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"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"

Published: Clinical Infectious Diseases Clinical Infectious Diseases ; 2011 ; 53 : 25 -76


Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. 

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*Every 12 to 18 months following publication, IDSA reviews its guidelines to determine whether an update is required. This guideline was last reviewed and deemed current as of 04/2013.



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?


  1. 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)
  2. 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)
  3. 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)
  4. 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)
  5. 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)
  6. 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)
  7. 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)


III. What Diagnostic Laboratory and Imaging Tests Should Be Used in a Child With Suspected CAP in an Outpatient or Inpatient Setting?


Microbiologic Testing

Blood Cultures: Outpatient

  1. Blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP managed in the outpatient setting. (strong recommendation; moderate-quality evidence)
  2. 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).

Blood Cultures: Inpatient

  1. Blood cultures should be obtained in children requiring hospitalization for presumed bacterial CAP that is moderate to severe, particularly those with complicated pneumonia. (strong recommendation; low-quality evidence)
  2. In improving patients who otherwise meet criteria for discharge, a positive blood culture with identification or susceptibility results pending should not routinely preclude discharge of that patient with appropriate oral or intravenous antimicrobial therapy. The patient can be discharged if close follow-up is assured. (weak recommendation; low-quality evidence)

Follow-up Blood Cultures

  1. Repeated blood cultures in children with clear clinical improvement are not necessary to document resolution of pneumococcal bacteremia. (weak recommendation; low-quality evidence)
  2. Repeated blood cultures to document resolution of bacteremia should be obtained in children with bacteremia caused by S. aureus, regardless of clinical status. (strong recommendation; low-quality evidence)

Sputum Gram Stain and Culture

  1. Sputum samples for culture and Gram stain should be obtained in hospitalized children who can produce sputum. (weak recommendation; low-quality evidence)

Urinary Antigen Detection Tests

  1. Urinary antigen detection tests are not recommended for the diagnosis of pneumococcal pneumonia in children; false-positive tests are common. (strong recommendation; high-quality evidence)

Testing For Viral Pathogens

  1. 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)
  2. 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).
  3. Testing for respiratory viruses other than influenza virus can modify clinical decision making in children with suspected pneumonia, because antibacterial therapy will not routinely be required for these children in the absence of clinical, laboratory, or radiographic findings that suggest bacterial coinfection. (weak recommendation; low-quality evidence)

Testing for Atypical Bacteria

  1. Children with signs and symptoms suspicious for Mycoplasma pneumoniae should be tested to help guide antibiotic selection. (weak recommendation; moderate-quality evidence)
  2. Diagnostic testing for Chlamydophila pneumoniae is not recommended as reliable and readily available diagnostic tests do not currently exist. (strong recommendation; high-quality evidence)

Ancillary Diagnostic Testing

Complete Blood Cell Count

  1. Routine measurement of the complete blood cell count is not necessary in all children with suspected CAP managed in the outpatient setting, but in those with more serious disease it may provide useful information for clinical management in the context of the clinical examination and other laboratory and imaging studies. (weak recommendation; low-quality evidence)
  2. A complete blood cell count should be obtained for patients with severe pneumonia, to be interpreted in the context of the clinical examination and other laboratory and imaging studies. (weak recommendation; low-quality evidence)

Acute-Phase Reactants

  1. Acute-phase reactants, such as the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) concentration, or serum procalcitonin concentration, cannot be used as the sole determinant to distinguish between viral and bacterial causes of CAP. (strong recommendation; high-quality evidence)
  2. Acute-phase reactants need not be routinely measured in fully immunized children with CAP who are managed as outpatients, although for more serious disease, acute-phase reactants may provide useful information for clinical management. (strong recommendation; low-quality evidence)
  3. In patients with more serious disease, such as those requiring hospitalization or those with pneumonia-associated complications, acute-phase reactants may be used in conjunction with clinical findings to assess response to therapy. (weak recommendation; low-quality evidence)

Pulse Oximetry

  1. 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)

Chest Radiography

Initial Chest Radiographs: Outpatient

  1. 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)
  2. 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)

Initial Chest Radiographs: Inpatient

  1. Chest radiographs (posteroanterior and lateral) should be obtained in all patients hospitalized for management of CAP to document the presence, size, and character of parenchymal infiltrates and identify complications of pneumonia that may lead to interventions beyond antimicrobial agents and supportive medical therapy. (strong recommendation; moderate-quality evidence)

Follow-up Chest Radiograph

  1. Repeated chest radiographs are not routinely required in children who recover uneventfully from an episode of CAP. (strong recommendation; moderate-quality evidence)
  2. Repeated chest radiographs should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration within 48–72 hours after initiation of antibiotic therapy. (strong recommendation; moderate-quality evidence)
  3. Routine daily chest radiography is not recommended in children with pneumonia complicated by parapneumonic effusion after chest tube placement or after video-assisted thoracoscopic surgery (VATS), if they remain clinically stable. (strong recommendation; low-quality evidence)
  4. Follow-up chest radiographs should be obtained in patients with complicated pneumonia with worsening respiratory distress or clinical instability, or in those with persistent fever that is not responding to therapy over 48-72 hours. (strong recommendation; low-quality evidence)
  5. Repeated chest radiographs 4–6 weeks after the diagnosis of CAP should be obtained in patients with recurrent pneumonia involving the same lobe and in patients with lobar collapse at initial chest radiography with suspicion of an anatomic anomaly, chest mass, or foreign body aspiration. (strong recommendation; moderate-quality evidence)

IV. What Additional Diagnostic Tests Should Be Used in a Child With Severe or Life-Threatening CAP?


  1. he clinician should obtain tracheal aspirates for Gram stain and culture, as well as clinically and epidemiologically guided testing for viral pathogens, including influenza virus, at the time of initial endotracheal tube placement in children requiring mechanical ventilation. (strong recommendation; low-quality evidence)
  2. Bronchoscopic or blind protected specimen brush sampling, bronchoalveolar lavage (BAL), percutaneous lung aspiration, or open lung biopsy should be reserved for the immunocompetent child with severe CAP if initial diagnostic tests are not positive. (weak recommendation; low-quality evidence)


V. Which Anti-Infective Therapy Should Be Provided to a Child With Suspected CAP in Both Outpatient and Inpatient Settings?



  1. 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)
  2. 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)
  3. 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)
  4. 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)
  5. 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, especially rapid antigen 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)


  1. Ampicillin or penicillin G should be administered to the fully immunized infant or school-aged child admitted to a hospital ward with CAP when local epidemiologic data document lack of substantial high-level penicillin resistance for invasive S. pneumoniae. Other antimicrobial agents for empiric therapy are provided in Table 7. (strong recommendation; moderate-quality evidence)
  2. Empiric therapy with a third-generation parenteral cephalosporin (ceftriaxone or cefotaxime) should be prescribed for hospitalized infants and children who are not fully immunized, in regions where local epidemiology of invasive pneumococcal strains documents high-level penicillin resistance, or for infants and children with life-threatening infection, including those with empyema (Table 7). Non–β-lactam agents, such as vancomycin, have not been shown to be more effective than third-generation cephalosporins in the treatment of pneumococcal pneumonia for the degree of resistance noted currently in North America. (weak recommendation; moderate-quality evidence)
  3. Empiric combination therapy with a macrolide (oral or parenteral), in addition to a β-lactam antibiotic, should be prescribed for the hospitalized child for whom M. pneumoniae and C. pneumoniae are significant considerations; diagnostic testing should be performed if available in a clinically relevant time frame (Table 7). (weak recommendation; moderate-quality evidence)
  4. Vancomycin or clindamycin (based on local susceptibility data) should be provided in addition to β-lactam therapy if clinical, laboratory, or imaging characteristics are consistent with infection caused by S. aureus (Table 7). (strong recommendation; low-quality evidence)

VI. How Can Resistance to Antimicrobials Be Minimized?


  1. Antibiotic exposure selects for antibiotic resistance; therefore, limiting exposure to any antibiotic, whenever possible, is preferred. (strong recommendation; moderate-quality evidence)
  2. Limiting the spectrum of activity of antimicrobials to that specifically required to treat the identified pathogen is preferred. (strong recommendation; low-quality evidence)
  3. Using the proper dosage of antimicrobial to be able to achieve a minimal effective concentration at the site of infection is important to decrease the development of resistance. (strong recommendation; low-quality evidence)
  4. Treatment for the shortest effective duration will minimize exposure of both pathogens and normal microbiota to antimicrobials and minimize the selection for resistance. (strong recommendation; low-quality evidence)

VII. What Is the Appropriate Duration of Antimicrobial Therapy for CAP?


  1. Treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for more mild disease managed on an outpatient basis. (strong recommendation; moderate-quality evidence)
  2. Infections caused by certain pathogens, notably CA-MRSA, may require longer treatment than those caused by S. pneumoniae. (strong recommendation; moderate-quality evidence)

VIII. How Should the Clinician Follow the Child With CAP for the Expected Response to Therapy?


  1. 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?


  1. 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?


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

XI. What Laboratory Testing Should Be Performed on Pleural Fluid?


  1. Gram stain and bacterial culture of pleural fluid should be performed whenever a pleural fluid specimen is obtained. (strong recommendation; high-quality evidence)
  2. Antigen testing or nucleic acid amplification through polymerase chain reaction (PCR) increase the detection of pathogens in pleural fluid and may be useful for management. (strong recommendation; moderate-quality evidence)
  3. Analysis of pleural fluid parameters, such as pH and levels of glucose, protein, and lactate dehydrogenase, rarely change patient management and are not recommended. (weak recommendation; very low-quality evidence)
  4. Analysis of the pleural fluid white blood cell (WBC) count, with cell differential analysis, is recommended primarily to help differentiate bacterial from mycobacterial etiologies and from malignancy. (weak recommendation; moderate-quality evidence)

XII. What Are the Drainage Options for Parapneumonic Effusions?


  1. Small, uncomplicated parapneumonic effusions should not routinely be drained and can be treated with antibiotic therapy alone. (strong recommendation; moderate-quality evidence)
  2. Moderate parapneumonic effusions associated with respiratory distress, large parapneumonic effusions, or documented purulent effusions should be drained. (strong recommendation; moderate-quality evidence)
  3. Both chest thoracostomy tube drainage with the addition of fibrinolytic agents and VATS have been demonstrated to be effective methods of treatment. The choice of drainage procedure depends on local expertise. Both of these methods are associated with decreased morbidity compared with chest tube drainage alone. However, in patients with moderate-to-large effusions that are free flowing (no loculations), placement of a chest tube without fibrinolytic agents is a reasonable first option. (strong recommendation; high-quality evidence)

XIII. When Should VATS or Open Decortication Be Considered in Patients Who Have Had Chest Tube Drainage, With or Without Fibrinolytic Therapy?


  1. VATS should be performed when there is persistence of moderate-large effusions and ongoing respiratory compromise despite ∼2–3 days of management with a chest tube and completion of fibrinolytic therapy. Open chest débridement with decortication represents another option for management of these children but is associated with higher morbidity rates. (strong recommendation; low-quality evidence)

XIV. When Should a Chest Tube Be Removed Either After Primary Drainage or VATS?

  1. A chest tube can be removed in the absence of an intrathoracic air leak and when pleural fluid drainage is <1 mL/kg/24 h, usually calculated over the last 12 hours. (strong recommendation; very low-quality evidence)

XV. What Antibiotic Therapy and Duration Is Indicated for the Treatment of Parapneumonic Effusion/Empyema?


  1. When the blood or pleural fluid bacterial culture identifies a pathogenic isolate, antibiotic susceptibility should be used to determine the antibiotic regimen. (strong recommendation; high-quality evidence)
  2. In the case of culture-negative parapneumonic effusions, antibiotic selection should be based on the treatment recommendations for patients hospitalized with CAP (see Evidence Summary for Recommendations 46–49). (strong recommendation; moderate-quality evidence)
  3. The duration of antibiotic treatment depends on the adequacy of drainage and on the clinical response demonstrated for each patient. In most children, antibiotic treatment for 2–4 weeks is adequate. (strong recommendation; low-quality evidence)


XVI.mWhat Is the Appropriate Management of a Child Who Is Not Responding to Treatment for CAP?


  1. Children who are not responding to initial therapy after 48–72 hours should be managed by one or more of the following:
    1. Clinical and laboratory assessment of the current severity of illness and anticipated progression in order to determine whether higher levels of care or support are required. (strong recommendation; low-quality evidence)
    2. Imaging evaluation to assess the extent and progression of the pneumonic or parapneumonic process. (weak recommendation; low-quality evidence)
    3. Further investigation to identify whether the original pathogen persists, the original pathogen has developed resistance to the agent used, or there is a new secondary infecting agent. (weak recommendation; low-quality evidence)
  2. A BAL specimen should be obtained for Gram stain and culture for the mechanically ventilated child. (strong recommendation; moderate-quality evidence)
  3. A percutaneous lung aspirate should be obtained for Gram stain and culture in the persistently and seriously ill child for whom previous investigations have not yielded a microbiologic diagnosis. (weak recommendation; low-quality evidence)
  4. An open lung biopsy for Gram stain and culture should be obtained in the persistently and critically ill, mechanically ventilated child in whom previous investigations have not yielded a microbiologic diagnosis. (weak recommendation; low-quality evidence)

XVII. How Should Nonresponders With Pulmonary Abscess or Necrotizing Pneumonia Be Managed?


  1. A pulmonary abscess or necrotizing pneumonia identified in a nonresponding patient can be initially treated with intravenous antibiotics. Well-defined peripheral abscesses without connection to the bronchial tree may be drained under imaging-guided procedures either by aspiration or with a drainage catheter that remains in place, but most abscesses will drain through the bronchial tree and heal without surgical or invasive intervention. (weak recommendation; very low-quality evidence)


XVIII. When Can a Hospitalized Child With CAP Be Safely Discharged?


  1. Patients are eligible for discharge when they have documented overall clinical improvement, including level of activity, appetite, and decreased fever for at least 12–24 hours. (strong recommendation; very low-quality evidence)
  2. Patients are eligible for discharge when they demonstrate consistent pulse oximetry measurements >90% in room air for at least 12–24 hours. (strong recommendation; moderate-quality evidence)
  3. Patients are eligible for discharge only if they demonstrate stable and/or baseline mental status. (strong recommendation; very low-quality evidence)
  4. Patients are not eligible for discharge if they have substantially increased work of breathing or sustained tachypnea or tachycardia (strong recommendation; high-quality evidence)
  5. Patients should have documentation that they can tolerate their home anti-infective regimen, whether oral or intravenous, and home oxygen regimen, if applicable, before hospital discharge. (strong recommendation; low-quality evidence)
  6. For infants or young children requiring outpatient oral antibiotic therapy, clinicians should demonstrate that parents are able to administer and children are able to comply adequately with taking those antibiotics before discharge. (weak recommendation; very low-quality evidence)
  7. For children who have had a chest tube and meet the requirements listed above, hospital discharge is appropriate after the chest tube has been removed for 12–24 hours, either if there is no clinical evidence of deterioration since removal or if a chest radiograph, obtained for clinical concerns, shows no significant reaccumulation of a parapneumonic effusion or pneumothorax. (strong recommendation; very low-quality evidence)
  8. In infants and children with barriers to care, including concern about careful observation at home, inability to comply with therapy, or lack of availability for follow-up, these issues should be identified and addressed before discharge. (weak recommendation; very low-quality evidence)

XIX. When Is Parenteral Outpatient Therapy Indicated, In Contrast to Oral Step-Down Therapy?


  1. Outpatient parenteral antibiotic therapy should be offered to families of children no longer requiring skilled nursing care in an acute care facility but with a demonstrated need for ongoing parenteral therapy. (weak recommendation; moderate-quality evidence)
  2. Outpatient parenteral antibiotic therapy should be offered through a skilled pediatric home nursing program or through daily intramuscular injections at an appropriate pediatric outpatient facility. (weak recommendation; low-quality evidence)
  3. Conversion to oral outpatient step-down therapy when possible, is preferred to parenteral outpatient therapy. (strong recommendation; low-quality evidence)


XX. Can Pediatric CAP Be Prevented?


  1. Children should be immunized with vaccines for bacterial pathogens, including S. pneumoniae, Haemophilus influenzae type b, and pertussis to prevent CAP. (strong recommendation; high-quality evidence)
  2. All infants ≥6 months of age and all children and adolescents should be immunized annually with vaccines for influenza virus to prevent CAP. (strong recommendation; high-quality evidence)
  3. Parents and caretakers of infants <6 months of age, including pregnant adolescents, should be immunized with vaccines for influenza virus and pertussis to protect the infants from exposure. (strong recommendation; weak-quality evidence)
  4. Pneumococcal CAP after influenza virus infection is decreased by immunization against influenza virus. (strong recommendation; weak-quality evidence)
  5. High-risk infants should be provided immune prophylaxis with respiratory syncytial virus (RSV)–specific monoclonal antibody to decrease the risk of severe pneumonia and hospitalization caused by RSV. (strong recommendation; high-quality evidence)

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