Community Aquired Pneumonia (CAP)
<p>Study Highlights</p>
<ul>
<li>If indicated, tests can be done for sputum Gram stain and culture, respiratory viruses, and Mycoplasma pneumoniae.</li>
<li>Complete blood cell count (CBC)  should be obtained in cases of severe pneumonia.</li>
<li>Acute-phase reactants (erythrocyte sedimentation rate, C-reactive protein, serum procalcitonin levels) should <b><i>not</i></b> be used to distinguish a viral vs bacterial cause, but they can be useful for serious disease.</li>
<li>Pulse oximetry is indicated in all children with pneumonia and suspected hypoxemia.</li>
<li>Chest radiographs should be done in the outpatient setting for cases of hypoxemia, significant respiratory distress, or failed antibiotic therapy and should also be performed in all hospitalized patients.</li>
<li>Follow-up chest radiographs are recommended in children whose condition does not improve within 48 to 72 hours after starting antibiotic therapy and for cases of recurrent pneumonia involving the same lobe.</li>
<li>Most preschool-aged children with CAP have a viral pathogen and do not require antimicrobial therapy in the outpatient setting.</li>
</ul>
<p> </p>
<ul>
<li>Anti-infective treatment in the outpatient setting includes the following:
<ul>
<li>Amoxicillin to treat Streptococcus pneumoniae in previously healthy, appropriately immunized infants, preschool-aged children, and school-aged children with mild to moderate bacterial CAP</li>
<li>Macrolide antibiotic for primarily school-aged children with CAP from a suspected atypical pathogen</li>
<li>Influenza antiviral treatment of moderate to severe CAP from suspected influenza, despite pending or negative influenza test results</li>
</ul>
</li>
</ul>
<p> </p>
<ul>
<li>Anti-infective treatment in the inpatient setting includes the following: </li>
</ul>
<p> </p>
<ul>
<li >
<ul>
<li>Ampicillin or penicillin G for fully immunized infants or school-aged children</li>
<li>Third-generation parenteral cephalosporin (ceftriaxone or cefotaxime) for cases of incomplete immunization, in locations of invasive pneumococcal strains with high-level penicillin resistance, and life-threatening infection</li>
<li>Empiric addition of an oral or parenteral macrolide to a beta-lactam antibiotic for suspected Mycoplasma pneumoniae and Chlamydophila pneumoniae</li>
<li>Vancomycin or clindamycin plus a beta-lactam antibiotic for suspected S aureus</li>
</ul>
</li>
</ul>
<p> </p>
<ul>
<li>The appropriate antimicrobial treatment duration is 10 days, but shorter courses might be effective or longer courses might be needed.</li>
<li>Parapneumonic effusion identified by chest radiograph, ultrasonography, or computed tomography might need drainage, depending on its size and degree of respiratory compromise.</li>
<li>Options for parapneumonic effusion drainage are chest thoracostomy tube drainage plus fibrinolytic agents or video-assisted thoracoscopic surgery.</li>
<li>Criteria for hospital discharge include overall clinical improvement for at least 12 to 24 hours, pulse oximetry of more than 90% in room air for at least 12 to 24 hours, baseline mental status, ability to tolerate home anti-infective and oxygen regimens, no deterioration 12 to 24 hours after removal of the chest tube, and attention to barriers to home care.</li>
<li>Appropriate immunization for children and caregivers can prevent CAP.
</li>
</ul>
<p> 
Clinical Implications
 </p>
<ul>
<li>The recommended anti-infective treatment of previously healthy, appropriately immunized children in the <b>outpatient setting</b> includes amoxicillin for preschool and school-aged children with mild to moderate bacterial CAP, macrolide antibiotics for school-aged children with suspected atypical bacterial pathogens, and influenza antiviral treatment in children with moderate to severe CAP from a suspected influenza virus.</li>
<li>The recommended anti-infective treatment of children <b>hospitalized</b> with CAP includes ampicillin or penicillin G for appropriately immunized children; a third-generation parenteral cephalosporin for children who are not fully immunized, those in locations with high-level penicillin resistance, or in cases of life-threatening infection; macrolide treatment plus a beta-lactam antibiotic for suspected M pneumoniae and C pneumoniae; and vancomycin or clindamycin plus beta-lactam treatment of suspected S aureus.</li>
</ul>