Practice Guidelines

PIDS and IDSA Issue Management Guidelines

for Community-Acquired Pneumonia in Infants
and Young Children
MICHAEL DEVITT

lung disease. This summary focuses on the management

Guideline source: Infectious Diseases Society of America of CAP in infants and young children as normally seen
Evidence rating system used? Yes by family physicians in the outpatient setting, such as an
Literature search described? Yes office or urgent care clinic.
Guideline developed by participants without relevant
Site-of-Care Management Decisions
financial ties to industry? No
When does a child or infant with CAP require hospital-
Published source: Clinical Infectious Diseases, October
2011
ization?
Children and infants who have moderate to severe CAP,
Available at: http://cid.oxfordjournals.org/
including respiratory distress and hypoxemia (Table 1),
content/53/7/617.full
should be hospitalized for management. Infants three
to six months of age with suspected bacterial CAP will
Coverage of guidelines from other organizations does not imply likely benefit from being hospitalized. If a child or infant
endorsement by AFP or the AAFP.
is suspected of having CAP, or is known to have CAP
A collection of Practice Guidelines published in AFP is available at as a result of a virulent pathogen such as community-
http://www.aafp.org/afp/practguide.
associated methicillin-resistant Staphylococcus aureus, the
Previously published guidelines for the management of patient should be hospitalized. If there is concern that
community-acquired pneumonia (CAP) in adults have the child or infant may not receive careful observation
been shown to decrease morbidity and mortality rates. at home or may not be able to comply with therapy, or
Although the effectiveness of these guidelines in adults that the physician may be unable to have a follow-up visit
has been clearly established, the clinical course of CAP in with the child, the patient should be hospitalized.
children varies considerably from one child to the next. As
a result, physicians may employ other approaches to the Diagnostic Testing for CAP in Children
diagnosis and treatment of CAP in infants and children, Which diagnostic laboratory and imaging tests should be
even when infection is caused by the same pathogen. In used in a child with suspected CAP in an outpatient setting?
response, the Pediatric Infectious Diseases Society (PIDS) Blood cultures usually are not needed in nontoxic, fully
and the Infectious Diseases Society of America (IDSA) immunized children with CAP. If the child does not
have created new guidelines to address the management demonstrate clinical improvement, or if the child shows
of CAP in infants and children. signs of clinical deterioration or a progression of symp-
The guidelines are designed to advise primary care toms after initial antibiotic therapy, then blood cultures
physicians and subspecialists who are responsible for the should be obtained.
management of CAP in otherwise healthy infants and Repeat blood cultures are not needed to document
children in inpatient and outpatient settings. Areas of resolution of pneumococcal bacteremia in children who
discussion include site-of-care management, diagnosis, demonstrate clear clinical improvement. If bacteremia is
antimicrobial therapy, and adjunctive surgical therapy. caused by S. aureus, repeated blood cultures should be
The scope of the guidelines does not include manage- obtained regardless of clinical status.
ment of CAP in newborns and infants younger than Although routine blood cell counts are not necessary
three months, children with compromised immune in all children with suspected CAP in the outpatient
systems, children receiving home mechanical ventila- setting, such testing may provide useful information
tion, or children with chronic conditions or underlying in children with more serious illness when taken in the
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 Practice Guidelines

unstable, or in patients with persistent fever that does not

Table 1. Criteria for Respiratory Distress respond to therapy within 48 to 72 hours. In children and
in Children and Infants with Pneumonia infants who have recurrent pneumonia that involves the
same lobe, and in patients with collapse of the lobe dur-
Altered mental status ing initial radiography, repeat chest radiography should
Apnea be performed four to six weeks after diagnosis.
Dyspnea
Grunting Anti-Infective Treatment
Nasal flaring Which anti-infective therapy should be provided to a child
Pulse oximetry < 90 percent on room air
with suspected CAP in the outpatient setting?
Retractions (i.e., suprasternal, intercostal, or subcostal)
Because viral pathogens are responsible for most clinical
Tachypnea, respiratory rate, breaths per minute*
disease, antimicrobial therapy is not routinely required
0 to 2 months: > 60
for preschool-aged children with CAP. Amoxicillin pro-
2 to 12 months: > 50
vides appropriate coverage for Streptococcus pneumoniae,
1 to 5 years: > 40
and should be used as a first-line therapy for previously
> 5 years: > 20
healthy, appropriately immunized infants, children, and
*—Adapted from World Health Organization criteria. adolescents with mild to moderate CAP of suspected bac-
Adapted with permission from Bradley JS, Byington CL, Shah SS, terial origin. For children who are allergic to amoxicillin,
et al. Executive summary: the management of community-acquired alternative agents include second- or third-generation
pneumonia in infants and children older than 3 months of age: cephalosporins (e.g., cefpodoxime, cefuroxime [Ceftin,
clinical practice guidelines by the Pediatric Infectious Diseases Soci-
ety and the Infectious Diseases Society of America. Clin Infect Dis. Zinacef], cefprozil [Cefzil]), levofloxacin (Levaquin), and
2011;53(7):620. Available at http://cid.oxfordjournals.org. linezolid (Zyvox).
Physicians should also consider atypical bacterial
pathogens and less common lower respiratory tract bac-
context of the clinical examination and other imaging terial pathogens when choosing a course of management
and laboratory studies. in school-aged children and adolescents. Macrolide
Pulse oximetry should be performed in all children antibiotics should be prescribed for school-aged and
with pneumonia and suspected hypoxemia; the presence adolescent patients who have CAP caused by atypical
of hypoxemia should determine decisions relating to site pathogens. Laboratory testing for Mycoplasma pneu-
of care and further diagnostic testing. moniae should be performed if time permits. The
Routine chest radiography is not necessary to confirm preferred agent for atypical pathogens is azithromy-
the presence of CAP in children and infants who are well cin (Zithromax); alternatives include clarithromycin
enough to be treated in the outpatient setting, provided (Biaxin), erythromycin, doxycycline, levofloxacin, and
they have already been evaluated in the office, clinic, moxifloxacin (Avelox).
or emergency department setting. Posteroanterior and In instances of widespread local circulation of influ-
lateral chest radiography should be performed in any enza, antiviral therapy should be given to children with
infants or children who may have or are known to have moderate to severe CAP consistent with influenza infec-
hypoxemia or significant respiratory distress (Table 1). tion as soon as possible, especially in children whose
Radiography is also indicated if an initial round of disease is clinically worsening. Treatments should not
antibiotics has been ineffective in ascertaining the pres- be delayed until confirmation of positive influenza test
ence or absence of any complications associated with results, because they may still provide some clinical
pneumonia, such as pneumothorax, parapneumonic benefit to patients with more severe illness, even after
effusions, and necrotizing pneumonia. 48 hours of symptomatic infection. Influenza antivi-
In children who recover from CAP without complica- ral therapies include oseltamivir (Tamiflu), zanamivir
tions, repeat chest radiography is not usually necessary. (Relenza), amantadine, and rimantadine (Flumadine).
However, it should be performed in children who do A list of preferred and alternative agents for pneu-
not demonstrate clinical improvement, and in children monia to be administered in the outpatient setting is
whose symptoms progress or who show signs of clinical provided in Table 2.
deterioration within 48 to 72 hours of initial antibiotic
therapy. How should the physician follow the child with CAP for the
Follow-up radiography should be performed in infants expected response to therapy?
and children who have complicated pneumonia with Provided a child has received adequate therapy, he
worsening respiratory distress or who are clinically or she should show clinical and laboratory signs of
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Practice Guidelines

Table 2. Empiric Therapy for CAP in Children in the Outpatient Setting

The rights holder did not grant the American Academy of Family Physicians the right to sublicense this material to a third party. For
the missing item, see the original print version of this publication.

Adapted with permission from Bradley JS, Byington CL, Shah SS, et al. 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. Clin Infect Dis. 2011;53(7):626. Available at http://cid.oxfordjournals.org.

improvement within 48 to 72 hours. For children whose sis and influenza to help protect infants from exposure
condition deteriorates after initiation of antimicrobial to these diseases. Immunization against influenza also
therapy, or who show no improvement within 72 hours, decreases the likelihood of pneumococcal CAP after
further evaluation is needed. influenza infection.
To decrease the risk of severe pneumonia and hospi-
Prevention talization caused by respiratory syncytial virus, high-
Can CAP in children be prevented? risk infants should receive immune prophylaxis with
To reduce the incidence of CAP, children should be virus-specific monoclonal antibody. ■
immunized with vaccines for bacterial pathogens such as
S. pneumoniae, Haemophilus influenzae type b, and per-
tussis. All infants six months and older, and all children Answers to This Issue’s CME Quiz
and adolescents, should also receive an annual influenza Q1. C Q4. A Q7. C
virus immunization. Q2. B, D Q5. B Q8. A, C, D
All parents and caretakers of infants younger than six Q3. A, B, C, D Q6. A, C Q9. B, D
months should be immunized with vaccines for pertus-

202 American Family Physician www.aafp.org/afp Volume 86, Number 2 ◆ July 15, 2012

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