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Neumonía adquirida en la comunidad en niños:

tratamiento ambulatorio
Autor: William J. Barson, MD
Editores de sección: Morven S Edwards, MD, George B Mallory, MD
Editor adjunto: Mary M Torchia, MD

Todos los temas se actualizan a medida que se dispone de nueva evidencia y se completa nuestro proceso de
revisión por pares .

Revisión de la literatura vigente hasta:  octubre de 2020. | Este tema se actualizó por última vez:  15 de abril
de 2020.

INTRODUCCIÓN

La neumonía adquirida en la comunidad (NAC) se define como una infección aguda del
parénquima pulmonar en un paciente que ha adquirido la infección en la comunidad, a
diferencia de la neumonía adquirida en el hospital (nosocomial). La NAC es una enfermedad
común y potencialmente grave con una morbilidad considerable.

La Sociedad de Enfermedades Infecciosas Pediátricas / Sociedad Estadounidense de

Enfermedades Infecciosas y la Sociedad Británica del Tórax han desarrollado guías de práctica
clínica para la evaluación y el tratamiento de la NAC en niños [ 1 , 2 ].

El tratamiento ambulatorio de la NAC en bebés y niños se revisará aquí. La neumonía neonatal,

la neumonía relacionada con la enfermedad del coronavirus 2019 y la etiología, las
características clínicas, el diagnóstico y el tratamiento hospitalario de la neumonía en niños se
analizan por separado.

● (Ver "Neumonía neonatal" ).

● (Ver "Enfermedad por coronavirus 2019 (COVID-19): Manifestaciones clínicas y diagnóstico
en niños" .)
● (Ver "Neumonía en niños: epidemiología, patogenia y etiología" ).
● (Ver "Neumonía adquirida en la comunidad en niños: características clínicas y diagnóstico"
).
 ● (Ver "Neumonía en niños: tratamiento hospitalario" ).

INDICACIONES DE HOSPITALIZACIÓN

La decisión de hospitalizar a un niño con NAC se individualiza según la edad, los problemas
médicos subyacentes y los factores clínicos, incluida la gravedad de la enfermedad ( tabla 1) [
1-3 ]. Por lo general, la hospitalización está justificada para bebés menores de tres a seis meses
de edad, a menos que se sospeche una etiología viral o Chlamydia trachomatis y sean
normoxémicos y relativamente asintomáticos. La hospitalización también está justificada para
un niño de cualquier edad cuya familia no pueda brindar la atención adecuada y asegurar el
cumplimiento del régimen terapéutico. Las indicaciones adicionales para la hospitalización
incluyen [ 1 , 2 ]:

● Hipoxemia (saturación de oxígeno <90 por ciento en aire ambiente al nivel del mar)

● Deshidratación o incapacidad para mantener la hidratación por vía oral; incapacidad para
alimentarse en un bebé

● Dificultad respiratoria de moderada a grave: frecuencia respiratoria> 70 respiraciones por

minuto para bebés <12 meses de edad y> 50 respiraciones por minuto para niños mayores;
dificultad para respirar (gruñidos, aleteo nasal, retracciones); apnea

● Aspecto tóxico (más común en la neumonía bacteriana y puede sugerir un curso más
grave) [ 4 ]

● Las condiciones subyacentes que pueden predisponer a un curso más grave de neumonía
(p. Ej., Enfermedad cardiopulmonar, síndromes genéticos, trastornos neurocognitivos),
pueden empeorar por neumonía, incluso neumonía viral (p. Ej., Trastorno metabólico) o
pueden afectar negativamente la respuesta al tratamiento (p. Ej., huésped
inmunodeprimido)

● Complicaciones (p. Ej., Derrame / empiema, proceso necrotizante, absceso) (ver

"Epidemiología, presentación clínica y evaluación del derrame paraneumónico y empiema
en niños" y "Manejo y pronóstico del derrame paraneumónico y empiema en niños" )

● Sospecha o confirmación de que la NAC se debe a un patógeno con mayor virulencia, como
Staphylococcus aureus o Streptococcus del grupo A

● Fracaso de la terapia ambulatoria (empeoramiento o ausencia de respuesta en 48 a 72

horas) (consulte 'Fracaso del tratamiento' a continuación)
TERAPIA EMPIRICA

Factores que influyen en la elección del régimen  : los  niños con NAC que reciben
tratamiento ambulatorio suelen ser tratados de forma empírica; Las pruebas para identificar
una etiología microbiológica no se recomiendan para la mayoría de los niños que están lo
suficientemente bien como para ser tratados de forma ambulatoria [ 1,2 ]. Las decisiones con
respecto a la terapia empírica se complican por la superposición sustancial en la presentación
clínica de neumonías bacterianas y no bacterianas [ 2, 5, 6 ].

Las decisiones de tratamiento generalmente se basan en algoritmos que incluyen la edad del
paciente ( Tabla 2), información epidemiológica y clínica ( Tabla 3) y estudios de diagnóstico
por imágenes y de laboratorio (si se obtienen tales estudios) [ 4 ]. La consulta con un
especialista en enfermedades infecciosas puede ser útil en niños con alergias a medicamentos
o condiciones comórbidas. (Ver "Neumonía adquirida en la comunidad en niños: características
clínicas y diagnóstico" y "Neumonía en niños: epidemiología, patogenia y etiología", sección
sobre "Agentes etiológicos" ).

Hay pocos ensayos controlados aleatorios para orientar la elección de antibióticos empíricos en
niños con NAC. Los factores que deben considerarse incluyen el espectro de patógenos
probables, susceptibilidad antimicrobiana, simplicidad, tolerabilidad, palatabilidad, seguridad y
costo [ 7 ]. Las recomendaciones de la mayoría de las guías se basan en observaciones sobre la
susceptibilidad del patógeno o patógenos más probables, más que en la evidencia de la
superioridad de un antibiótico sobre otro [ 1 , 2 ]. La respuesta clínica a los antimicrobianos más
utilizados parece ser similar, independientemente de la etiología [ 8-10]. La respuesta dentro de
las primeras 48 a 72 horas de la terapia empírica (o la falta de terapia si es más probable una
etiología viral) ayuda a determinar si es necesaria una evaluación adicional o cambios en la
terapia. (Consulte 'Seguimiento de la respuesta' a continuación).

Niños <5 años

Recién nacidos  :  el tratamiento de la neumonía neonatal se analiza por separado. (Ver
"Neumonía neonatal" ).

De uno a seis meses  : los  bebés menores de tres a seis meses de edad con sospecha de
NAC bacteriana o hipoxémicos (saturación de oxígeno <90 por ciento en el aire ambiente al
nivel del mar) deben ser ingresados en el hospital para recibir tratamiento empírico. (Ver
"Neumonía en niños: tratamiento hospitalario", sección sobre "Terapia empírica" ).
In afebrile infants one to four months of age with CAP, the most likely bacterial pathogen is C.
trachomatis (ie, "afebrile pneumonia of infancy") [4,11]. Infants who are thought to have afebrile
pneumonia of infancy can be treated in the outpatient setting if they are not hypoxemic and
remain afebrile [4]. (See "Chlamydia trachomatis infections in the newborn", section on
'Treatment'.)

Bordetella pertussis is a less common, but more severe, cause of pneumonia in young infants;
fever may or may not be present. Like C. trachomatis, B. pertussis is susceptible to the macrolides
[4]. However, young infants who are thought to have B. pertussis-associated pneumonia should
be admitted to the hospital because they are at risk for complications (eg, hypoxia, apnea,
pulmonary hypertension, etc). (See "Pertussis infection in infants and children: Clinical features
and diagnosis", section on 'Infants' and "Pertussis infection in infants and children: Treatment
and prevention", section on 'Hospitalization'.)

Six months to five years

Suspected viral etiology — Viral etiologies predominate during early childhood. Viral

pneumonia (suggested by gradual onset, preceding upper respiratory tract symptoms, diffuse
findings on auscultation, lack of toxic appearance ( table 3)) should not be treated with
antibiotics. Antiviral agents generally are not used for viral pneumonia in the outpatient setting,
with the exception of neuraminidase inhibitors for influenza pneumonia. (See "Community-
acquired pneumonia in children: Clinical features and diagnosis", section on 'Clues to etiology'
and "Pneumonia in children: Epidemiology, pathogenesis, and etiology", section on 'Etiologic
agents'.)

Infants and young children with known or suspected chronic disease (eg, cardiopulmonary
disease, neuromuscular disease, etc) are at increased risk for severe or complicated viral lower
respiratory tract infection (LRTI). If such children are not admitted to the hospital, they merit
close monitoring in the outpatient setting.

● Suspected influenza – In children with suspected influenza who are at increased risk of
complications ( table 4), initiation of antiviral treatment is recommended as soon as
possible; 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: Clinical features and diagnosis", section on 'Clinical features' and
"Seasonal influenza in children: Prevention and treatment with antiviral drugs", section on
'Antiviral therapy'.)

Suspected bacterial etiology — Streptococcus pneumoniae is the most frequent cause of

"typical" bacterial pneumonia in children of all ages [1,2]. Bacterial pneumonia in preschool
children usually causes more severe infection, with abrupt onset and moderate to severe
respiratory distress, which may require inpatient therapy. (See 'Indications for hospitalization'
above and "Pneumonia in children: Inpatient treatment", section on 'Empiric therapy'.)

For appropriately immunized, healthy children younger than five years who are thought to have
bacterial CAP based upon clinical presentation, examination findings, and supportive
radiographic or laboratory data if obtained (eg, lobar consolidation on radiograph, white blood
cell count >15,000/microL, C-reactive protein >35 to 60 mg/L [3.5 to 6 mg/dL] ( table 3)), but
do not require inpatient therapy, amoxicillin is usually considered the drug of choice [1,2,12].
We suggest high-dose amoxicillin (90 to 100 mg/kg per day divided into two or three doses;
maximum dose 4 g/day) ( table 2).

Amoxicillin is preferred because it is effective against the majority of bacterial pathogens for
CAP in this age group, is well tolerated, and is inexpensive [1,2]. Amoxicillin is more active in
vitro than any of the oral cephalosporins against these isolates.

The higher dose of amoxicillin is suggested because of the concern for antibiotic-resistant S.
pneumoniae isolated from patients with community-acquired respiratory tract infections [13,14],
although this is less of a concern following universal infant immunization with the
pneumococcal conjugate vaccine. (See "Impact of universal infant immunization with
pneumococcal conjugate vaccines in the United States", section on 'Antibiotic resistance' and
"Resistance of Streptococcus pneumoniae to beta-lactam antibiotics".)

Universal infant immunization with the 7-valent pneumococcal conjugate vaccine (PCV7)
resulted in a decreased prevalence of penicillin-resistant pneumococci. However, it was
associated with the emergence of antibiotic-resistant invasive serotypes, some of which are
included in the 13-valent pneumococcal conjugate vaccine (PCV13) (eg, serotype 19A), which
replaced PCV7 in 2010 [1]. Surveillance after the introduction of PCV13 suggests further
reduction of pneumococcal resistance to penicillin and ceftriaxone. In a study of pneumococcal
pneumonia from eight children's hospitals in the United States, the proportion of isolates
resistant to penicillin declined after the introduction of PCV13 (from 8 to 3 percent); after 2010,
only 1 percent of isolates were resistant to ceftriaxone [15]. Pending additional information and
continued surveillance to determine whether high-dose amoxicillin is necessary for S.
pneumoniae pneumonia, we continue to suggest the high dose rather than standard dose (ie,
40 to 45 mg/kg per day) when amoxicillin is used for empiric treatment of CAP in children. (See
"Impact of universal infant immunization with pneumococcal conjugate vaccines in the United
States", section on 'Antibiotic resistance' and "Resistance of Streptococcus pneumoniae to beta-
lactam antibiotics".)
Although there are prospective, comparative data supporting the efficacy of twice daily dosing
of amoxicillin for the treatment of acute otitis media [16-18], similar data are not available for
documented pneumococcal pneumonia in children. Unless the etiologic agent is identified as a
S. pneumoniae isolate with a minimum inhibitory concentration (MIC) of <2 mcg/mL, dividing the
total daily 90 to 100 mg/kg dose of amoxicillin into three doses may be warranted. Twice daily
dosing for pneumonia due to a S. pneumoniae isolate with an MIC of 2 mcg/mL is predicted to
achieve a clinical and microbiologic cure in only 65 percent of children, whereas the same total
daily dose divided in three equal portions is predicted to achieve a cure in 90 percent [19].

For children with non-type 1 hypersensitivity reactions to penicillin ( table 5), a second- or
third-generation cephalosporin (eg, cefdinir) is an acceptable alternative to amoxicillin [1]. For
children with type 1 hypersensitivity reactions ( table 5) to penicillin, clindamycin or a
macrolide may be used [1,2]. However, if local resistance rates are high for clindamycin and
macrolides, levofloxacin or linezolid may be preferable. Doses are provided in the table (
table 2).

For the infant or child who is suspected to have bacterial CAP and is unable to tolerate liquids at
the time of presentation, a single initial dose of ceftriaxone (50 to 75 mg/kg) may be
administered intramuscularly or intravenously before starting oral antibiotics [20,21].
Administration of intramuscular ceftriaxone to children with uncomplicated CAP who are able to
tolerate liquids is expensive and provides no benefit over oral antibiotics.

Suspected atypical pneumonia — Mycoplasma pneumoniae and Chlamydia pneumoniae

are less common than S. pneumoniae in children younger than five years with CAP [5]. However,
they can occur in this age group and should be considered in children without a pneumonia-
associated complication who fail to improve after 48 to 72 hours of empiric therapy for S.
pneumoniae (eg, amoxicillin), at which time a macrolide could be added or substituted (
table 2). (See 'Treatment failure' below.)

Children ≥5 years

Suspected typical or atypical bacterial etiology — S. pneumoniae is the most frequent

cause of "typical" bacterial pneumonia in children of all ages [1,2]. However, in otherwise
healthy children five years and older with CAP who are not ill enough to require hospitalization,
M. pneumoniae and C. pneumoniae are the most likely pathogens [4,11,22].

For children ≥5 years with clinical features strongly suggestive of typical bacterial or S.
pneumoniae pneumonia ( table 3), amoxicillin is the drug of choice ( table 2) [1]. (See
'Suspected bacterial etiology' above.)
We suggest macrolide antibiotics for initial empiric therapy for suspected atypical CAP (
table 3) in children older than five years who are treated as outpatients ( table 2).
Macrolide antibiotics provide coverage for atypical pathogens and some coverage for S.
pneumoniae, although macrolide resistance exists among both M. pneumoniae and S.
pneumoniae.

The prevalence of macrolide-resistant M. pneumoniae is increasing in some geographic regions,

including Asia, Europe, Israel, and the United States [23-31]. The reported prevalence of
resistance among M. pneumoniae isolates ranges from approximately 10 percent in the United
States to 90 percent in China and some parts of Japan [25,28,32,33]. Alternative agents include
levofloxacin and doxycycline [1]. The long-held concern for enamel staining associated with
doxycycline in children younger than eight years use is unfounded [34,35].

Among the macrolide antibiotics, clarithromycin and azithromycin have a more convenient
dosing schedule and fewer side effects than erythromycin, but erythromycin is less expensive
[8,36,37]. Macrolide antibiotics may provide coverage for S. pneumoniae, which is the most
frequent typical bacterial pathogen for all age groups [38-40]. However, approximately 40 to 50
percent of S. pneumoniae isolates are resistant to macrolides. Failure to respond to macrolide
therapy may indicate the development of a complication, a macrolide-resistant pathogen,
and/or the need to alter therapy to provide better pneumococcal coverage. (See 'Treatment
failure' below.)

Given the significant resistance of S. pneumoniae to macrolides, fluoroquinolones (eg,

levofloxacin, moxifloxacin) are another reasonable alternative for the outpatient treatment of
CAP in the older child when typical pneumonia is also a consideration based on clinical findings
( table 3). 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, and C. pneumoniae [41].
However, S. pneumoniae resistant to levofloxacin have been identified [42].

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

soon as possible is recommended for children with suspected influenza who are at high risk for
complications of influenza pneumonia ( table 4); 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: Prevention and treatment with antiviral drugs",
section on 'Antiviral therapy'.)

Suspected aspiration pneumonia — Community-acquired aspiration pneumonia is usually

treated with amoxicillin-clavulanate. Clindamycin is an alternative for patients allergic to
penicillin. Doses are provided in the table ( table 2). In neurologically compromised
adolescents who may be prone to aspiration events, empiric treatment with moxifloxacin (400
mg once per day) is an alternative. Moxifloxacin is active against anaerobic bacteria, as well as
the usual treatable causes of CAP: S. pneumoniae, M. pneumoniae, and C. pneumoniae.
Fluoroquinolone antibiotics generally are not recommended for children younger than 18 years
of age when there is a safe and effective alternative. (See "Fluoroquinolones", section on
'Children'.)

Duration — Few randomized controlled trials have been performed to determine the

appropriate duration of antimicrobial therapy in radiographically confirmed childhood
pneumonia [2,43]. Practice in the developed world determines the duration of therapy based
upon the age of the host, likely causative agent, and severity of disease:

● We suggest that infants ≥4 months and children with uncomplicated pneumonia suspected
or confirmed to be caused by routine pathogens (ie, S. pneumoniae, M. pneumoniae, C.
pneumoniae) be treated for 7 to 10 days; the course of azithromycin is five days [1,8]

● The duration of treatment for C. trachomatis pneumonia in young infants is discussed

separately (see "Chlamydia trachomatis infections in the newborn", section on 'Treatment')

A meta-analysis found three days of oral antimicrobial therapy to be as effective as five days for
nonsevere CAP in children aged 2 to 59 months [44]. However, the studies included in the meta-
analysis were performed in developing countries, where it is not feasible to perform
radiographs or evaluation for a microbiologic etiology; pneumonia was diagnosed by the World
Health Organization (WHO) criteria, which are based on clinical findings and respiratory rate
thresholds. In another study, only 14 percent of children diagnosed with nonsevere pneumonia
by the WHO criteria had radiographic evidence of pneumonia [45]. Many of the children in the
meta-analysis probably had viral pneumonia, for which antibiotic therapy is not warranted. This
is supported by a subsequent randomized trial in which the clinical outcomes did not differ for
children aged 2 to 59 months who were diagnosed with nonsevere pneumonia by the WHO
criteria and treated for three days with amoxicillin versus placebo [46].

In a subsequent randomized trial in a developed country, 4 of 10 children who received three

days of outpatient treatment (amoxicillin 80 mg/kg per day divided in three doses) for
radiologically confirmed CAP required rescue therapy or hospitalization versus none of 12
children treated for 10 days [47]. In the second stage of the trial, five days of treatment
(amoxicillin 80 mg/kg per day divided in three doses) was as effective as 10 days in preventing
the need for rescue therapy or hospitalization, but with fewer than 60 patients in each arm, the
study may have been underpowered to detect a difference. Additional, larger studies are
necessary to confirm these results before we suggest five days of therapy for uncomplicated
CAP.

Monitoring response — Children with CAP who are treated as outpatients (including those
who were not initially treated with antibiotics) should have follow-up within 24 to 48 hours [1,2].
Follow-up may be performed by phone. Children with CAP who are appropriately treated
generally show signs of improvement within 48 to 72 hours.

Treatment failure — Among patients who do not improve as anticipated, the following

possibilities must be considered [1,2,14,48]:

● Alternative or coincident diagnoses (eg, foreign body aspiration) (see "Community-acquired

pneumonia in children: Clinical features and diagnosis", section on 'Differential diagnosis')

● Development of complications (see "Community-acquired pneumonia in children: Clinical

features and diagnosis", section on 'Complications')

● Ineffective antibiotic coverage (lack of coverage for the actual etiology or resistant
organism)

Worsened condition — Patients whose condition has worsened require additional

evaluation and hospitalization. They also should undergo radiologic evaluation to look for the
development of complications. Laboratory tests should be performed to try to establish a
microbiologic diagnosis. (See "Community-acquired pneumonia in children: Clinical features
and diagnosis", section on 'Laboratory evaluation' and "Pneumonia in children: Inpatient
treatment", section on 'Hospitalization'.)

Failure to improve — In patients who fail to improve but have not worsened, it may be
reasonable to add or strengthen coverage for S. pneumoniae or atypical bacteria if these
organisms were not covered in the initial therapy ( table 2) [1,4]. It is also important to
consider underlying or comorbid conditions (eg, immunodeficiency, anatomic abnormality).
(See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on
'Differential diagnosis'.)

● Patients initially treated with beta-lactam antibiotics – Failure to improve while being
treated with a beta-lactam antibiotic (amoxicillin or cephalosporin) may indicate infection
caused by penicillin-resistant S. pneumoniae or S. aureus (either methicillin-susceptible or -
resistant) [49]. If penicillin-resistant S. pneumoniae is suspected, a change in antibiotic
therapy to clindamycin or linezolid may be indicated. Levofloxacin is an option if there is a
high rate of pneumococcal resistance to clindamycin. Doses are provided in the table (
table 2). If S. aureus is suspected based upon a rapidly worsening clinical course with
 progressive radiographic findings that may include multiple patchy alveolar infiltrates
coalescing to form large consolidated areas in a young, immunocompetent host often with
a preceding viral illness, the child should be hospitalized given the increased risk of
complications (eg, necrosis, abscess, empyema, pneumatocele) and death. (See
"Pneumonia in children: Inpatient treatment".)

● Patients initially treated with macrolide antibiotics – Failure to improve while being
treated with a macrolide antibiotic may indicate the need to perform a diagnostic test (eg,
polymerase chain reaction) to confirm an M. pneumoniae etiologic diagnosis and/or alter
therapy to provide better coverage for S. pneumoniae or macrolide-resistant M. pneumoniae.
(See "Mycoplasma pneumoniae infection in children", section on 'Pneumonia'.)

For patients initially treated with macrolides, better pneumococcal coverage can be
achieved by the addition of high-dose amoxicillin, a cephalosporin (eg, cefdinir,
cefpodoxime), or clindamycin. Among these options, we prefer high-dose amoxicillin
because it is well tolerated and inexpensive. Amoxicillin and cephalosporins may provide
coverage for other potential, albeit less common causes, of bacterial pneumonia in older
children (eg, Haemophilus influenzae type b, nontypeable H. influenzae, Moraxella catarrhalis,
group A Streptococcus) [11], although it does not provide coverage against beta-lactamase-
producing strains of H. influenzae and M. catarrhalis. Clindamycin provides coverage for
most S. aureus infections. For children who have type 1 hypersensitivity ( table 5) to
penicillins, a fluoroquinolone (eg, levofloxacin, moxifloxacin) may be used. Tetracyclines (eg,
doxycycline) and fluoroquinolones can be used if macrolide-resistant M. pneumoniae is
suspected [50]. Fluoroquinolones also provide coverage for most typical bacterial etiologies
of CAP except S aureus. Doses are provided in the table ( table 2). (See "Mycoplasma
pneumoniae infection in children", section on 'Management'.)

SUPPORTIVE CARE

The families of children who are managed as outpatients should be instructed regarding
management of fever and pain, maintaining adequate hydration, and identification of
deterioration (eg, persistent fever, increased retractions, use of accessory muscles, grunting,
inability to feed) [2].

● Children with pneumonia usually have fever and may have pleuritic chest pain, which can
lead to shallow breathing and impaired ability to cough [2]. Administration of antipyretics
and/or analgesics can be used to keep the child comfortable. Adequate pain control may
promote coughing, which facilitates airway clearance. Antitussives should be avoided as
 none have been found to be effective in pneumonia [51]. Symptomatic treatment of cough
is discussed separately. (See "The common cold in children: Management and prevention",
section on 'Cough'.)

● Infants and young children with respiratory distress may be better able to maintain
hydration if fluids are provided in small volumes more frequently than in large volumes less
often.

● Gentle suction of the nares may be helpful in infants and children whose nares are blocked
by nasal secretions.

FOLLOW-UP

Clinical course — Children who are appropriately treated for CAP gradually improve with time
[52]. The symptoms associated with viral lower respiratory tract infections, particularly cough,
usually resolve in less than one month in healthy infants and children but may rarely last for up
to three to four months. Cough may also persist for as long as three to four months after
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 [52].

Radiographs — Follow-up radiographs are not necessary in asymptomatic children with

uncomplicated CAP. Follow-up radiographs two to three weeks after completion of therapy may
be helpful in assessing alternate diagnoses or coincident conditions in children with recurrent
pneumonia, persistent symptoms, severe atelectasis, unusually located infiltrates, or round
pneumonia (ie, pulmonary consolidation that appears to be spherical) [1,2,53]. Conditions that
must be considered if a round pneumonia fails to resolve on follow-up imaging include
congenital lung sequestration, metastatic Wilms tumor, cavitary necrosis, pleural pseudocyst,
and primary lung carcinoma [53-57]. (See "Community-acquired pneumonia in children: Clinical
features and diagnosis", section on 'Differential diagnosis'.)

Several studies have evaluated the utility of follow-up radiographs in cohorts of children with
acute radiologically proven CAP [58-63]. Three of the studies included clinical as well as
radiologic follow-up at three to seven weeks after initial diagnosis [58-61]. In each of these
studies, follow-up radiographs were normal or improved in asymptomatic children. Residual
findings, even when present, did not result in additional therapy.

PROGNOSIS
Most otherwise healthy children who develop pneumonia recover without any long-term
sequelae [40]. Although some prospective studies suggest that pneumonia in childhood is
associated with subsequent symptoms of asthma that may persist into adulthood, 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 CAP [64,65].

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 education" and the keyword[s] of interest.)

● Basics topics (see "Patient education: Pneumonia in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

● 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. The clinical
manifestations and diagnosis of CAP are discussed separately. (See "Community-acquired
pneumonia in children: Clinical features and diagnosis".)

● The decision to hospitalize a child with pneumonia must be individualized and is based
upon age, underlying medical problems, and severity of illness ( table 1). (See 'Indications
 for hospitalization' above.)

● Children with CAP who are treated in the outpatient setting are treated empirically. It is not
necessary to identify a microbiologic etiology in children who are well enough to be treated
as outpatients. 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. (See 'Factors influencing choice of regimen' above.)

● Infants younger than three to six months of age with suspected bacterial CAP or who are
hypoxemic should be admitted to the hospital for management. Afebrile infants one to four
months of age who are thought to have afebrile pneumonia of infancy (eg, Chlamydia
trachomatis) can be treated in the outpatient setting if they are not hypoxemic and remain
afebrile. (See "Pneumonia in children: Inpatient treatment" and "Chlamydia trachomatis
infections in the newborn".)

● We recommend that empiric antibiotic therapy for CAP in children six months to five years
of age who are thought to have bacterial pneumonia (eg, abrupt onset, moderate to severe
respiratory distress, and supportive laboratory data if obtained ( table 3)) include
coverage for Streptococcus pneumoniae ( table 2) (Grade 1B). (See 'Children <5 years'
above.)

● For children ≥5 years with clinical features strongly suggestive of typical bacterial (eg, S.
pneumoniae) pneumonia ( table 3), amoxicillin is the drug of choice ( table 2). We
initiate macrolide antibiotics for initial empiric therapy for suspected atypical CAP (
table 3) in children ≥5 years who are treated as outpatients. (See 'Children ≥5 years'
above.)

● In infants and children six months and older, the usual duration of antimicrobial therapy is
five days for azithromycin and 7 to 10 days for other agents. (See 'Duration' above.)

● Children who are treated for CAP as outpatients should have follow-up within 24 to 48
hours. Those whose condition has worsened at follow-up should be evaluated for potential
complications and hospitalized. (See 'Monitoring response' above and "Pneumonia in
children: Inpatient treatment".)

● Children recovering from CAP may continue to 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 in children with uncomplicated CAP who remain asymptomatic are
not needed. Follow-up radiographs two to three weeks after completion of therapy may be
helpful in children with recurrent pneumonia, persistent symptoms, severe atelectasis,
unusually located infiltrates, or round pneumonia. (See 'Radiographs' above.)

● Most otherwise healthy children who develop pneumonia recover without any long-term
sequelae. (See 'Prognosis' above.)

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long-course therapy of the same antibiotic for community-acquired pneumonia in
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Clin Infect Dis 2011; 52:293.

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community-acquired alveolar pneumonia in ambulatory children: a double-blind,
randomized, placebo-controlled trial. Pediatr Infect Dis J 2014; 33:136.

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mimics of community-acquired pneumonia. Respir Med 2004; 98:488.

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society of america for the treatment of methicillin-resistant Staphylococcus aureus
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to antibiotics. Future Microbiol 2011; 6:423.

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in children. Pediatrics 1979; 63:30.
 59. Virkki R, Juven T, Mertsola J, Ruuskanen O. Radiographic follow-up of pneumonia in
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60. Gibson NA, Hollman AS, Paton JY. Value of radiological follow up of childhood pneumonia.
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61. Heaton P, Arthur K. The utility of chest radiography in the follow-up of pneumonia. N Z
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63. Surén P, Try K, Eriksson J, et al. Radiographic follow-up of community-acquired pneumonia

in children. Acta Paediatr 2008; 97:46.

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follow up study. BMJ 2000; 320:1514.

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adults: a longitudinal study. Pediatrics 2015; 135:607.

Topic 5987 Version 44.0

GRAPHICS

Severity of community-acquired pneumonia in infants and children

Clinical features of mild pneumonia Clinical features of severe 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 that defines RR >70 breaths/minute for infants; RR >50
moderate to severe respiratory distress breaths/minute for older children
Mild or absent retractions Moderate/severe suprasternal, intercostal, or
No grunting subcostal retractions (<12 months)
No nasal flaring Severe difficulty breathing (≥12 months)
No apnea Grunting
Mild shortness of breath Nasal flaring
Apnea
Significant shortness of breath

Normal color Cyanosis

Normal mental status Altered mental status

Normoxemia (oxygen saturation ≥92 percent in room air) Hypoxemia (sustained oxygen saturation <90 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

Initial oral empiric antibiotics for outpatient treatment of pediatric community-acquired
pneumonia

Age group Empiric regimen

1 to 6 months

Bacterial (not Chlamydia Infants <3 to 6 months of age with suspected bacterial pneumonia should be hospitalized
trachomatis)

C. trachomatis Refer to UpToDate topic on C. trachomatis infections in the newborn

6 months to 5 years

Typical bacterial* Amoxicillin ¶ 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day), or

Amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin component in 2 or 3 divided doses

(MAX 4 g/day amoxicillin component), or

For patients with non-type 1 hypersensitivity to penicillins:

- Cefdinir 14 mg/kg per day in 2 divided doses (MAX 600 mg/day), or

For patients with type 1 hypersensitivity to penicillins:

- Levofloxacin Δ 16 to 20 mg/kg per day in 2 divided doses (MAX 750 mg/day), or

- Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 1.8 g/day), or

- Erythromycin 40 to 50 mg/kg per day in 4 divided doses (MAX 2 g/day as base, 3.2 g/day as
ethylsuccinate), or

- Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (MAX 500 mg on
day 1 and 250 mg thereafter), or

- Clarithromycin 15 mg/kg per day in 2 divided doses (MAX 1 g/day), or

In communities with a high rate of pneumococcal resistance to penicillin:

- Levofloxacin Δ 16 to 20 mg/kg per day in 2 divided doses (MAX 750 mg/day), or

- Linezolid 30 mg/kg per day in 3 divided doses (MAX 1800 mg/day)

≥5 years

Mycoplasma pneumoniae or Azithromycin ¶ 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (MAX 500 mg on
Chlamydia pneumoniae day 1 and 250 mg thereafter), or

Clarithromycin 15 mg/kg per day in 2 divided doses (MAX 1 g/day), or

Erythromycin 40 to 50 mg/kg per day in 4 divided doses (MAX 2 g/day as base, 3.2 g/day as
ethylsuccinate), or

Doxycycline 4 mg/kg per day in 2 divided doses (MAX 200 mg/day), or

Levofloxacin Δ § 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 500 mg/day); 500 mg
once per day for children for children ≥16 years, or

Moxifloxacin Δ◊ 400 mg once per day

Typical bacterial* Amoxicillin ¶ 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day), or

For patients with non-type 1 hypersensitivity to penicillins:

- Cefdinir 14 mg/kg per day in 2 divided doses (MAX 600 mg/day), or

- Cefpodoxime 10 mg/kg per day in 2 divided doses (MAX 400 mg/day), or

For patients with type 1 hypersensitivity to penicillins:

- Levofloxacin Δ 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 750 mg/day); 750 mg
once daily for children ≥16 years

- Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 1.8 g/day), or

- Erythromycin 40 to 50 mg/kg per day in 4 divided doses (MAX 2 g/day as base, 3.2 g/day as
ethyl succinate), or
 - Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (MAX 500 mg on
day 1 and 250 mg thereafter), or

- Clarithromycin 15 mg/kg per day in 2 divided doses (MAX 1 g/day), or

In communities with a high rate of pneumococcal resistance to penicillin:

- Levofloxacin Δ 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 750 mg/day); 750 mg
once daily for children ≥16 years, or

- Linezolid 30 mg/kg per day divided in 3 doses (MAX 1800 mg/day) for children <12 years; 20
mg/kg per day divided in 2 doses (MAX 1200 mg/day) for children ≥12 years

Aspiration pneumonia

Community-acquired Amoxicillin-clavulanate 40 to 50 mg/kg per day in 2 or 3 divided doses (MAX 1750 mg/day
amoxicillin component), or

For patients with type 1 hypersensitivity to beta-lactam antibiotics:

- Clindamycin 30 to 40 mg/kg per day, divided in 3 or 4 doses (MAX 1.8 g/day)

MAX: maximum.
* For the infant or child who is suspected to have bacterial community-acquired pneumonia and is unable to tolerate liquids at the time
of presentation, a single initial dose of ceftriaxone (50 to 75 mg/kg) may be administered intramuscularly or intravenously before
starting oral antibiotics.
¶ Preferred agent.
Δ In the United States, fluoroquinolones (eg, levofloxacin and moxifloxacin) are approved by the US Food and Drug Administration for
community-acquired pneumonia for patients ≥18 years of age. However, they may be used in younger children if other antibiotics are
inappropriate (eg, due to hypersensitivity or local antimicrobial resistance patterns).
◊ Also covers typical bacterial pathogens.

Data from:
1. McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
2. 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.
3. American Academy of Pediatrics. Tables of antibacterial drug dosages. In: Red Book: 2018 Report of the Committee on Infectious
Diseases, 31st ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, IL 2018. p.914.

Graphic 80561 Version 26.0

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

Atypical bacterial
(Mycoplasma pneumoniae,
Chlamydia pneumoniae)
Children of all ages (most common in children >5 years) M. pneumoniae:
Abrupt onset with constitutional findings (malaise, myalgia, Lobar or segmental
headache, rash, conjunctivitis, photophobia, sore throat, consolidation (37%)
headache)
Parahilar or peribronchial
Gradually worsening nonproductive cough infiltrates (27%)
Wheezing Localized reticulonodular
Extrapulmonary manifestations or complications (eg, infiltrates (21%)
Stevens-Johnson syndrome, hemolytic anemia, hepatitis, Patchy infiltrates (15%)
etc)

Viral Usually children <5 years Interstitial infiltrates

Gradual onset
Preceding upper airway symptoms
Nontoxic appearing
Diffuse, bilateral auscultatory findings
Wheezing
May have associated rash (eg, measles, varicella)

Afebrile pneumonia of infancy
(most commonly Chlamydia
trachomatis)
Usually in infants 2 weeks to 4 months Hyperinflation with interstitial
Insidious onset infiltrates
Rhinorrhea
Staccato cough pattern
Peripheral eosinophilia (if CBC obtained)

Fungal Appropriate geographic or environmental exposure Mediastinal or hilar

adenopathy

Mycobacterium tuberculosis Children of any age Mediastinal or hilar

Chronic cough adenopathy
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.
 4. McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
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.

Graphic 52021 Version 11.0

Groups at high risk for serious influenza complications

Children <5 years, but especially <2 years*

Adults ≥65 years of age

Women who are pregnant or up to 2 weeks postpartum

Residents of nursing homes and long-term care facilities

American Indians, including Alaska Natives

People with medical conditions including:

Asthma
Neurologic and neurodevelopmental conditions (including disorders of the brain, spinal cord, and peripheral nerve and
muscle such as cerebral palsy, epilepsy, stroke, intellectual disability, moderate-to-severe developmental delay, muscular
dystrophy, and spinal cord injury)
Chronic lung disease (eg, chronic obstructive pulmonary disease, cystic fibrosis)
Heart disease (eg, congenital heart disease, congestive heart failure, coronary artery disease)
Blood disorders (eg, sickle cell disease)
Endocrine disorders (eg, diabetes mellitus)
Kidney disorders
Liver disorders
Metabolic disorders (eg, inherited metabolic disorders and mitochondrial disorders)
Weakened immune system due to disease (eg, HIV, AIDS, cancer) or medication (eg, chemotherapy or radiation therapy,
chronic glucocorticoids)
Children <19 years of age who are receiving long-term aspirin therapy
People with extreme obesity (body mass index [BMI] ≥40)

* In young children, rates of hospitalization and mortality are greatest among those <6 months of age.

Adapted from: Centers for Disease Control and Prevention. People at high risk for flu complications. Available at:
www.cdc.gov/flu/about/disease/high_risk.htm (Accessed on August 24, 2019).

Graphic 72029 Version 21.0

Gell and Coombs classification of immunologic drug reactions

Type Description Mechanism Clinical features

I IgE-mediated, Antigen exposure causes IgE-mediated activation Anaphylaxis
Immediate reaction immediate-type of mast cells and basophils, with release of Angioedema
(within one hour) hypersensitivity vasoactive substances, such as histamine,
Bronchospasm
prostaglandins, and leukotrienes.
Urticaria (hives)
Hypotension

II Antibody-dependent An antigen or hapten that is intimately associated Hemolytic anemia

cytotoxicity with a cell binds to antibody, leading to cell or Thrombocytopenia
tissue injury.
Neutropenia

III Immune complex Damage is caused by formation or deposition of Serum sickness

disease antigen-antibody complexes in vessels or tissue. Arthus reaction
Deposition of immune complexes causes
complement activation and/or recruitment of
neutrophils by interaction of immune complexes
with Fc IgG receptors.

IV Cell-mediated or Antigen exposure activates T cells, which then Contact dermatitis

delayed mediate tissue injury. Depending upon the type of Some morbilliform
hypersensitivity T cell activation and the other effector cells reactions
recruited, different subtypes can be differentiated
Severe exfoliative
(ie, types IVa to IVd).
dermatoses (eg,
SJS/TEN)
AGEP
DRESS/DiHS
Interstitial nephritis
Drug-induced hepatitis
Other presentations

IgE: immunoglobulin E; Fc IgG: Fc portion of immunoglobulin G; SJS/TEN: Stevens-Johnson syndrome/toxic epidermal necrolysis; AGEP:
acute generalized exanthematous pustulosis; DRESS/DiHS: drug rash with eosinophilia and systemic symptoms/drug-induced
hypersensitivity syndrome.

Adapted from: Weiss ME, Adkinson NF. Immediate hypersensitivity reactions to penicillin and related antibiotics. Clin Allergy 1988; 18:515.

Graphic 80466 Version 18.0

Contributor Disclosures
William J Barson, MD Apoyo a la subvención / investigación / ensayo clínico: Pfizer [Neumonía]. Morven
S Edwards, MD Subvención / Investigación / Apoyo a ensayos clínicos: Pfizer [Estreptococo del grupo B].
George B Mallory, MD Subvención / Investigación / Apoyo a ensayos clínicos: TOPP-2 [Hipertensión
pulmonar]. Mary M Torchia, MD Nada que revelar

El grupo editorial revisa las divulgaciones de los colaboradores para detectar conflictos de intereses.
Cuando se encuentran, estos se abordan mediante un proceso de revisión de varios niveles y mediante los
requisitos para que se proporcionen referencias para respaldar el contenido. Se requiere que todos los
autores tengan contenido debidamente referenciado y éste debe cumplir con los estándares de evidencia
de UpToDate.

Política de conflicto de intereses