2011 Guidelines for Community Acquired Pneumonia in Pediatrics

Links to the 2011 Guidelines for Community Acquired Pneumonia in Pediatrics are below (and some excerpts from the guidelines) along with a link to a 2014 Audio Digest Pediatrics lecture summary that reviews the guidelines.

See 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, [full text html], [full text pdf], Clin Infect Dis. (2011) 53 (7): e25-e76.  doi: 10.1093/cid/cir531.

Abstract and Articles that cite the above guideline

The Executive Summary is an excellent brief review of the critical points. Executive Summary: 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, [full text html], [full text pdf], Clin Infect Dis. (2011) 53 (7): 617-630. doi: 10.1093/cid/cir625.


The summary of PNEUMONIA/PERTUSSIS Audio-Digest Pediatrics is an excellent summary of the guidelines and it is worth ordering and listening to the lecture.
Volume 60, Issue 23 June 21, 2014
Community-Acquired Pneumonia in Otherwise Healthy Children – William V. Raszka, MD
Update on Pertussis – Timothy R. Peters, MD.

Some points from Dr. Raszka’s Lecture:

One study of inpatient pediatric pneumonia found that viral and bacterial co-infection is very common (23% of patients). There is no data on ambulatory pediatric pneumonia patients.

Neither blood cultures nor chest x-ray are necessary in outpatient pediatric pneumonia. You would get a chest x-ray in patient who failed to improve or who worsened (looking for a complication such as effusion) or in a patient with a recurrent pneumonia.

In pre-school children, the guidelines recommend no antibiotic in pediatric ambulatory pneumonia unless the patient is positive for influenza because, in this group, the vast majority of pneumonias are viral.

But the guidelines do recommend antibiotic treatment for mild to moderate bacterial infection (except how would you know–“I think it looks bacterial”).

And the antibiotic, if you are going to treat, is amoxicillin at a dose of 90 to 100 mg/kg.

If the patient is allergic to penicillin, then you should use a third generation cephalosporin.

If atypical pneumonia suspected, you could use azithromycin.


What follows are some of the points dealing with out-patient pediatric pneumonia from the Executive Summary:

Table 2.

Complications Associated With Community-Acquired Pneumonia

    Pleural effusion or empyema
    Lung abscess
    Bronchopleural fistula
    Necrotizing pneumonia
    Acute respiratory failure
    Central nervous system abscess
    Septic arthritis
    Systemic inflammatory response syndrome or sepsis

    Hemolytic uremic syndrome


I. When Does a Child or Infant With CAP Require Hospitalization?

  1. Children and infants who have moderate to severe CAP, as defined by several factors, including respiratory distress and hypoxemia (sustained saturation of peripheral oxygen [SpO2], <90 % at sea level) (Table 3) should be hospitalized for management, including skilled pediatric nursing care. (strong recommendation; high-quality evidence)
  2. Infants less than 3–6 months of age with suspected bacterial CAP are likely to benefit from hospitalization. (strong recommendation; low-quality evidence)
  3. Children and infants with suspected or documented CAP caused by a pathogen with increased virulence, such as community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) should be hospitalized. (strong recommendation; low-quality evidence)
  4. Children and infants for whom there is concern about careful observation at home or who are unable to comply with therapy or unable to be followed up should be hospitalized. (strong recommendation; low-quality evidence)

II. When Should a Child With CAP Be Admitted to an Intensive Care Unit (ICU) or a Unit With Continuous Cardiorespiratory Monitoring?

5. A child should be admitted to an ICU if the child requires invasive ventilation via a nonpermanent artificial airway (eg, endotracheal tube). (strong recommendation; high-quality evidence)

6. A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child acutely requires use of noninvasive positive pressure ventilation (eg, continuous positive airway pressure or bilevel positive airway pressure). (strong recommendation; very low-quality evidence)

7. A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child has impending respiratory failure. (strong recommendation; moderate-quality evidence)

8. A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child has sustained tachycardia, inadequate blood pressure, or need for pharmacologic support of blood pressure or perfusion. (strong recommendation; moderate-quality evidence)

9. A child should be admitted to an ICU if the pulse oximetry measurement is <92% on inspired oxygen of ≥0.50. (strong recommendation; low-quality evidence)

10. A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child has altered mental status, whether due to hypercarbia or hypoxemia as a result of pneumonia. (strong recommendation; low-quality evidence)

11. Severity of illness scores should not be used as the sole criteria for ICU admission but should be used in the context of other clinical, laboratory, and radiologic findings. (strong recommendation; low-quality evidence)

Blood Cultures: Outpatient

  • 12. Blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP managed in the outpatient setting. (strong recommendation; moderate-quality evidence)

  • 13. Blood cultures should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy (strong recommendation; moderate-quality evidence).

  • 20. Sensitive and specific tests for the rapid diagnosis of influenza virus and other respiratory viruses should be used in the evaluation of children with CAP. A positive influenza test may decrease both the need for additional diagnostic studies and antibiotic use, while guiding appropriate use of antiviral agents in both outpatient and inpatient settings. (strong recommendation; high-quality evidence)

  • 21. Antibacterial therapy is not necessary for children, either outpatients or inpatients, with a positive test for influenza virus in the absence of clinical, laboratory, or radiographic findings that suggest bacterial coinfection.(strong recommendation; high-quality evidence).

  • 23. Children with signs and symptoms suspicious for Mycoplasmapneumoniae should be tested to help guide antibiotic selection. (weak recommendation; moderate-quality evidence)

  • 24. Diagnostic testing for Chlamydophila pneumoniae is not recommended as reliable and readily available diagnostic tests do not currently exist.(strong recommendation; high-quality evidence)

Pulse Oximetry

  • 30. Pulse oximetry should be performed in all children with pneumonia and suspected hypoxemia. The presence of hypoxemia should guide decisions regarding site of care and further diagnostic testing. (strong recommendation; moderate-quality evidence)

Initial Chest Radiographs: Outpatient

  • 31. Routine chest radiographs are not necessary for the confirmation of suspected CAP in patients well enough to be treated in the outpatient setting (after evaluation in the office, clinic, or emergency department setting). (strong recommendation; high-quality evidence)

  • 32. Chest radiographs, posteroanterior and lateral, should be obtained in patients with suspected or documented hypoxemia or significant respiratory distress (Table 3) and in those with failed initial antibiotic therapy to verify the presence or absence of complications of pneumonia, including parapneumonic effusions, necrotizing pneumonia, and pneumothorax. (strong recommendation; moderate-quality evidence)

Table 3.

Criteria for Respiratory Distress in Children With Pneumonia

Signs of Respiratory Distress
1. Tachypnea, respiratory rate, breaths/mina
    Age 0–2 months: >60
    Age 2–12 months: >50
    Age 1–5 Years: >40
    Age >5 Years: >20
2. Dyspnea
3. Retractions (suprasternal, intercostals, or subcostal)
4. Grunting
5. Nasal flaring
6. Apnea
7. Altered mental status
8. Pulse oximetry measurement <90% on room air
  • a Adapted from World Health Organization criteria.

Table 4.

Criteria for CAP Severity of Illness in Children with Community-Acquired Pneumonia

Major criteria
    Invasive mechanical ventilation
    Fluid refractory shock
    Acute need for NIPPV
    hypoxemia requiring FiO2 greater than inspired concentration or flow feasible in general care area
Minor criteria
    Respiratory rate higher than WHO classification for age
    Increased work of breathing (eg, retractions, dyspnea, nasal flaring, grunting)
    PaO2/FiO2 ratio <250
    Multilobar infiltrates
    PEWS score >6
    Altered mental status
    Presence of effusion
    Comorbid conditions (eg, HgbSS, immunosuppression, immunodeficiency)
    Unexplained metabolic acidosis
  •  Modified from Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults [27, table 4]. Clinician should consider care in an intensive care unit or a unit with continuous cardiorespiratory monitoring for the child having ≥1 major or ≥2 minor criteria.

  •  Abbreviations: FiO2, fraction of inspired oxygen; HgbSS, Hemoglobin SS disease; NIPPV, noninvasive positive pressure ventilation; PaO2, arterial oxygen pressure; PEWS, Pediatric Early Warning Score [70].


  • 41. Antimicrobial therapy is not routinely required for preschool-aged children with CAP, because viral pathogens are responsible for the great majority of clinical disease. (strong recommendation; high-quality evidence)

  • 42. Amoxicillin should be used as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. Amoxicillin provides appropriate coverage for Streptococcus pneumoniae, the most prominent invasive bacterial pathogen. Table 5 lists preferred agents and alternative agents for children allergic to amoxicillin (strong recommendation; moderate-quality evidence)

  • 43. Amoxicillin should be used as first-line therapy for previously healthy appropriately immunized school-aged children and adolescents with mild to moderate CAP for S. pneumoniae, the most prominent invasive bacterial pathogen. Atypical bacterial pathogens (eg, M. pneumoniae), and less common lower respiratory tract bacterial pathogens, as discussed in the Evidence Summary, should also be considered in management decisions.(strong recommendation; moderate-quality evidence)

  • 44. Macrolide antibiotics should be prescribed for treatment of children (primarily school-aged children and adolescents) evaluated in an outpatient setting with findings compatible with CAP caused by atypical pathogens. Laboratory testing for M. pneumoniae should be performed if available in a clinically relevant time frame. Table 5 lists preferred and alternative agents for atypical pathogens. (weak recommendation; moderate-quality evidence)

  • 45. Influenza antiviral therapy (Table 6) should be administered as soon as possible to children with moderate to severe CAP consistent with influenza virus infection during widespread local circulation of influenza viruses, particularly for those with clinically worsening disease documented at the time of an outpatient visit. Because early antiviral treatment has been shown to provide maximal benefit, treatment should not be delayed until confirmation of positive influenza test results. Negative results of influenza diagnostic tests do not conclusively exclude influenza disease. Treatment after 48 hours of symptomatic infection may still provide clinical benefit to those with more severe disease. (strong recommendation; moderate-quality evidence)

  • 56. Children on adequate therapy should demonstrate clinical and laboratory signs of improvement within 48–72 hours. For children whose condition deteriorates after admission and initiation of antimicrobial therapy or who show no improvement within 48–72 hours, further investigation should be performed. (strong recommendation; moderate-quality evidence)

IX. How Should a Parapneumonic Effusion Be Identified?


  • 57. History and physical examination may be suggestive of parapneumonic effusion in children suspected of having CAP, but chest radiography should be used to confirm the presence of pleural fluid. If the chest radiograph is not conclusive, then further imaging with chest ultrasound or computed tomography (CT) is recommended. (strong recommendation; high-quality evidence)

X. What Factors Are Important in Determining Whether Drainage of the Parapneumonic Effusion Is Required?


  • 58. The size of the effusion is an important factor that determines management (Table 8Figure 1). (strong recommendation; moderate-quality evidence)

  • 59. The child’s degree of respiratory compromise is an important factor that determines management of parapneumonic effusions (Table 8Figure 1(strong recommendation; moderate-quality evidence)

Table 8.

Factors Associated with Outcomes and Indication for Drainage of Parapneumonic Effusions

Size of effusion Bacteriology Risk of poor outcome Tube drainage with or without fibrinolysis or VATSa
Small: <10 mm on lateral decubitus radiograph oropacifies less than one-fourth of hemithorax Bacterial culture and Gram stain results unknown or negative Low No; sampling of pleural fluid is not routinely required
Moderate: >10-mm rim of fluid but opacifies less than half of the hemithorax Bacterial culture and/or Gram stain results negative orpositive (empyema) Low to moderate No if the patient has no respiratory compromise and the pleural fluid is not consistent with empyema (sampling of pleural fluid by simple thoracentesis may help determine presence or absence of empyema and need for a drainage procedure, and sampling with a drainage catheter may provide both diagnostic and therapeutic benefit); Yes, if the patient has respiratory compromise or if pleural fluid is consistent with empyema if the patient has respiratory compromise or if pleural fluid is consistent with empyema
Large: opacifies more than half of the hemithorax Bacterial culture and/or Gram stain results positive (empyema) High Yes in most cases
  • a VATS, video-assisted thoracoscopic surgery.



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