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The inpatient treatment of CAP and hospital-acquired pneumonia in children will be reviewed here.The outpatient treatment of CAP is discussed separately, as are the epidemiology, etiolog

Pneumonia in children: Inpatient treatment

Literature review current through: Nov 2017 | This topic last updated: Dec 01, 2017.

INTRODUCTION — 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, as

distinguished from hospital-acquired (nosocomial) pneumonia CAP is a common and potentially serious illness with considerable morbidity

The inpatient treatment of CAP and hospital-acquired pneumonia in children will be reviewed here.The outpatient treatment of CAP is discussed separately, as are the epidemiology, etiology, clinicalfeatures, and diagnosis (See "Community-acquired pneumonia in children: Outpatient

treatment" and "Pneumonia in children: Epidemiology, pathogenesis, and

etiology" and "Community-acquired pneumonia in children: Clinical features and diagnosis".)The recommendations provided below are largely consistent with practice guidelines provided

by The Pediatric Infectious Diseases Society/Infectious Diseases Society of America and

the British Thoracic Society [1,2]

HOSPITALIZATION

Indications — The decision to hospitalize a child with community-acquired pneumonia (CAP) is

individualized based upon age, underlying medical problems, and clinical factors including severity

of illness (table 1) [1-3] Hospitalization generally is warranted for infants younger than three to six

months of age, unless a viral etiology or Chlamydia trachomatis is suspected and they are not

hypoxemic and relatively asymptomatic Hospitalization is also warranted for a child of any age whose family cannot provide appropriate care and assure compliance with the management plan Additional indications for hospitalization include [1,2]:

●Hypoxemia (oxygen saturation [SpO2] <90 percent in room air at sea level)

●Dehydration, or inability to maintain hydration orally; inability to feed in an infant

●Moderate to severe respiratory distress: Respiratory rate >70 breaths/minute for infants <12 months of age and >50 breaths per minute for older children; retractions; nasal flaring;

difficulty breathing; apnea; grunting

●Toxic appearance (more common in bacterial pneumonia and may suggest a more severe course) [4]

●Underlying conditions that may predispose to a more serious course of pneumonia (eg, cardiopulmonary disease, genetic syndromes, neurocognitive disorders), may be worsened

by pneumonia (eg, metabolic disorder) or may adversely affect response to treatment (eg, immunocompromised host)

●Complications (eg, effusion/empyema, abscess)

●Suspicion or confirmation that CAP is due to a pathogen with increased virulence, such

as Staphylococcus aureus or group A Streptococcus

●Failure of outpatient therapy (worsening or no response in 48 to 72 hours)

Indications for intensive care — The decision to treat a child with pneumonia in an intensive

care setting is individualized, based upon clinical, laboratory, and radiologic findings Treatment in

an intensive care setting generally is warranted for children who manifest [1,2]:

●The need for ventilatory support beyond that which can be provided outside the intensive care unit (eg, mechanical ventilation, noninvasive positive pressure ventilation, failure to maintain oxygen saturation [SpO2] >92 percent in FiO2 >0.5)

●Signs of impending respiratory failure (lethargy, increasing work of

breathing, and/or exhaustion with or without hypercarbia)

●Recurrent apnea or slow irregular respirations

●Cardiovascular compromise with progressive tachycardia and/or hypotension that requires

or is refractory to fluid management

Care in the intensive care unit also may be warranted for children with two or more of the following[1

●Respiratory rate >70 breaths/minute for infants <12 months of age and

>50 breaths/minute for older children

●Apnea

●Increased work of breathing (retractions, dyspnea, nasal flaring, grunting)

●PaO2/FiO2 ratio <250

●Multilobar infiltrates

●Altered mental status

●Hypotension

●Pleural effusion

●Comorbid condition (eg, sickle cell disease, immune deficiency, immunosuppression)

●Unexplained metabolic acidosis

●Pediatric Early Warning Score >6 [5]

Infection control — CAP can be caused by a variety of microbial agents requiring a variety of

infection-control measures [6] If possible, rapid diagnostic tests should be performed at the time ofadmission, to facilitate decisions regarding appropriate precautions (See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Rapid diagnostic tests'.)

Hand washing is the single most important procedure to prevent the spread of infection Additional infection control measures depend upon the likely pathogen(s), as follows [6,7]:

●Respiratory syncytial and parainfluenza viruses – Gown and gloves (ie, contact precautions)

●Influenza virus, group A Streptococcus (for the first 24 hours of treatment),

methicillin-susceptible S aureus, Bordetella pertussis (until patient has received five days of effective therapy), and Mycoplasma pneumoniae – Mask within 3 feet (ie, droplet precautions)

●Adenovirus – Contact and droplet precautions

●Methicillin-resistant S aureus and other multidrug resistant organisms – Special organism

precautions; contact and droplet precautions and dedicated patient equipment

These precautions are discussed separately (see "Infection prevention: Precautions for preventingtransmission of infection") Guidelines for hand hygiene in healthcare settings can be accessed through the Centers for Disease Control and Prevention

SUPPORTIVE CARE — Supportive care includes ensuring adequate antipyresis, analgesia,

respiratory support, and hydration

Antipyresis and analgesia — Children hospitalized with pneumonia usually have fever and may

have pleuritic chest pain, which can lead to shallow breathing and impaired ability to cough Administration of antipyretics and/or analgesics (eg, acetaminophen, ibuprofen) can be used to keep the child comfortable; opioid analgesia is rarely necessary in children without a chest tube in place Adequate pain control may promote coughing, which facilitates airway clearance

Antitussives should be avoided as none have been found to be effective in pneumonia [8]

Symptomatic treatment of cough is discussed separately (See "The common cold in children: Management and prevention", section on 'Cough'.)

Respiratory support — Children hospitalized with pneumonia should receive ventilatory support

as indicated by their clinical condition [1,2] A supported sitting position may help to expand the lungs and improve respiratory symptoms [2

We suggest that children with oxygen saturation [SpO2] <95 percent in room air be treated with supplemental oxygen to maintain oxygen saturation ≥95 percent while they are in respiratory distress Different thresholds for supplemental oxygen are suggested by other experts (eg, the British Thoracic Society guidelines suggest supplemental oxygenation to maintain oxygenation saturation >92 percent) [2] Gentle bulb suction of the nares may be helpful in infants and children whose nares are blocked with secretions Minimal handling seems to reduce oxygen requirements.(See "Continuous oxygen delivery systems for infants, children, and adults".)

In children who are severely ill, it may be necessary to monitor carbon dioxide tension via blood gas analysis in addition to oxygen saturation (SpO2) by oximetry Hypercarbia is an important sign

of impending respiratory failure, particularly in the young infant who is tiring but may have

preserved oxygenation

Fluid management — Children who cannot maintain adequate fluid intake because of

breathlessness, fatigue, or risk of aspiration [9] may require intravenous fluid therapy Nasogastric (NG) tubes should be avoided if possible because they may compromise breathing; if necessary, the smallest NG tube possible should be used [2] (See "Maintenance fluid therapy in children".)Children with pneumonia are at risk for inappropriate secretion of antidiuretic hormone (SIADH) [10,11] Serum electrolytes, fluid balance, and urine specific gravity should be monitored if there is clinical suspicion of SIADH [11] Confirmation of SIADH is discussed separately Isotonic, rather than hypotonic, intravenous fluids should be provided if SIADH is suspected

(See "Pathophysiology and etiology of the syndrome of inappropriate antidiuretic hormone

secretion (SIADH)", section on 'Pulmonary disease' and "Maintenance fluid therapy in children", section on 'Hospitalized children'.)

Chest physiotherapy — Chest physiotherapy is not beneficial for children with uncomplicated

community-acquired pneumonia (CAP) [2] In randomized and observational studies in children and adults, chest physiotherapy had no conclusive effect on length of hospital stay, duration of fever, or radiographic resolution [12-17]

Adjunctive glucocorticoid therapy — We do not routinely provide adjunctive glucocorticoid

therapy to children hospitalized with pneumonia Although a systematic review and meta-analysis

of randomized trials in adult patients hospitalized with CAP found that corticosteroid therapy may

be beneficial in reducing the development of acute respiratory distress syndrome, need for

mechanical ventilation, and the duration of hospitalization [18], additional studies in children are necessary A retrospective study evaluating adjunctive glucocorticoid therapy for children being treated for CAP in the outpatient setting found an association between adjunctive glucocorticoid therapy and treatment failure in children without underlying asthma [19]

EMPIRIC THERAPY

Overview — Prompt initiation of antimicrobial therapy is crucial in children with

community-acquired pneumonia (CAP) The initial treatment of children who are hospitalized with pneumonia

is empiric (table 2) Factors that must be considered include the spectrum of likely pathogens, antimicrobial susceptibility, simplicity, tolerability, palatability, safety, and cost [20]

The recommendations of most guidelines are based on in vitro susceptibilities of the most likely pathogen or pathogens, rather than evidence of the superiority of one antibiotic over another Clinical response to empiric therapy and results of microbiologic studies, when available, help to determine whether additional evaluation or changes in therapy are necessary [1,2]

(See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Microbiology' and 'Specific therapy' below and 'Response to therapy' below.)

There are few randomized controlled trials to guide the choice of empiric antibiotics in children withCAP Decisions regarding empiric therapy are complicated by the substantial overlap in the clinicalpresentation of bacterial and nonbacterial pneumonias [21-23] Treatment decisions usually are based upon algorithms that include patient age, epidemiologic and clinical information, and

diagnostic laboratory and imaging studies (table 2) [4] The scope of empiric therapy (ie, narrow or broad) depends upon the severity of illness and presence of complications Agents other than those suggested in the table may be more appropriate if there are clinical or epidemiologic

features strongly suggestive of a specific cause (eg, mediastinal or hilar lymphadenopathy,

residence in the central United States, and exposure to caves and/or bat guano suggestive of pulmonary histoplasmosis) [24].

Consultation with a specialist in infectious disease may be helpful in children with medication allergies, comorbid conditions, failure of outpatient therapy, or multiple-drug-resistant organisms Consultation with a pediatric pulmonologist may be helpful in children with recurrent pneumonia (See "Community-acquired pneumonia in children: Clinical features and

diagnosis" and "Community-acquired pneumonia in children: Outpatient treatment", section on 'Treatment failure'.)

Etiologic clues — Certain clinical and epidemiologic features can be used to determine the most

likely pathogen(s) to aid in decisions regarding empiric therapy Because these features often overlap, they cannot be used with complete confidence, but are helpful in guiding empiric therapy until results of microbiologic tests are available (table 3) These features are discussed in greater detail separately (See "Community-acquired pneumonia in children: Clinical features and

diagnosis", section on 'Clues to etiology' and "Community-acquired pneumonia in children: Clinicalfeatures and diagnosis", section on 'Etiologic clues'.)

Neonates — The treatment of neonatal pneumonia is discussed separately (See "Neonatal

pneumonia".)

Viral pneumonia — Most children younger than three to five years of age who are admitted to the

hospital with pneumonia have viral pneumonia (eg, respiratory syncytial virus) [25] This is

particularly true in the absence of lobar (or lobular) infiltrate and pleural effusion [4] Viral

pneumonia does not require antibiotic therapy, unless a mixed infection or secondary bacterial infection is suspected (See "Respiratory syncytial virus infection: Treatment", section on

'Overview' and "Respiratory syncytial virus infection: Clinical features and diagnosis", section on 'Clinical manifestations'.)

No effective antivirals are available for most viral pneumonias, with a few important exceptions, described below

Influenza pneumonia — Initiation of antiviral treatment for influenza (eg, oseltamivir) as soon as

possible is recommended for children hospitalized with presumed influenza pneumonia; laboratoryconfirmation should not delay initiation of antiviral therapy The diagnosis and treatment of

influenza in children are discussed separately (See "Seasonal influenza in children: Prevention and treatment with antiviral drugs", section on 'Antiviral therapy' and "Seasonal influenza in children: Clinical features and diagnosis", section on 'Diagnosis'.)

For children with influenza pneumonia in whom secondary bacterial pneumonia is suspected,

empiric antibiotic therapy should include coverage for S aureus, including methicillin-resistant S aureus (MRSA) Coinfection with S aureus may be particularly severe and rapidly fatal.

Other viral pneumonias — Acyclovir can be used in the treatment of pneumonia due to herpes

simplex virus (HSV) or varicella zoster virus (VZV) Ganciclovir be used in the treatment of

pneumonia due to cytomegalovirus (CMV) (See "Treatment of varicella (chickenpox) infection", section on 'Individuals with complications'.)

Common respiratory viruses may cause serious infections in immunocompromised children and require consideration of antiviral therapy: ribavirin for respiratory syncytial virus (RSV) or

parainfluenza and cidofovir for adenovirus Concomitant immunoglobulin therapy is an additional consideration: palivizumab for RSV, CMV immune globulin for CMV, and intravenous

immunoglobulin for the other viral etiologies (See "Respiratory syncytial virus infection:

Treatment", section on 'Pharmacotherapy' and "Diagnosis, treatment, and prevention of

adenovirus infection", section on 'Treatment'.)

Uncomplicated bacterial pneumonia — Streptococcus pneumoniae is the most common

bacterial cause of pneumonia in children of all ages [4,26] Other potential bacterial pathogens that

may need to be included in empiric therapy for hospitalized children include S aureus, including MRSA, S pyogenes (group A Streptococcus), Haemophilus influenzae type b (Hib) (if

unimmunized), nontypeable H influenzae, and Moraxella catarrhalis [2,4,26-31].

The table provides several suggested parenteral empiric antibiotic regimens

for uncomplicated bacterial pneumonia in hospitalized children when S aureus is not a

consideration (table 2) [4,32,33] The treatment of complicated CAP and severe CAP (particularly

when S aureus is a consideration) are discussed below (See 'Complicated CAP' below

and 'Severe CAP requiring ICU admission' below.)

Ampicillin or penicillin G generally provides adequate coverage for the fully immunized child (table 4) in communities without substantial prevalence of penicillin-resistant S pneumoniae [1,34,35]

We suggest a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) for children younger than 12 months and those who are not fully immunized because third-generation cephalosporins

provide coverage for the beta-lactamase producing pathogens (eg, H influenzae and M

catarrhalis) that may occur in these children We also suggest third-generation cephalosporins for

children with more severe illness (table 1) because third-generation cephalosporins provide

coverage for a broader range of pathogens, including penicillin-resistant S pneumoniae, than

ampicillin [1,36,37] The fifth-generation parenteral cephalosporin, ceftaroline, is approved by the

US Food and Drug Administration (FDA) for treatment of community-acquired bacterial pneumonia

due to S pneumoniae, methicillin-susceptible S aureus (MSSA), and H influenzae in children ≥2

months of age Although ceftaroline exhibits in vitro activity against MRSA [38], clinical experience

is insufficient to suggest its use when MRSA is a consideration In a randomized trial in children between 2 months and <18 years who were hospitalized with CAP, ceftaroline and ceftriaxone hadsimilar cure rates [39] Three children with S aureus infection (two with MSSA recovered from sputum and one with MRSA recovered from blood) were successfully treated with ceftaroline However, patients considered at risk for MRSA infection or those with sputum demonstrating a predominance of gram-positive cocci in clusters were excluded from the trial, precluding

conclusions about efficacy in this population

A macrolide may be added (table 2) if M pneumoniae, C pneumoniae, or legionellosis is

suspected, although the benefits of combination therapy are uncertain In a prospective

population-based study of 1418 children hospitalized with radiographically confirmed CAP, the addition of a macrolide to beta-lactam antimicrobial therapy was not associated with decreased length of stay, intensive care admission, rehospitalization, or self-reported recovery [40] In

subgroup analysis, combination therapy was not associated with decreased length of stay in children in whom atypical bacteria were detected, children older than five years, children admitted

to the intensive care unit, or children with wheezing (See 'Atypical pneumonia' below.)

We suggest that children who require hospitalization for treatment of CAP be treated initially with parenteral antibiotics However, oral amoxicillin may be an alternative for infants and children fully

immunized against Hib and S pneumoniae with uncomplicated pneumonia that is not thought to

be due to S aureus In a multicenter randomized trial, treatment with amoxicillin was equivalent to

treatment with penicillin G in children with CAP who required hospital admission but did not have wheezing, hypotension, chronic pulmonary conditions (other than asthma), immunodeficiency, pleural effusion requiring drainage, or oxygen saturations <85 percent in room air [41] The British Thoracic Society guidelines suggest that oral antibiotics are safe and effective even for children with severe pneumonia as long as they are able to tolerate oral fluids, are not vomiting, and do nothave signs of septicemia or complicated pneumonia [2

Atypical pneumonia — Atypical bacterial pathogens include C trachomatis in afebrile infants,

and M pneumoniae and C pneumoniae in older children and adolescents The table provides

several suggested empiric regimens for atypical bacterial pneumonia in hospitalized children (table2) [4,32]

For children older than four years, coverage for typical bacterial pathogens (eg, ampicillin or a third-generation cephalosporin) may be added to empiric coverage for atypical pathogens if there

is strong evidence of a bacterial cause Strong evidence of a bacterial cause includes white blood cell count >15,000/microL, C-reactive protein (CRP) >35 to 60 mg/L (3.5 to 6 mg/dL), chills, or no response to outpatient therapy with a macrolide or doxycycline [4,42]

Fluoroquinolones (eg, levofloxacin, moxifloxacin) may be reasonable empiric therapy for the older child and adolescent with suspected atypical pneumonia who could actually have pneumococcal pneumonia The fluoroquinolones also may be used in the older child or adolescent who has a type 1 hypersensitivity (table 5) to beta-lactam antibiotics In addition to their excellent gram-negative spectrum, the fluoroquinolones are active against a number of the pathogens responsible

for CAP, including beta-lactam-susceptible and nonsusceptible S pneumoniae, M

pneumoniae (including macrolide-resistant M pneumoniae), and C pneumoniae [43] However, S pneumoniae resistant to levofloxacin have been identified [44].

Severe CAP

Severe CAP not requiring ICU admission — Children with severe community-acquired

pneumonia (CAP) that does not require admission to the intensive care unit (ICU) (table 1) may benefit from combination empiric therapy with a macrolide and a beta-lactam antibiotic (eg,

penicillin or third-generation cephalosporin) (table 2) Combination therapy improves coverage for resistant organisms and mixed bacterial/atypical bacterial infections Antimicrobial therapy can be adjusted as necessary when results of microbiologic testing become available Invasive diagnostic testing, including bronchoscopy with bronchoalveolar lavage, may be necessary for specific microbiologic diagnosis (See 'Uncomplicated bacterial pneumonia' above and 'Atypical

pneumonia' above and "Community-acquired pneumonia in children: Clinical features and

diagnosis", section on 'Invasive studies'.)

Severe CAP requiring ICU admission — Children who are admitted to the intensive care unit for

serious or life-threatening infections require broad-spectrum empiric coverage that addresses

potential beta-lactam resistance and community-associated methicillin-resistant S aureus

(CA-MRSA) (See 'Indications for intensive care' above.)

A suggested regimen for such children may include (table 2) [45-47]:

●Vancomycin 60 mg/kg per day intravenously (IV) in four divided doses up to a maximum of

4 g/day, and

●A third-generation cephalosporin (cefotaxime 150 mg/kg per day IV in four divided doses up

to a maximum of 10 g/day or ceftriaxone 100 mg/kg per day IV in two divided doses up to a maximum dose of 4 g/day), and

●Azithromycin 10 mg/kg once per day IV for two days (maximum 500 mg/day), followed by

5 mg/kg once per day IV (maximum 250 mg/day), and possibly

●Nafcillin or oxacillin 150 mg/kg per day IV in four divided doses; maximum 12 g/day if S

aureus is likely (methicillin-susceptible S aureus is more rapidly killed by nafcillin than

by vancomycin), and possibly

●Antiviral therapy for influenza, if the child is hospitalized during influenza season; laboratory confirmation of influenza should not delay initiation of antiviral therapy (see "Seasonal

influenza in children: Prevention and treatment with antiviral drugs", section on 'Antiviral therapy')

This combination is necessary because of reports of treatment failure resulting from treatment of

nonsusceptible S pneumoniae with beta-lactams, increasing clindamycin resistance among S pneumoniae, and concern for MRSA [45] Virtually all strains of MRSA are susceptible

to vancomycin [46] (See "Methicillin-resistant Staphylococcus aureus in children: Treatment of invasive infections", section on 'Pneumonia'.)

Linezolid is an oxazolidinone antibiotic with activity against gram-positive cocci, including

beta-lactam-resistant S pneumoniae and MRSA Linezolid could be substituted

for vancomycin and nafcillin in the above regimen The dose for linezolid is 10 mg/kg per dose (maximum 600 mg); it is administered every eight hours in children younger than 12 years and every 12 hours in children 12 years and older

Complicated CAP — Complicated community-acquired pneumonia (CAP) (eg, parapneumonic

effusion, lung abscess) requires a broader spectrum of antibiotic coverage if etiologies other

than S pneumoniae are being considered The expanded spectrum should include coverage for

beta-lactam-resistant isolates and CA-MRSA Coverage for anaerobes and gram-negative

organisms also may be necessary for children with lung abscess [48] Antimicrobial therapy can beadjusted as necessary when results of microbiologic testing become available (See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on

'Complications' and "Management and prognosis of parapneumonic effusion and empyema in children".)

Complicated CAP requires a prolonged course of antimicrobial therapy, usually initiated

parenterally [24] Appropriate regimens may include [32]:

●Ceftriaxone 100 mg/kg IV in two divided doses up to a maximum dose of

4 g/day, OR cefotaxime 150 mg/kg per day IV in four divided doses up to a maximum of

10 g/day,PLUS clindamycin 30 to 40 mg/kg per day IV in three or four divided doses to a

maximum of 1 to 2 g/day if S aureus or anaerobes are a consideration.

Vancomycin 40 to 60 mg/kg per day IV in three or four divided doses up to a maximum of

4 g/day is an alternative to clindamycin if the patient is allergic to clindamycin or if

clindamycin-resistant S aureus is prevalent in the community The threshold prevalence of

clindamycin-resistant MRSA (constitutive plus inducible) for choosing vancomycin varies fromcenter to center, usually ranging from 10 to 25 percent, trying to balance the benefit of

definitive therapy for the patient with the risk of increasing vancomycin resistance in the community Additional considerations in the decision to choose vancomycin include the prevalence of MRSA in the community, the severity of illness, and the turn-around time for susceptibilities (See "Methicillin-resistant Staphylococcus aureus in children: Treatment of invasive infections", section on 'MRSA infections'.)

●Ampicillin-sulbactam 150 to 200 mg/kg per day of the ampicillin component IV in four divideddoses (maximum 8 g/day for the ampicillin component) alone may be effective if a lung abscess is thought to be secondary to an aspiration event (See 'Aspiration

pneumonia' below.)

The duration of therapy and other considerations in the management of complicated pneumonia depend upon the type of complication:

●Parapneumonic effusion/empyema – The treatment of parapneumonic effusion and

empyema is discussed in detail separately (See "Management and prognosis of

parapneumonic effusion and empyema in children".)

●Necrotizing pneumonia – Treatment of necrotizing pneumonia requires a prolonged course

of antibiotic therapy The duration is determined by the clinical response but is usually a total

of four weeks or two weeks after the patient is afebrile and has improved clinically

Interventional procedures (eg, percutaneous drainage catheter placement) should be

performed cautiously in children with necrotizing pneumonia; such procedures increase the risk of complications, such as the development of bronchopleural fistulae [48-51]

●Lung abscess – Treatment of lung abscess requires a prolonged course of antibiotic

therapy The duration is determined by the clinical response, but is usually a total of four weeks or two weeks after the patient is afebrile and has clinical improvement The average duration of fever is four to eight days [24] Eighty to 90 percent of lung abscesses in children resolve with antibiotic therapy alone and spontaneous drainage through the tracheobronchial tree, provided that bronchial obstruction is removed [52]

In cases that fail to resolve with antibiotics alone, needle aspiration or percutaneous catheter drainage may provide diagnostic information and therapeutic benefit without the increased risk of complications that occurs in children with necrotizing pneumonia [48,49,53,54]

Percutaneous drainage may be warranted in children with lung abscess whose condition fails

to improve or worsens after 72 hours of antibiotic therapy [48] At least three weeks of IV antibiotic therapy should be delivered before lobectomy is considered for treatment failure [55]

●Pneumatocele – Most pneumatoceles involute spontaneously [56-58] However, on

occasion, pneumatoceles result in pneumothorax [59]

Hospital-acquired pneumonia — Empiric treatment of hospital-acquired pneumonia should

include coverage for S aureus, Enterobacteriaceae, Pseudomonas aeruginosa, and anaerobes

Acceptable broad spectrum regimens usually include an aminoglycoside (for gram-negative pathogens) and another agent to address gram-positive pathogens and anaerobes (table 2):

●Aminoglycoside (usually gentamicin; amikacin if extended spectrum or Amp C

beta-lactamase producing gram-negative rods are possible etiologies) plus one of the following:

•Piperacillin-tazobactam 300 mg/kg per day IV in four divided doses up to a maximum of

12 g/day, or

•Meropenem 60 mg/kg per day IV in three divided doses, up to a maximum of 6 g/day if extended-spectrum or Amp C beta-lactamase-producing gram-negative rods are

possible etiologies, or

•Ceftazidime 125 to 150 mg/kg per day in three divided doses; maximum of 6 g/day, or

•Cefepime 150 mg/kg per day in three divided doses; maximum of 4 g/day

•Clindamycin 30 to 40 mg/kg per day in three or four divided doses; maximum

3.6 g/day (for patients with type 1 hypersensitivity (table 5) to beta-lactam antibiotics)The combination of amikacin and meropenem should be used if extended-spectrum or Amp C beta-lactamase-producing gram-negative rods are possible etiologies

The cephalosporin/aminoglycoside combination lacks anaerobic coverage so should NOT be usedwhen aspiration pneumonia is a possibility (See 'Aspiration pneumonia' below.)

Vancomycin should be added to the empiric regimen if MRSA is a consideration

Aspiration pneumonia — Empiric antibiotic regimens for community-acquired aspiration

pneumonia must cover oral anaerobes Appropriate antibiotic regimens for hospitalized children include [48]:

●Ampicillin-sulbactam 150 to 200 mg/kg per day of the ampicillin component IV in four divided

doses; maximum 8 g/day of the ampicillin component, or

●Clindamycin 30 to 40 mg/kg per day IV in three or four divided doses to a maximum of 1 to

2 g/day if MRSA etiology is suspected

In neurologically compromised older adolescents prone to aspiration events, empiric treatment for CAP with a fluoroquinolone like moxifloxacin (400 mg once daily) may be reasonable Moxifloxacin

has activity against anaerobic bacteria, as well as the usual treatable causes of CAP (S

pneumoniae, M pneumoniae, and C pneumoniae).

Appropriate antibiotic regimens for children with healthcare-associated aspiration who are known

to be colonized with unusual gram-negative pathogens (eg, Klebsiella pneumoniae) include:

●Piperacillin-tazobactam 300 mg/kg per day IV in four divided doses up to a maximum of

12 g/day, or

●Meropenem 60 mg/kg per day IV in three divided doses, up to a maximum of 6 g/day

Vancomycin should be added to the empiric regime if MRSA is a consideration

Patients with true beta-lactam hypersensitivity (ie, type 1 hypersensitivity reaction) (table 5) can betreated with a combination of clindamycin and an aminoglycoside.

Immunocompromised host — Empiric treatment for pneumonia in immunocompromised hosts

also requires broad-spectrum gram-positive and gram-negative coverage, similar to that required for hospital-acquired pneumonia, with the addition of vancomycin if MRSA is considered, and possibly trimethoprim-sulfamethoxazole for Pneumocystis jirovecii (formerly P carinii) Empiric regimens may need to be modified once results of cultures and antibiotic susceptibility testing are available Invasive testing may be required to obtain a satisfactory specimen in such patients (see "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'Invasive studies') Treatment of CAP in the immunocompromised host should occur in

consultation with an infectious disease specialist

An aggressive approach to specific microbial diagnosis is indicated in immunocompromised hosts with clinically significant pneumonias For patients with an endotracheal tube in place, specific microbial diagnosis may involve early flexible bronchoscopy for bronchoalveolar lavage with viral, fungal, and bacterial cultures Although the protected specimen brush technique has been utilized

in some settings, quantitative bacterial cultures are more commonly used to differentiate

colonization from true lower respiratory tract infection (See "Flexible bronchoscopy in adults: Indications and contraindications", section on 'Diagnostic indications' and "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia", section on 'Diagnostic evaluation'.)

SPECIFIC THERAPY — Once results of microbiologic tests are available, antimicrobial therapy

can be directed toward the responsible pathogen or pathogens Specific antibiotic therapy for bacterial community-acquired pneumonia (CAP) is summarized in the table (table 6) Specific antimicrobial and/or supportive therapy for the pathogens that commonly cause CAP in children is discussed in the topic reviews listed below

●S pneumoniae (see "Pneumococcal pneumonia in children", section on 'Specific therapy')

●M pneumoniae (see "Mycoplasma pneumoniae infection in children", section on

'Treatment')

●C pneumoniae (see "Pneumonia caused by Chlamydia species in children")

●Methicillin-susceptible S aureus – Methicillin-susceptible S aureus pneumonia may be

treated with oxacillin, nafcillin, or cefazolin [1,4]

●Methicillin-resistant S aureus (MRSA) (see "Methicillin-resistant Staphylococcus aureus in

children: Treatment of invasive infections", section on 'Definitive therapy')

●Respiratory syncytial virus (see "Respiratory syncytial virus infection: Treatment")

●Influenza (see "Seasonal influenza in children: Prevention and treatment with antiviral drugs", section on 'Antiviral therapy')

●Parainfluenza (see "Parainfluenza viruses in children", section on 'Treatment')

●Adenovirus (see "Diagnosis, treatment, and prevention of adenovirus infection", section on 'Treatment')