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The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America have published a comprehensive guideline for the diagnosis, treatment, and management of community-acquired pneumonia (CAP) in otherwise healthy infants and children older than 3 months. The evidenced-based guideline includes detailed recommendations for every aspect of care and explanations for each recommendation. Some notable features are as follows:
Hospitalization: Children who are likely to require hospitalization include those with oxygen saturation <90% or community-acquired methicillin-resistant Staphylococcus aureus (MRSA), those who are unable to be followed or to comply with therapy, and those between ages 3 and 6 months.
Testing for respiratory viruses: Children with CAP should be tested for respiratory viruses, particularly influenza. A positive result can decrease antibiotic use and hasten treatment of influenza.
Diagnostic tests in outpatients: Children who are well enough to be managed as outpatients do not require chest x-rays or complete blood cell count; fully immunized children do not require blood cultures.
Treatment in outpatients: Many preschool-age children have viral disease and can be supported without antibiotics. When bacterial disease is suspected, amoxicillin remains the mainstay of therapy. A macrolide can be added when infection caused by an atypical pathogen is suspected.
Treatment in hospitalized patients: Treatment options can range from amoxicillin or penicillin to vancomycin (or clindamycin) and ceftriaxone depending on such factors as suspicion for various pathogens, knowledge of local susceptibility patterns, and concern for MRSA.
Duration of antibiotic therapy: Duration can range from 7 to 10 days for outpatients and patients who respond well to antibiotics. Duration is longer (often 2 to 4 weeks) for patients with MRSA or complicated CAP. Change from intravenous to oral medications when patients can tolerate them.
Management of complicated CAP: The guideline offers suggestions for managing CAP with effusions, loculations, and abscess formation. Surgical consultation is useful for making management decisions in complicated cases
Follow-up chest x-rays: Routine follow-up x-rays are not indicated for children with clinical resolution without complications.
Bradley JS 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 Oct; 53:617.
Comment
Management of CAP involves numerous points of clinical decision making, and this guideline summarizes a rational approach. The less aggressive approach in children who can be followed as outpatients is important to emphasize because it involves fewer lab tests, less irradiation, and no or narrow-spectrum antibiotics. For children who require hospitalization, the guideline provides useful tables for making antibiotic choices and an algorithm for managing complicated infections. Early consultation and partnering with surgical colleagues and frequent discussion about the correct timing and the most appropriate patients for surgical intervention are critical. Anyone who treats children should keep a copy of this document easily accessible.