clinical pharmacist, who will provide
recommendations for initial dosing. Refer to UpToDate content on invasive staphylococcal
infections in children for details of trough-guided and AUC-guided vancomycin dosing.
References:
1. American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2021-2024 Report of the
Committee on Infectious Diseases, 32 nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American
Academy of Pediatrics, Itasca, IL 2021. p.876.
3. American Academy of Pediatrics. Fluoroquinolones. In: Red Book: 2021-2024 Report of the Committee on
Infectious Diseases, 32 nd ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of
Pediatrics, Itasca, IL 2021. p.864.
4. Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant
Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-
System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the
Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2020; 77:835.

Clinical and radiographic clues to the etiology of pneumonia in children*
Etiology Clinical features Radiographic features
Bacteria Children of all ages Alveolar infiltrates

(most commonly Abrupt onset Segmental consolidation
Streptococcus
Ill-appearance Lobar consolidation
pneumoniae)
Chills "Round" pneumonia
Moderate to severe respiratory Complications:
distress
Pleural effusion/empyema
Focal auscultatory findings
Lung abscess
Localized chest pain
Necrotizing pneumonia
WBC count >15,000/microL (if
Pneumatocele
obtained)
Elevated acute phase reactants (if
obtained)
Atypical bacterial Children of all ages (most M. pneumoniae:

(Mycoplasma common in children >5 years) Lobar or segmental
pneumoniae, Abrupt onset with constitutional consolidation (37%)
Chlamydia findings (malaise, myalgia, Parahilar or peribronchial
pneumoniae) headache, rash, conjunctivitis, infiltrates (27%)
photophobia, sore throat) Localized reticulonodular
Gradually worsening infiltrates (21%)
nonproductive cough Patchy infiltrates (15%)
Wheezing
Extrapulmonary manifestations or
complications (eg, polymorphous
mucocutaneous eruptions,
hemolytic anemia, hepatitis,
pancreatitis, myopericarditis,
aseptic meningitis)
Viral Usually children <5 years Interstitial infiltrates

Gradual onset Associated bronchiolitis:
Preceding upper airway Patchy atelectasis
symptoms Peribronchial infiltrations with
Nontoxic appearing air bronchograms
Diffuse, bilateral auscultatory Hyperinflation with flattening
findings of the diaphragms
Wheezing
May have associated rash (eg,
measles, varicella)
Afebrile Usually in infants 2 weeks to 4 Hyperinflation with interstitial

pneumonia of months infiltrates
infancy Insidious onset
(most commonly Tachypnea, diffuse crackles

Chlamydia Rhinorrhea
trachomatis) Staccato cough pattern
Peripheral eosinophilia (if CBC
obtained)
Fungal Appropriate geographic or Mediastinal or hilar adenopathy

environmental exposure
Mycobacterium Children of any age Mediastinal or hilar adenopathy

tuberculosis Chronic cough
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.
5. Cho YJ, Han MS, Kim WS, et al. Correlation between chest radiographic findings and clinical features in
hospitalized children with Mycoplasma pneumoniae pneumonia. PLoS One 2019; 14:e0219463.
6. Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health
1990; 26:209.

Suggested criteria for full Haemophilus influenza type b and Streptococcus

pneumoniae immunization status when considering empiric antibiotics
for community-acquired pneumonia in children
Current age* Criteria for full immunization ¶
Haemophilus influenzae type b
12 to 15 months ≥2 doses of Hib conjugate vaccine, with at least

one dose at ≥12 months of age
15 months to 5 years ≥2 doses of Hib conjugate vaccine, with at least

one dose at ≥12 months of age, or
≥1 dose of Hib conjugate vaccine at ≥15

months of age
≥5 years, not high risk Δ Hib immunization not necessary
Streptococcus pneumoniae
12 to 24 months ≥3 doses of PCV at <16 months, with ≥1 dose

at ≥12 months, or
2 doses of PCV, both at ≥12 months
24 months through 5 years ≥3 doses of PCV at <16 months, with ≥1 dose

at ≥12 months, or
2 doses of PCV, both at ≥12 months, or
≥1 dose of PCV at ≥24 months
>5 years, not high risk ◊ PCV immunization not necessary
Hib: H. influenzae type b; PCV: pneumococcal conjugate vaccine.
* Children younger than 12 months are incompletely immunized against Hib and S. pneumoniae.
¶ Immunizations must be completed at least two weeks before pneumonia diagnosis.
Δ Children at high risk for invasive Hib disease include chemotherapy recipients and those with
anatomic or functional asplenia (including sickle cell disease), HIV infection, immunoglobulin
deficiency, or early component complement deficiency. Please refer to the UpToDate topic on
prevention of H. influenzae infection for a discussion of full Hib immunization in children at high
risk for invasive Hib disease.
◊ Children at high risk for invasive S. pneumoniae disease include those with chronic heart
disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease
(including asthma if treated with high-dose oral corticosteroid therapy); diabetes mellitus;
cerebrospinal fluid leak; cochlear implant; sickle cell disease and other hemoglobinopathies;
anatomic or functional asplenia; HIV infection; chronic renal failure; nephrotic syndrome;
diseases associated with treatment with immunosuppressive drugs or radiation therapy,
including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; solid organ
transplantation; or congenital immunodeficiency. Please refer to the UpToDate topics on PCVs

and pneumococcal polysaccharide vaccines for a discussion of full S. pneumoniae immunization

in children at high risk for invasive S. pneumoniae disease.

Type of drug reactions
Type of reaction Common features
Non-allergic reaction Adverse effects (eg, diarrhea, vomiting, yeast vaginitis)

Family history of penicillin allergy but no personal history
Mild non-IgE-mediated Maculopapular rash (with or without itching)

reaction Medical record lists penicillin allergy but patient unaware of
reaction
IgE-mediated reaction Anaphylaxis

Angioedema
Wheezing
Laryngeal edema
Hypotension
Hives/urticaria
Serious delayed reactions Toxic epidermal necrolysis (TEN)

Stevens-Johnson syndrome (SJS)
Drug reaction with eosinophilia and systemic symptoms/drug-
induced hypersensitivity syndrome (DRESS/DiHS)
Other exfoliating dermatoses/erythroderma
Serum sickness-like reactions
Drug-induced cytopenias
Drug-induced renal, hepatic, or other specific organ damage
IgE: immunoglobulin E.

Alternative approaches to vancomycin dosing for children and

adolescents with normal kidney function
Subsequent dose and

Strategy Initial dose and interval
interval adjustments
Traditional approach for Typically 15 mg/kg per dose IV Either:

children >1 month and every 6 to 8 hours [1] : Continue initial dose (for
adolescents Use the every-6-hour most children,
interval for serious particularly if duration
infections* of vancomycin is
Maximum daily dose: 4 expected to be <3
g/day days) ¶
Based on trough-guided
serum concentration
monitoring for select
children (eg, those with
renal dysfunction,
infective endocarditis,
risk factors for altered
vancomycin kinetics [eg,
fluid overload, critical
illness])
AUC-guided approach Δ [2] Generally requires Based on AUC-guided serum

consultation with a clinical concentration monitoring
pharmacist (generally requires
consultation with a clinical
pharmacist)
The approach to vancomycin dosing is generally determined at the institutional level. Refer to
UpToDate content on invasive staphylococcal infections in children for details of trough-guided
and AUC-guided vancomycin dosing and traditional dosing of vancomycin for neonates.
IV: intravenous; AUC: area under the curve; MRSA: methicillin-resistant Staphylococcus aureus.
* Serious infections may include, but are not limited to, infective endocarditis, pneumonia
requiring hospitalization, osteomyelitis, central nervous system infection, and infection causing
critical illness.
¶ The value of trough-monitoring before achieving steady state (usually on day 2 to 3 of

treatment) is uncertain.
Δ Some experts suggest this approach for serious* MRSA infections in children of all ages.
References:
1. American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2021-2024 Report of the
Committee on Infectious Diseases, 32 nd ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American
Academy of Pediatrics, Itasca, IL 2021. p.876.

2. Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant
Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-
System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the
Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2020; 77:835.

Important aspects of the history in a child with pneumonia
Historical feature Possible significance
Age of the child Viral etiologies are most common in infants and preschool children
Atypical bacterial pathogens are more common in school-age

children
Recent viral upper May predispose to bacterial superinfection with Streptococcus

respiratory tract infection pneumoniae or Staphylococcus aureus
Associated symptoms Mycoplasma pneumoniae is often associated with extrapulmonary

manifestations (eg, headache, sore throat, conjunctivitis,
photophobia, rash)
Cough, chest pain, "Classic" features of pneumonia, but nonspecific

shortness of breath,
difficulty breathing
Increased work of Suggestive of severe pneumonia

breathing in the absence of
stridor or wheezing
Fluid and nutrition intake Difficulty or inability to feed suggests severe illness
Choking episode May indicate foreign body aspiration
Duration of symptoms Chronic cough (>4 weeks) suggests etiology other than acute
pneumonia (refer to UpToDate topic on causes of chronic cough in
children)
Previous episodes Recurrent episodes may indicate aspiration, congenital or acquired

anatomic abnormality, cystic fibrosis, immunodeficiency, asthma,
missed foreign body
Immunization status Completion of the primary series of immunizations for Haemophilus

influenzae type b, S. pneumoniae, Bordetella pertussis, and seasonal
influenza decreases, but does not eliminate, the risk of infection
with these organisms
Previous antibiotic therapy Increases the likelihood of antibiotic-resistant bacteria
Maternal history of May indicate Chlamydia trachomatis infection

chlamydia during
pregnancy (for infants <4
months of age)
Exposure to tuberculosis May indicate Mycobacterium tuberculosis infection
Ill contacts More common with viral etiologies
Travel to or residence in Measles: Resource-limited countries

certain areas that suggest Coccidioidomycosis: Southwestern United States, northern
endemic pathogens Mexico, Central and South America

Blastomycosis: Southeastern and Central United States; states

bordering the Great Lakes
Histoplasmosis: Ohio, Missouri, and Mississippi River valleys in
the United States; Canada; Central America; eastern and
southern Europe; parts of Africa; eastern Asia; and Australia
Hantavirus: West of the Mississippi River; four corners region of
United States (where borders of Colorado, New Mexico, Arizona,
and Utah meet)
Middle East respiratory syndrome (MERS): Countries in or near
Arabian Peninsula
Animal exposure May indicate histoplasmosis, psittacosis, Q fever
Day care center attendance Exposure to viruses and antibiotic-resistant bacteria

Contributor Disclosures
William J Barson, MD Grant/Research/Clinical Trial Support: Pfizer [Pneumonia]. All of the relevant
financial relationships listed have been mitigated. Morven S Edwards, MD Grant/Research/Clinical
Trial Support: Pfizer [Group B Streptococcus]. Other Financial Interest: Texas State University personal
services agreement [Chagas disease]. All of the relevant financial relationships listed have been
mitigated. Mary M Torchia, MD No relevant financial relationship(s) with ineligible companies 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.
Conflict of interest policy

Pneumonia in Children - Inpatient Treatment - UpToDate

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3/4/23, 10:28 PM Pneumonia in children: Inpatient treatment - UpToDate

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Pneumonia in children: Inpatient treatment

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

The inpatient treatment of CAP and hospital-acquired pneumonia in children will be

● (See "Community-acquired pneumonia in children: Outpatient treatment".)

Indications — The decision to hospitalize a child with community-acquired pneumonia (CAP)

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● Dehydration, or inability to maintain hydration orally; inability to feed in an infant

● Moderate to severe respiratory distress: Respiratory rate >70 breaths/minute for

● Complications (eg, effusion/empyema, necrotizing process, abscess)

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

● Signs of impending respiratory failure (lethargy, increasing work of breathing, and/or

● Recurrent apnea or slow irregular respirations

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● Cardiovascular compromise with progressive tachycardia and/or hypotension that

● Respiratory syncytial, parainfluenza, and human metapneumovirus – Gown and gloves

● Adenovirus – Contact and droplet precautions

● Methicillin-resistant S. aureus and other multidrug resistant organisms – Special

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Respiratory support — Children hospitalized with pneumonia should receive ventilatory

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Chest physiotherapy — Chest physiotherapy is not beneficial for children with

Adjunctive glucocorticoid therapy — We do not routinely provide adjunctive glucocorticoid

Overview — Prompt initiation of antimicrobial therapy is crucial in children with community-

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available, help to determine whether additional evaluation or changes in therapy are

Consultation with a specialist in infectious disease may be helpful in children with

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

COVID-19 pneumonia — The management of coronavirus 2019 (COVID-19)-related

Influenza pneumonia — Initiation of antiviral treatment for influenza (eg, oseltamivir) as

For children with influenza pneumonia in whom secondary bacterial pneumonia is

Common respiratory viruses may cause serious infections in immunocompromised children

Uncomplicated bacterial pneumonia — Streptococcus pneumoniae is the most common

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We suggest a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) for children

When community-associated-MRSA (CA-MRSA) is considered a potential pathogen for CAP in

A macrolide may be added ( table 2A-B) if M. pneumoniae, Chlamydia pneumoniae, or

Atypical pneumonia — Atypical bacterial pathogens include C. trachomatis in afebrile

If S. aureus is an etiologic consideration, options include:

● Adding either vancomycin or clindamycin (depending upon local susceptibility patterns)

● Switching from the combination macrolide and beta-lactam to ceftaroline plus

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Antimicrobial therapy can be adjusted as necessary when results of microbiologic testing

● Vancomycin ( table 6), and

● A third-generation cephalosporin (cefotaxime 150 mg/kg per day IV in four divided

This combination is necessary because of reports of treatment failure resulting from

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An alternative non-vancomycin-containing regimen for children in whom S. aureus is a

Complicated CAP — Complicated CAP (eg, parapneumonic effusion, necrotizing process,

Complicated CAP requires a prolonged course of antimicrobial therapy, usually initiated

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If S. aureus or anaerobes are a consideration, add clindamycin 30 to 40 mg/kg per day

Vancomycin ( table 6) is an alternative to clindamycin if the patient is allergic to

● Monotherapy with ceftaroline is an alternative if S. aureus is a consideration:

In a multicenter randomized trial in 40 children with complicated community-acquired

The duration of therapy and other considerations in the management of complicated

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● Parapneumonic effusion/empyema – The treatment of parapneumonic effusion and

● Necrotizing pneumonia – Treatment of necrotizing pneumonia requires a prolonged

● Lung abscess – Treatment of lung abscess requires a prolonged course of antibiotic

● Pneumatocele – Most pneumatoceles involute spontaneously [69-71]. However, on

Hospital-acquired pneumonia — Empiric treatment of hospital-acquired pneumonia