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Bottom Line Recommendations: Summary of Pediatric Emergency Care Information for Healthcare Providers

Community Acquired Pneumonia

Developed by:Dr. Todd Florin (Northwestern University Feinberg School of Medicine); Dr. Sriram Ramgopal (Northwestern University Feinberg School of Medicine); Dr. Jeffrey Pernica (McMaster University)

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Last Updated
Mar 2024

Topic
Pneumonia (Community Acquired)

Summary

Viruses are the leading cause of pneumonia in healthy young children, followed by bacteria and rarely, other organisms. This document focuses on uncomplicated community acquired pneumonia (CAP).

Initial Assessment

HISTORY & PHYSICAL EXAMINATION

  • Signs and symptoms cannot be used to differentiate etiology of CAP.
  • Relevant history includes: cough, nasal congestion, shortness of breath, wheezing, abdominal or chest pain, presence and duration of fever, oral intake, urine output, vomiting, and sick contacts.
  • While no individual examination finding is sensitive or specific for making the diagnosis,1 hypoxemia and work of breathing have better correlation with radiographic pneumonia than other findings. Published clinical prediction rules suggest that combinations of findings (age, fever duration, hypoxemia, rales, diminished breath sounds) may be more useful than individual findings, but these rules require validation.2,3
  • Wheezing is negatively associated with radiographic pneumonia.4

IMAGING

  • For children with mild CAP (i.e., no substantial respiratory distress or hypoxemia) or where the history and physical are more suggestive of bronchiolitis (i.e., children <2 years old with symptoms of an upper respiratory infection and diffuse coarse breath sounds or wheezing), imaging is not indicated as it does not change outcomes and leads to antimicrobial overuse. Refer to TREKK Recommendations on Bronchiolitis.
  • Chest radiography (CXR) should be obtained if:
    • the diagnosis of CAP is uncertain,
    • there is concern for complicated pneumonia,
    • and/or the patient requires hospitalization.
  • In outpatients, it is reasonable to treat empirically without CXR when clinical suspicion is high.
  • Intra- and inter-rater reliability for the identification of streaky or interstitial infiltrates on CXR is limited, though reliability is better for lobar consolidations.
  • Children with no infiltrate on CXR are extremely unlikely to have CAP. The presence of an infiltrate on CXR does not necessarily mean that the child has bacterial disease.5
  • Chest ultrasound may serve a role in diagnosing CAP and may be a suitable replacement for CXR in the presence of a trained provider.6 Ultrasound can identify and characterize parapneumonic effusions and empyemas.

BLOOD TESTING

  • Laboratory testing (e.g., complete blood count, C-reactive protein, or procalcitonin) is not helpful in the diagnosis of CAP but may be helpful in cases where CXRs are indeterminate or to assist with prognostication, particularly for hospitalized patients.
  • Blood cultures are not advised for patients with CAP unless they are ill-appearing or require hospitalization with moderate to severe disease, due to the low yield of pathogenic bacteria and risk of contaminated culture in most children with CAP.7

Disposition

  • Most children with CAP can be managed as outpatients.7
  • The presence of older age, abnormal vital signs for age, impaired oxygenation, significant retractions, prolonged capillary refill, and medical comorbidities are associated with greater disease severity.8,9
  • Consult Pediatrics/Pediatric Referral Centre/Transport Team as required.

Discharge Home

Admission to Hospital Admission to PICU

Admission to PICU

  • Normal vital signs
  • O2 saturation >90% in room air
  • Ability to tolerate PO medication
  • No/minimal − respiratory distress
  • Ability to maintain hydration
  • Ability to access follow up as required
  • O2 saturation <90% in room air
  • Need for IV/NG hydration
  • Inability to tolerate PO medication
  • Increased/moderate respiratory distress (e.g., significant retractions, grunting)
  • Significant parapneumonic effusion/empyema
  • Concerns regarding access to follow up

Other features to consider:

  • Younger than 3 months
  • Complex underlying medical problem(s) (e.g., sickle cell disease (TREKK Recommendations on Sickle Cell Disease), immunosuppression/deficiency, neuromuscular disease, tracheostomy))
  • Need for non-invasive or positive pressure ventilatory support
  • Impending respiratory failure (e.g., decreased level of consciousness, lethargy, cyanosis, decreased  respiratory effort, rising PCO2)
  • Hypotension, inadequate perfusion
  • Septic shock
  • Altered mental status

The above are suggested guidelines for disposition and are subject to clinician discretion.

Antimicrobial Treatment

  • Most cases of CAP in preschool children well enough to be managed as outpatients are viral in origin. In such cases, mild CAP should be treated with supportive care and does not necessarily require antibiotics.7
  • When antibiotics are prescribed for CAP, the following are recommended:

Clinical Scenario

Antibiotic

Notes

Outpatient

Amoxicillin 45 mg/kg/day PO divided TID -OR-

90 mg/kg/day PO divided TID or BID (MAX 3 – 4 g/day)*

Amoxicillin is first-line treatment for CAP. Treat for 5 days.10,11

Hospitalized

Ampicillin 200 mg/kg/day IV divided q6h (MAX 8 g/day)

IV ampicillin is first-line if unable to tolerate amoxicillin/need hospitalization.

For known penicillin allergy or if prior life-threatening allergy refer to TREKK CAP Antimicrobial Treatment table.

*Use higher range of dosing divided TID in regions with higher rates of pneumococcal resistance to beta-lactams.

Development Team

Thank you to the following content experts who led the development of the Community Acquired Pneumonia (CAP) Bottom Line Recommendations:

Todd Florin, MD, MSCE, Associate Professor of Pediatrics, Department of Pediatrics, Northwestern University Feinberg School of Medicine; Director of Research, Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of  Chicago; Director, Grainger Research Program in Pediatric Emergency Medicine 

Sriram Ramgopal MD, Assistant Professor of Pediatrics, Department of Pediatrics, Northwestern University Feinberg  School of Medicine, Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago

Jeffrey Pernica, MD, MSc, Head, Division of Infectious Disease, Department of Pediatrics, McMaster University

Thank you to the TREKK Editorial Committee, editor Dr. Sarah Reid (CHEO), CHRIM Parent and Youth Advisory Committee, and EIIC KEAP Program who provided editorial support and expertise in the development of this resource. Thank you as well to Megan Bale-Nick, TREKK Project Coordinator (University of Manitoba) who coordinated the development process.

To see our resource development process please visit our website here.

Key References

(as cited in the Community Acquired Pneumonia (CAP) Bottom Line Recommendations)

  1. Shah SN, Bachur RG, Simel DL, Neuman MI. Does This Child Have Pneumonia?: The Rational Clinical Examination  Systematic Review. JAMA. 2017;318(5):462-471.
  2. Ramgopal S, Ambroggio L, Lorenz D, Shah SS, Ruddy RM, Florin TA. A Prediction Model for Pediatric Radiographic  Pneumonia. Pediatrics. 2021;149(1):e2021051405.
  3. Ramgopal S, Lorenz D, Navanandan N, et al. Validation of Prediction Models for Pneumonia Among Children in the  Emergency Department. Pediatrics. 2022;150(1):e2021055641.
  4. Lipsett SC, Hirsch AW, Monuteaux MC, Bachur RG, Neuman MI. Development of the Novel Pneumonia Risk Score to  Predict Radiographic Pneumonia in Children. Pediatr Infect Dis J. 2022;41(1):24-30.
  5. Jain S, Williams DJ, Arnold SR, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med. 2015;372(9):835-845.
  6. Shah VP, Tunik MG, Tsung JW. Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in  children and young adults. JAMA Pediatr. 2013;167(2):119-125.
  7. 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(7):25-76.
  8. Florin TA, Ambroggio L, Lorenz D, et al. Development and Internal Validation of a Prediction Model to Risk Stratify Children with Suspected Community-Acquired Pneumonia. Clin Infect Dis. 2021;73(9):e2713-e2721.
  9. Williams DJ, Zhu Y, Grijalva CG, et al. Predicting severe pneumonia outcomes in children. Pediatrics. 2016;138(4).
  10. Kuitunen I, Jääskeläinen J, Korppi M, Renko M. Antibiotic Treatment Duration for Community-Acquired Pneumonia in  Outpatient Children in High-Income Countries-A Systematic Review and Meta-Analysis. Clin Infect Dis. 2022;ciac374.
  11. Gao Y, Liu M, Yang K, et al. Shorter Versus Longer-term Antibiotic Treatments for Community-Acquired Pneumonia in Children: A Meta-analysis. Pediatrics. 2023;151(6):e2022060097.

Evidence Repository

For a complete list of the evidence that informed the creation of the Community Acquired Pneumonia Bottom Line Recommendations see the Evidence Repository here.

Disclaimer

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use