Community-acquired pneumonia in children

Community-acquired pneumonia (CAP) in childhood typically presents with fever and cough, together with hypoxaemia (oxygen saturation ≤96% on pulse oximetry), tachypnoea, and often signs of increased work of breathing (e.g., chest retractions, nasal flaring, head bobbing, grunting). Most cases are caused by viruses, particularly in infants and younger children, and there is no reliable way clinically to distinguish viral from bacterial aetiology.

In a previously healthy child with non-severe symptoms, the diagnosis can be made clinically without any need for blood tests, imaging, or microbiology investigations, and the child can be safely managed in the community, with appropriate safety-netting. Chest x-ray and blood cultures are only indicated for children who are hospitalised for severe CAP or complications of CAP (e.g., pleural effusion, empyema, necrotising pneumonia, lung abscess).

Empirical antibiotic therapy is indicated for all children who are clinically diagnosed with CAP. High-dose oral amoxicillin is the recommended first-line option for most children. Children who are managed in hospital for severe CAP may also need supplemental oxygen and fluid therapy. If microbiological investigations are indicated and a causative pathogen is identified, the child is switched to a targeted regimen, based on local susceptibility patterns.

Reassessment is required for any child who fails to show improvement within 48-72 hours after starting appropriate antimicrobial therapy, with consideration of the need for investigations and/or an escalation of care setting.

​Community-acquired pneumonia (CAP) is defined clinically as the presence of signs and symptoms of pneumonia in a previously healthy child due to an infection that has been acquired outside hospital.[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 Oct;53(7):e25-76. https://academic.oup.com/cid/article/53/7/e25/424286 http://www.ncbi.nlm.nih.gov/pubmed/21880587?tool=bestpractice.com [2]de Benedictis FM, Kerem E, Chang AB, et al. Complicated pneumonia in children. Lancet. 2020 Sep 12;396(10253):786-98. http://www.ncbi.nlm.nih.gov/pubmed/32919518?tool=bestpractice.com [3]Haq IJ, Battersby AC, Eastham K, et al. Community acquired pneumonia in children. BMJ. 2017 Mar 2;356:j686. http://www.ncbi.nlm.nih.gov/pubmed/28255071?tool=bestpractice.com ​​ Uncomplicated (or simple) pneumonia is defined as either bronchopneumonia (primary involvement of airways and surrounding interstitium) or lobar pneumonia involving a single lobe.[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 Oct;53(7):e25-76. https://academic.oup.com/cid/article/53/7/e25/424286 http://www.ncbi.nlm.nih.gov/pubmed/21880587?tool=bestpractice.com  Complicated pneumonia is defined as pulmonary parenchymal infection that is complicated by parapneumonic effusions, multi-lobar disease, abscesses or cavities, necrotising pneumonia, empyema, or pneumothorax of bronchopleural fistula; or pneumonia that is a complication of bacteraemic disease that includes other sites of infection.[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 Oct;53(7):e25-76. https://academic.oup.com/cid/article/53/7/e25/424286 http://www.ncbi.nlm.nih.gov/pubmed/21880587?tool=bestpractice.com  

This topic covers childhood CAP caused by typical bacterial or non-COVID-19 viral pathogens (including viral-bacterial co-infection, which is common). For CAP with atypical bacterial aetiology, see Atypical pneumonia. For COVID-19 pneumonia, see Coronavirus disease 2019 (COVID-19).