Vol. 103 (2014) No. 3 p. 572-580
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.
●The decision to hospitalize a child with pneumonia must be individualized and is based upon age, underlying medical problems, and severity of illness.
●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.
●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.
●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) include coverage for Streptococcus pneumoniae (Grade 1B).
●We suggest that empiric antibiotic therapy for CAP in children ≥5 years include coverage for atypical bacteria (Grade 2B).
●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.
●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.
●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.
●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.
●Most otherwise healthy children who develop pneumonia recover without any long-term sequelae.
Most initial treatment regimens for community-acquired pneumonia (CAP) are empiric. A limited number of pathogens are responsible for the majority of cases of CAP (table 1). Antibiotics should be started as soon as possible once the diagnosis of CAP is established. The presence of an infiltrate on plain chest radiograph is considered the gold standard for diagnosing pneumonia when clinical (and, in some cases, microbiologic) features are supportive.
●Emerging drug-resistant Streptococcus pneumoniae complicates the use of empiric treatment. Treatment failures have been demonstrated with use of macrolides for macrolide-resistant organisms. We recommend not using macrolide monotherapy for patients who have received an antibiotic within the preceding three months or for patients who reside in regions where the local rate of macrolide resistance is >25 percent (including all regions in the United States and certain other countries) (Grade 1B).
●Despite in vitro resistance, penicillin-resistant pneumococci will likely respond to higher-dose beta-lactams other than cefuroxime.
●North American and British guidelines differ in their recommendations for first-line therapy for outpatient pneumonia. British guidelines promote amoxicillin and place less significance on atypical pathogens. North American guidelines from 2007 advocate treating both atypical pathogens and pneumococcus and suggest macrolides or doxycycline when antibiotic resistance is not anticipated.
For nonhospitalized patients with an established diagnosis of CAP who also have comorbidities, a history of recent antibiotic use, or when the local rate of macrolide resistance is >25 percent (including all regions of the United States and certain other countries), we suggest empiric monotherapy with a respiratory fluoroquinolone or combination therapy with a beta-lactam plus either a macrolide or doxycycline (Grade 2A). Appropriate fluoroquinolones include levofloxacin 750 mg daily, moxifloxacin 400 mg daily, and gemifloxacin 320 mg daily. For nonpregnant patients at risk for QT interval prolongation, we favor combination therapy with a beta-lactam plus doxycycline in order to avoid the QT interval-prolonging effects of fluoroquinolones and macrolides.
●For uncomplicated pneumonia in patients who have no significant comorbidities and/or risk factors for macrolide resistance (use of antibiotics within the last three months, local rate of macrolide resistance >25 percent), we suggest empiric treatment with an advanced macrolide (Grade 2A). Regimens include azithromycin (500 mg on day 1 followed by four days of 250 mg a day or 500 mg daily for three days), clarithromycin (500 mg twice daily), or clarithromycin XL (two 500 mg tablets once daily). We suggest doxycycline (100 mg twice daily) as an alternative to a macrolide, especially in nonpregnant patients at high risk for QT interval prolongation (Grade 2C).
●Most outpatients with CAP should be treated for five days, including those receiving azithromycin 500 mg on the first day followed by 250 mg daily on subsequent days and those receiving any other antibiotic. Because of its long half-life, patients receiving azithromycin at a dose of 500 mg daily can usually be treated for three days. Patients should be afebrile for ≥48 hours and clinically stable before therapy is discontinued. When this is achieved, the persistence of other symptoms (eg, dyspnea, cough) is not an indication to extend the course of antibiotic therapy.
●Patients who have not responded to therapy after 48 to 72 hours should be reevaluated.