Community-acquired pneumonia in children: Outpatient treatment
- William J Barson, MD
William J Barson, MD
- Professor of Pediatrics
- The Ohio State University College of Medicine
- Section Editors
- Morven S Edwards, MD
Morven S Edwards, MD
- Section Editor — Pediatric Infectious Diseases
- Professor of Pediatrics
- Baylor College of Medicine
- George B Mallory, MD
George B Mallory, MD
- Section Editor — Pediatric Pulmonology
- Associate Professor of Pediatrics
- Baylor College of Medicine
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 Pediatric Infectious Diseases Society/Infectious Diseases Society of America and the British Thoracic Society have developed clinical practice guidelines for the evaluation and treatment of CAP in children [1,2].
The outpatient treatment of CAP in infants and children will be reviewed here. Neonatal pneumonia and inpatient treatment of pneumonia are discussed separately, as are the epidemiology, etiology, clinical features, and diagnosis. (See "Neonatal pneumonia" and "Pneumonia in children: Inpatient treatment" and "Pneumonia in children: Epidemiology, pathogenesis, and etiology" and "Community-acquired pneumonia in children: Clinical features and diagnosis".)
INDICATIONS FOR HOSPITALIZATION
The decision to hospitalize a child with CAP is individualized based upon age, underlying medical problems, and clinical factors including severity of illness (table 1) [1-3]. Hospitalization generally is warranted for infants younger than three to six months of age, unless a viral etiology or Chlamydia trachomatis is suspected and they are normoxemic and relatively asymptomatic. Hospitalization is also warranted for a child of any age whose family cannot provide appropriate care and assure compliance with the therapeutic regimen. Additional indications for hospitalization include [1,2]:
●Hypoxemia (oxygen saturation <90 percent in room air at sea level)
- 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.
- 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 Suppl 2:ii1.
- Russell G. Community acquired pneumonia. Arch Dis Child 2001; 85:445.
- McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
- Esposito S, Bosis S, Cavagna R, et al. Characteristics of Streptococcus pneumoniae and atypical bacterial infections in children 2-5 years of age with community-acquired pneumonia. Clin Infect Dis 2002; 35:1345.
- Virkki R, Juven T, Rikalainen H, et al. Differentiation of bacterial and viral pneumonia in children. Thorax 2002; 57:438.
- Low DE, Pichichero ME, Schaad UB. Optimizing antibacterial therapy for community-acquired respiratory tract infections in children in an era of bacterial resistance. Clin Pediatr (Phila) 2004; 43:135.
- Harris JA, Kolokathis A, Campbell M, et al. Safety and efficacy of azithromycin in the treatment of community-acquired pneumonia in children. Pediatr Infect Dis J 1998; 17:865.
- Wubbel L, Muniz L, Ahmed A, et al. Etiology and treatment of community-acquired pneumonia in ambulatory children. Pediatr Infect Dis J 1999; 18:98.
- Ambroggio L, Test M, Metlay JP, et al. Comparative Effectiveness of Beta-lactam Versus Macrolide Monotherapy in Children with Pneumonia Diagnosed in the Outpatient Setting. Pediatr Infect Dis J 2015; 34:839.
- Jadavji T, Law B, Lebel MH, et al. A practical guide for the diagnosis and treatment of pediatric pneumonia. CMAJ 1997; 156:S703.
- Tapiainen T, Aittoniemi J, Immonen J, et al. Finnish guidelines for the treatment of community-acquired pneumonia and pertussis in children. Acta Paediatr 2016; 105:39.
- Gordon KA, Biedenbach DJ, Jones RN. Comparison of Streptococcus pneumoniae and Haemophilus influenzae susceptibilities from community-acquired respiratory tract infections and hospitalized patients with pneumonia: five-year results for the SENTRY Antimicrobial Surveillance Program. Diagn Microbiol Infect Dis 2003; 46:285.
- Hyde TB, Gay K, Stephens DS, et al. Macrolide resistance among invasive Streptococcus pneumoniae isolates. JAMA 2001; 286:1857.
- Kaplan SL, Barson WJ, Lin PL, et al. Early trends for invasive pneumococcal infections in children after the introduction of the 13-valent pneumococcal conjugate vaccine. Pediatr Infect Dis J 2013; 32:203.
- Hoberman A, Paradise JL, Burch DJ, et al. Equivalent efficacy and reduced occurrence of diarrhea from a new formulation of amoxicillin/clavulanate potassium (Augmentin) for treatment of acute otitis media in children. Pediatr Infect Dis J 1997; 16:463.
- Behre U, Burow HM, Quinn P, et al. Efficacy of twice-daily dosing of amoxycillin/clavulanate in acute otitis media in children. Infection 1997; 25:163.
- Principi N, Marchisio P, Bigalli L, Massironi E. Amoxicillin twice daily in the treatment of acute otitis media in infants and children. Eur J Pediatr 1986; 145:522.
- Bradley JS, Garonzik SM, Forrest A, Bhavnani SM. Pharmacokinetics, pharmacodynamics, and Monte Carlo simulation: selecting the best antimicrobial dose to treat an infection. Pediatr Infect Dis J 2010; 29:1043.
- Baskin MN, O'Rourke EJ, Fleisher GR. Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. J Pediatr 1992; 120:22.
- Chumpa A, Bachur RG, Harper MB. Bacteremia-associated pneumococcal pneumonia and the benefit of initial parenteral antimicrobial therapy. Pediatr Infect Dis J 1999; 18:1081.
- Hammerschlag MR. Atypical pneumonias in children. Adv Pediatr Infect Dis 1995; 10:1.
- Peuchant O, Ménard A, Renaudin H, et al. Increased macrolide resistance of Mycoplasma pneumoniae in France directly detected in clinical specimens by real-time PCR and melting curve analysis. J Antimicrob Chemother 2009; 64:52.
- Averbuch D, Hidalgo-Grass C, Moses AE, et al. Macrolide resistance in Mycoplasma pneumoniae, Israel, 2010. Emerg Infect Dis 2011; 17:1079.
- Yamada M, Buller R, Bledsoe S, Storch GA. Rising rates of macrolide-resistant Mycoplasma pneumoniae in the central United States. Pediatr Infect Dis J 2012; 31:409.
- Kawai Y, Miyashita N, Yamaguchi T, et al. Clinical efficacy of macrolide antibiotics against genetically determined macrolide-resistant Mycoplasma pneumoniae pneumonia in paediatric patients. Respirology 2012; 17:354.
- Chironna M, Sallustio A, Esposito S, et al. Emergence of macrolide-resistant strains during an outbreak of Mycoplasma pneumoniae infections in children. J Antimicrob Chemother 2011; 66:734.
- Liu Y, Ye X, Zhang H, et al. Characterization of macrolide resistance in Mycoplasma pneumoniae isolated from children in Shanghai, China. Diagn Microbiol Infect Dis 2010; 67:355.
- Miyashita N, Kawai Y, Akaike H, et al. Macrolide-resistant Mycoplasma pneumoniae in adolescents with community-acquired pneumonia. BMC Infect Dis 2012; 12:126.
- Centers for Disease Control and Prevention (CDC). Mycoplasma pneumoniae respiratory illness - two rural counties, West Virginia, 2011. MMWR Morb Mortal Wkly Rep 2012; 61:834.
- Wu PS, Chang LY, Lin HC, et al. Epidemiology and clinical manifestations of children with macrolide-resistant Mycoplasma pneumoniae pneumonia in Taiwan. Pediatr Pulmonol 2013; 48:904.
- Kawai Y, Miyashita N, Kubo M, et al. Nationwide surveillance of macrolide-resistant Mycoplasma pneumoniae infection in pediatric patients. Antimicrob Agents Chemother 2013; 57:4046.
- Zheng X, Lee S, Selvarangan R, et al. Macrolide-Resistant Mycoplasma pneumoniae, United States. Emerg Infect Dis 2015; 21:1470.
- Todd SR, Dahlgren FS, Traeger MS, et al. No visible dental staining in children treated with doxycycline for suspected Rocky Mountain Spotted Fever. J Pediatr 2015; 166:1246.
- Block S, Hedrick J, Hammerschlag MR, et al. Mycoplasma pneumoniae and Chlamydia pneumoniae in pediatric community-acquired pneumonia: comparative efficacy and safety of clarithromycin vs. erythromycin ethylsuccinate. Pediatr Infect Dis J 1995; 14:471.
- Chien SM, Pichotta P, Siepman N, Chan CK. Treatment of community-acquired pneumonia. A multicenter, double-blind, randomized study comparing clarithromycin with erythromycin. Canada-Sweden Clarithromycin-Pneumonia Study Group. Chest 1993; 103:697.
- Pelton SI, Hammerschlag MR. Overcoming current obstacles in the management of bacterial community-acquired pneumonia in ambulatory children. Clin Pediatr (Phila) 2005; 44:1.
- Bartlett JG, Mundy LM. Community-acquired pneumonia. N Engl J Med 1995; 333:1618.
- Sandora TJ, Harper MB. Pneumonia in hospitalized children. Pediatr Clin North Am 2005; 52:1059.
- Bradley JS, Arguedas A, Blumer JL, et al. Comparative study of levofloxacin in the treatment of children with community-acquired pneumonia. Pediatr Infect Dis J 2007; 26:868.
- Davidson R, Cavalcanti R, Brunton JL, et al. Resistance to levofloxacin and failure of treatment of pneumococcal pneumonia. N Engl J Med 2002; 346:747.
- Haider BA, Saeed MA, Bhutta ZA. Short-course versus long-course antibiotic therapy for non-severe community-acquired pneumonia in children aged 2 months to 59 months. Cochrane Database Syst Rev 2008; :CD005976.
- Hazir T, Nisar YB, Qazi SA, et al. Chest radiography in children aged 2-59 months diagnosed with non-severe pneumonia as defined by World Health Organization: descriptive multicentre study in Pakistan. BMJ 2006; 333:629.
- Hazir T, Nisar YB, Abbasi S, et al. Comparison of oral amoxicillin with placebo for the treatment of world health organization-defined nonsevere pneumonia in children aged 2-59 months: a multicenter, double-blind, randomized, placebo-controlled trial in pakistan. Clin Infect Dis 2011; 52:293.
- Greenberg D, Givon-Lavi N, Sadaka Y, et al. Short-course antibiotic treatment for community-acquired alveolar pneumonia in ambulatory children: a double-blind, randomized, placebo-controlled trial. Pediatr Infect Dis J 2014; 33:136.
- Alves dos Santos JW, Torres A, Michel GT, et al. Non-infectious and unusual infectious mimics of community-acquired pneumonia. Respir Med 2004; 98:488.
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
- Bébéar C, Pereyre S, Peuchant O. Mycoplasma pneumoniae: susceptibility and resistance to antibiotics. Future Microbiol 2011; 6:423.
- Chang CC, Cheng AC, Chang AB. Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults. Cochrane Database Syst Rev 2014; :CD006088.
- Gaston B. Pneumonia. Pediatr Rev 2002; 23:132.
- Griscom NT. Pneumonia in children and some of its variants. Radiology 1988; 167:297.
- McLennan MK. Radiology rounds. Round pneumonia. Can Fam Physician 1998; 44:751, 757.
- Kim YW, Donnelly LF. Round pneumonia: imaging findings in a large series of children. Pediatr Radiol 2007; 37:1235.
- Eggli KD, Newman B. Nodules, masses, and pseudomasses in the pediatric lung. Radiol Clin North Am 1993; 31:651.
- Rose RW, Ward BH. Spherical pneumonias in children simulating pulmonary and mediastinal masses. Radiology 1973; 106:179.
- Grossman LK, Wald ER, Nair P, Papiez J. Roentgenographic follow-up of acute pneumonia in children. Pediatrics 1979; 63:30.
- Virkki R, Juven T, Mertsola J, Ruuskanen O. Radiographic follow-up of pneumonia in children. Pediatr Pulmonol 2005; 40:223.
- Gibson NA, Hollman AS, Paton JY. Value of radiological follow up of childhood pneumonia. BMJ 1993; 307:1117.
- Heaton P, Arthur K. The utility of chest radiography in the follow-up of pneumonia. N Z Med J 1998; 111:315.
- Wacogne I, Negrine RJ. Are follow up chest x ray examinations helpful in the management of children recovering from pneumonia? Arch Dis Child 2003; 88:457.
- Surén P, Try K, Eriksson J, et al. Radiographic follow-up of community-acquired pneumonia in children. Acta Paediatr 2008; 97:46.
- Clark CE, Coote JM, Silver DA, Halpin DM. Asthma after childhood pneumonia: six year follow up study. BMJ 2000; 320:1514.
- Chan JY, Stern DA, Guerra S, et al. Pneumonia in childhood and impaired lung function in adults: a longitudinal study. Pediatrics 2015; 135:607.
- INDICATIONS FOR HOSPITALIZATION
- EMPIRIC THERAPY
- Children <5 years
- - Neonates
- - One to six months
- - Six months to five years
- Suspected viral etiology
- Suspected bacterial etiology
- Suspected atypical pneumonia
- Children ≥5 years
- - Suspected typical or atypical bacterial etiology
- - Suspected influenza
- Suspected aspiration pneumonia
- Monitoring response
- - Treatment failure
- Worsened condition
- Failure to improve
- SUPPORTIVE CARE
- Clinical course
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS