Pneumonia - Community-Acquired (Pediatric) Management

Indications for Hospital Admission

Indications for hospital admission include children and infants with moderate to severe community-acquired pneumonia, as defined by the presence of respiratory distress (ie tachypnea, dyspnea, suprasternal/intercostal/subcostal retractions, grunting, nasal flaring, apnea, altered mental status, and pulse oximetry measurement <90% on room air). Hospitalization is also recommended for patients <3-6 months old with possible bacterial CAP; children and infants with suspected or documented CAP caused by an agent with increased virulence (eg CA-MRSA); patients for whom there is concern about careful observation at home or who may be unable to comply with medications or cannot be followed up; those with significant comorbid conditions (eg cardiopulmonary disease, genetic syndromes); patients with dehydration, vomiting, or inability to take oral medications or maintain adequate hydration; and those with unsuccessful outpatient oral antimicrobial treatment or with new or progressive respiratory distress.

Indications for Intensive Care Unit (ICU) Admission¹

Patients with ≥1 major or ≥2 minor criteria should be transferred to an ICU or a unit with continuous cardiorespiratory monitoring. 

• Major criteria: Invasive mechanical ventilation, fluid-refractory shock, acute need for noninvasive positive pressure ventilation (NIPPV), or hypoxemia requiring fraction of inspired oxygen (FiO₂) > inspired concentration
• Minor criteria: Tachypnea, apnea, retractions, dyspnea, nasal flaring, grunting, arterial oxygen pressure (PaO₂)/FiO₂ <250, multilobar infiltrates, Pediatric Early Warning Score (PEWS) >6, altered mental status, hypotension, presence of effusion, comorbid conditions, or unexplained metabolic acidosis

 

The British Thoracic Society indications for referral to a pediatric ICU² include respiratory failure needing assisted ventilation and pneumonia with septicemia. Clinical features include the presence of shock and raised RR and HR together with severe respiratory distress and exhaustion with or without increased pCO₂, slow irregular breathing or recurrent apnea, and inability to maintain oxygen saturations >92% with FiO₂ of 60%.

¹Reference: St Peter SD, Ampofo K, Brogan T, et al. Clinical practice guideline by the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society: 2026 guideline update on the management of community-acquired pneumonia in infants and children older than 3 months of age. Clin Infect Dis. Mar 2026:ciag186.

²Reference: Harris M, Clark J, Coote N, et al, on behalf of the British Thoracic Society Standards of Care Committee. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax. 2011 Oct;66(2):ii16. 

Penicillins

Amoxicillin

Amoxicillin is a first-line agent at any age if S pneumoniae is the likely pathogen. This may also be given to patients with pneumonia caused by β-lactamase-negative strains (eg H influenzae). This has a broader spectrum of activity, better oral pharmacokinetics (better absorption from the gastrointestinal tract), and better tolerability (less frequent dosing and better taste) as compared with Penicillin. This is a preferred step-down oral therapy for hospitalized patients initially treated with Ampicillin for S pneumoniae or β-lactamase-negative H influenzae infection. Amoxicillin may also be given as step-down therapy in patients initially treated with broad-spectrum antimicrobials in whom no cultures are obtained or were only obtained after starting antibiotics.

Ampicillin or Penicillin G

Ampicillin or Penicillin G is recommended for hospitalized, fully immunized infants and school-aged children when local epidemiologic data shows lack of resistance to invasive S pneumoniae. These are also considered a first-line option in hospitalized patients with group A Streptococcus infection. Ampicillin is the preferred agent for infections caused by β-lactamase-negative H influenzae. Penicillin G represents the most narrow-spectrum and effective antibiotic for pneumococcal infections but requires a more frequent dosing interval. These are also active against Streptococcus pyogenes that causes severe necrotizing pneumonia.

Antistaphylococcal Penicillin

Example drugs: Oxacillin (IV), Nafcillin (IV)

Antistaphylococcal Penicillin is used for patients admitted to the hospital for methicillin-susceptible S aureus (MSSA) infection.

Penicillin with Beta-lactamase Inhibitor

Example drugs: Amoxicillin/clavulanic acid, Ampicillin/sulbactam

Amoxicillin/clavulanic acid is the preferred oral step-down therapy for infections caused by β-lactamase producing H influenzae. These may also be given through an intravenous route in patients with severe CAP, which has been shown to be as effective as Ceftriaxone for strains with Amoxicillin minimum inhibitory concentration (MIC) of up to 2 mcg/mL.

Macrolides

Example drugs: Azithromycin, Clarithromycin, Erythromycin, Roxithromycin

Macrolides are first-line agents in school-aged children and adolescents with atypical pneumonia (eg M pneumoniae, C pneumoniae). These are recommended first-line treatments for Penicillin-allergic pediatric patients. These may be added at any age if there is no improvement with first-line therapy after 48 hours of treatment. These are not advised as empiric therapy for pneumococcal CAP because currently isolated strains of S pneumoniae have shown significant resistance against macrolides. Azithromycin is the preferred agent for M pneumoniae, Chlamydia pneumoniae or C trachomatis infections.

Cephalosporins 







First-generation drugs (eg Cefazolin IV) may be used for inpatients with MSSA infections. Second-generation (eg Cefuroxime) or third-generation (eg Ceftriaxone, Cefotaxime) agents are active against both β-lactamase-negative and -positive strains. Parenteral Ceftriaxone or Cefotaxime is recommended in hospitalized infants and children that are incompletely immunized, in places where local epidemiology shows lack of resistance for invasive S pneumoniae, or in infants and children with life-threatening infections (eg empyema). These are also the preferred agents for infections caused by β-lactamase-producing H influenzae. IV Ceftriaxone is the preferred agent for penicillin-resistant S pneumoniae. An IM injection of Ceftriaxone may be given once a day as an outpatient therapy. Oral Cefpodoxime, Cefprozil or Cefuroxime may be considered as alternative agents in patients with allergies to Amoxicillin. Cephalosporins are also active against S pyogenes causing severe necrotizing pneumonia.

Quinolones

Example drug: Levofloxacin

Quinolones may be used as an alternative for patients with a history of severe allergy to Amoxicillin or β-lactam antibiotics. These have a comparable effect to macrolides and tetracyclines in treating patients with M pneumoniae infections. These are a preferred oral step-down therapy in patients infected with penicillin-resistant S pneumoniae.

Tetracyclines

Example drug: Doxycycline

Tetracycline may be used for children >8 years with macrolide-resistant M pneumoniae.

Other Antibiotics

Vancomycin is the first-line agent for infections caused by community-acquired methicillin-resistant S aureus (CA-MRSA). Linezolid is the preferred oral step-down therapy and an alternative parenteral agent for CA-MRSA infections. This is useful especially in patients with pre-existing renal impairment or who are receiving other nephrotoxic drugs. This may be given to children with severe allergies to β-lactam drugs who cannot tolerate Vancomycin or Clindamycin but should be used with caution since it has a relatively high adverse effect profile. IV Clindamycin may be used as an alternative agent in patients with infections caused by susceptible MSSA or MRSA but is not recommended in patients with empyema.

Influenza Antiviral Therapy

The influenza antiviral therapy should be administered as soon as possible to patients with moderate to severe CAP caused by influenza virus infection, specifically to those with clinically worsening CAP during outpatient visits. This should not wait for the results of the confirmation test since early treatment has been shown to provide maximal advantage. This may still be of benefit when used after 48 hours of symptomatic infection in patients with more severe disease.

Combination Therapy

A macrolide plus a β-lactam antibiotic may be given to inpatients with probable M pneumoniae and C pneumoniae. Vancomycin or Clindamycin should be added to β-lactam antibiotics in patients highly considered to have S aureus infections, depending on local susceptibility data. Clindamycin plus a β-lactam is recommended in children with toxic-like syndromes.

Duration of Therapy

A 10-day treatment course has been well studied, but a shorter period may be similarly effective for mild CAP. CA-MRSA infections may require longer treatment duration than those caused by S pneumoniae. 

Supportive Therapy

Parents of children who do not require hospitalization should be advised about the use of antipyretics to manage fever, preventing dehydration, and determining signs of deterioration or signs of other serious illness after 48 hours of antibiotic therapy. Patients admitted to the hospital whose oxygen saturation is <92% while breathing room air should be given oxygen via nasal cannula, head box, or face mask to sustain oxygen saturation >95%. Fluid therapy (eg IV fluid replacement, nasogastric feeds) is recommended in patients who are unable to maintain their fluid intake secondary to breathlessness, fatigue, or vomiting. Plasma sodium, potassium, urea, and/or creatinine should be measured at baseline and at least daily in patients with intravenous fluids. Mucolytics do not improve cough resolution in children with pneumonia. Vasopressors may be necessary in patients with sepsis to support blood pressure and restore hemodynamic stability.

Other Preventive Measures

Frequent handwashing, breastfeeding, limiting exposure to other children, and reducing exposure to smoking are important measures that should be taken.

Vaccination

Children should be given vaccines against bacterial pathogens, including S pneumoniae, H influenzae type b, and Bordetella pertussis. The pneumococcal conjugate vaccine and the combination vaccine against pertussis may be given as early as 6 weeks old, and the influenza vaccine at 6 months of age as part of the recommended routine immunization schedule. Parents and caretakers of infants <6 months of age should be vaccinated against influenza virus and pertussis to protect the infants from exposure to these pathogens.

Influenza Vaccine³

Children ≥6 months of age should be given the influenza virus vaccine yearly. Two doses separated by a 4-week interval should be administered to children 6 months to 8 years old receiving the influenza vaccine for the first time, then 1 dose yearly after the initial dose.

Pertussis Vaccine³

The pertussis vaccine is given as a part of the combination vaccine DTaP (diphtheria, tetanus, acellular pertussis) of the recommended routine immunization schedule and with the booster dose Tdap or Td annually for children with complete immunization. Three doses at age 2, 4, and 6 months, followed by booster doses at ages 15-18 months and 4-6 years.

Pneumococcal Vaccine³

The introduction of the pneumococcal vaccine greatly reduced the incidence of community-acquired pneumonia in children caused by S pneumoniae. The pneumococcal 15-valent conjugate vaccine (PCV15) or pneumococcal 20-valent conjugate vaccine (PCV20) is recommended as a 3-dose series starting at 2 months of age given at 8-week intervals with a booster dose given at 12-15 months of age for primary immunization. Pneumococcal 13-valent conjugate vaccine (PCV13) and PCV15 can be used interchangeably. Children who previously received PCV13 may complete the remaining doses with either PCV15 or PCV20. PCV20 is not indicated for children without risk conditions who have already received four doses of PCV13 or PCV15 or any age-appropriate complete PCV series.

Patients aged ≥2 years at high risk of invasive pneumococcal disease should be given the pneumococcal 23-valent polysaccharide vaccine (PPSV23) 8 weeks after the PCV13 dose. Pneumococcal 10-valent conjugate vaccine (PCV10) may be considered in patients <5 years old at high risk for acute otitis media.

³Recommendations for vaccination may vary between countries. Please refer to local guidelines.

Immunotherapy

RSV-specific monoclonal antibodies (eg Palivizumab) may be considered as prophylaxis during RSV season in premature infants and in those with comorbid diseases (eg underlying lung pathology, congenital abnormalities of the airways, hemodynamically significant congenital heart disease, neuromuscular diseases).