IDSA GUIDELINES

Executive Summary: 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
John S. Bradley,1,a Carrie L. Byington,2,a Samir S. Shah,3,a Brian Alverson,4 Edward R. Carter,5 Christopher Harrison,6
Sheldon L. Kaplan,7 Sharon E. Mace,8 George H. McCracken Jr,9 Matthew R. Moore,10 Shawn D. St Peter,11
Jana A. Stockwell,12 and Jack T. Swanson13
1Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, San Diego, California;
2Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah; 3Departments of Pediatrics, and Biostatistics and Epidemiology,
University of Pennsylvania School of Medicine, and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
4Department of Pediatrics, Rhode Island Hospital, Providence, Rhode Island; 5Pulmonary Division, Seattle Children's Hospital, Seattle Washington;
6Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri; 7Department of Pediatrics, Baylor College of Medicine, Houston, Texas;
8Department of Emergency Medicine, Cleveland Clinic, Cleveland, Ohio; 9Department of Pediatrics, University of Texas Southwestern, Dallas, Texas;
10Centers for Disease Control and Prevention, Atlanta, Georgia; 11Department of Pediatrics, University of MissouriKansas City School of Medicine,

Kansas City, Missouri; 12Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; and 13Department of Pediatrics, McFarland
Clinic, Ames, Iowa

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia
(CAP) were prepared by an expert panel comprising clinicians and investigators representing community
pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine,
infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and
subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in
both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive
surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

EXECUTIVE SUMMARY guidelines were created to assist the clinician in the care
of a child with CAP. They do not represent the only
Guidelines for the management of community-acquired approach to diagnosis and therapy; there is considerable
pneumonia (CAP) in adults have been demonstrated to variation among children in the clinical course of pe-
decrease morbidity and mortality rates [1, 2]. These diatric CAP, even with infection caused by the same
pathogen. The goal of these guidelines is to decrease
morbidity and mortality rates for CAP in children by
Received 1 July 2011; accepted 8 July 2011.
a
J. S. B., C. L. B., and S. S. S. contributed equally to this work.
presenting recommendations for clinical management
Correspondence: John S. Bradley, MD, Rady Children's Hospital San Diego/ that can be applied in individual cases if deemed ap-
UCSD, 3020 Children's Way, MC 5041, San Diego, CA 92123 ([email protected]).
propriate by the treating clinician.
Clinical Infectious Diseases 2011;53(7):617630
The Author 2011. Published by Oxford University Press on behalf of the
This document is designed to provide guidance in the
Infectious Diseases Society of America. All rights reserved. For Permissions, care of otherwise healthy infants and children and ad-
please e-mail: [email protected].
1058-4838/2011/537-0001$14.00
dresses practical questions of diagnosis and management
DOI: 10.1093/cid/cir625 of CAP evaluated in outpatient (offices, urgent care

Pediatric Community Pneumonia Guidelines d CID 2011:53 (1 October) d 617

clinics, emergency departments) or inpatient settings in the child acutely requires use of noninvasive positive pressure
United States. Management of neonates and young infants ventilation (eg, continuous positive airway pressure or bilevel
through the first 3 months, immunocompromised children, positive airway pressure). (strong recommendation; very low-
children receiving home mechanical ventilation, and children with quality evidence)
chronic conditions or underlying lung disease, such as cystic fi- 7. A child should be admitted to an ICU or a unit with
brosis, are beyond the scope of these guidelines and are not dis- continuous cardiorespiratory monitoring capabilities if the child
cussed. has impending respiratory failure. (strong recommendation;
Summarized below are the recommendations made in the moderate-quality evidence)
new 2011 pediatric CAP guidelines. The panel followed a process 8. A child should be admitted to an ICU or a unit with
used in the development of other Infectious Diseases Society of continuous cardiorespiratory monitoring capabilities if the child
America (IDSA) guidelines, which included a systematic has sustained tachycardia, inadequate blood pressure, or need for
weighting of the quality of the evidence and the grade of the pharmacologic support of blood pressure or perfusion. (strong
recommendation [3] (Table 1). A detailed description of the recommendation; moderate-quality evidence)
methods, background, and evidence summaries that support 9. A child should be admitted to an ICU if the pulse
each of the recommendations can be found in the full text of the oximetry measurement is ,92% on inspired oxygen of $0.50.
guidelines. (strong recommendation; low-quality evidence)
10. A child should be admitted to an ICU or a unit with
continuous cardiorespiratory monitoring capabilities if the
SITE-OF-CARE MANAGEMENT DECISIONS
child has altered mental status, whether due to hypercarbia or
hypoxemia as a result of pneumonia. (strong recommendation;
I. When Does a Child or Infant With CAP Require Hospitalization?
low-quality evidence)
Recommendations
11. Severity of illness scores should not be used as the sole
1. Children and infants who have moderate to severe CAP, criteria for ICU admission but should be used in the context of
as defined by several factors, including respiratory distress and other clinical, laboratory, and radiologic findings. (strong
hypoxemia (sustained saturation of peripheral oxygen [SpO2], recommendation; low-quality evidence)
,90 % at sea level) (Table 3) should be hospitalized for
management, including skilled pediatric nursing care. (strong
DIAGNOSTIC TESTING FOR PEDIATRIC CAP
recommendation; high-quality evidence)
2. Infants less than 36 months of age with suspected
III. What Diagnostic Laboratory and Imaging Tests Should Be
bacterial CAP are likely to benefit from hospitalization. (strong
Used in a Child With Suspected CAP in an Outpatient or
recommendation; low-quality evidence) Inpatient Setting?
3. Children and infants with suspected or documented Recommendations
CAP caused by a pathogen with increased virulence, such as Microbiologic Testing
community-associated methicillin-resistant Staphylococcus aureus Blood Cultures: Outpatient
(CA-MRSA) should be hospitalized. (strong recommendation; low-
quality evidence) 12. Blood cultures should not be routinely performed in
4. Children and infants for whom there is concern about nontoxic, fully immunized children with CAP managed in the
careful observation at home or who are unable to comply with outpatient setting. (strong recommendation; moderate-quality
therapy or unable to be followed up should be hospitalized. evidence)
(strong recommendation; low-quality evidence) 13. Blood cultures should be obtained in children who fail to
demonstrate clinical improvement and in those who have
progressive symptoms or clinical deterioration after initiation
II. When Should a Child With CAP Be Admitted to an Intensive of antibiotic therapy (strong recommendation; moderate-quality
Care Unit (ICU) or a Unit With Continuous Cardiorespiratory
evidence).
Monitoring?
Recommendations Blood Cultures: Inpatient

5. A child should be admitted to an ICU if the child requires 14. Blood cultures should be obtained in children requiring
invasive ventilation via a nonpermanent artificial airway (eg, hospitalization for presumed bacterial CAP that is moderate to
endotracheal tube). (strong recommendation; high-quality severe, particularly those with complicated pneumonia. (strong
evidence) recommendation; low-quality evidence)
6. A child should be admitted to an ICU or a unit with 15. In improving patients who otherwise meet criteria
continuous cardiorespiratory monitoring capabilities if the for discharge, a positive blood culture with identification or

618 d CID 2011:53 (1 October) d Bradley et al

Table 1. Strength of Recommendations and Quality of Evidence

Strength of recommendation Clarity of balance between Methodologic quality of supporting

and quality of evidence desirable and undesirable effects evidence (examples) Implications
Strong recommendation
High-quality evidence Desirable effects clearly Consistent evidence from well- Recommendation can apply to
outweigh undesirable effects, performed RCTsa or exceptionally most patients in most
or vice versa strong evidence from unbiased circumstances; further
observational studies research is unlikely to change
our confidence in the
estimate of effect.
Moderate-quality evidence Desirable effects clearly Evidence from RCTs with important Recommendation can apply to
outweigh undesirable effects, limitations (inconsistent results, most patients in most
or vice versa methodologic flaws, indirect, or circumstances; further
imprecise) or exceptionally strong research (if performed) is
evidence from unbiased likely to have an important
observational studies impact on our confidence in
the estimate of effect and
may change the estimate.
Low-quality evidence Desirable effects clearly Evidence for $1 critical outcome Recommendation may change
outweigh undesirable effects, from observational studies, RCTs when higher quality evidence
or vice versa with serious flaws or indirect becomes available; further
evidence research (if performed) is
likely to have an important
impact on our confidence in
the estimate of effect and is
likely to change the estimate.
Very low-quality evidence Desirable effects clearly Evidence for $1 critical outcome Recommendation may change
(rarely applicable) outweigh undesirable effects, from unsystematic clinical when higher quality evidence
or vice versa observations or very indirect becomes available; any
evidence estimate of effect for $1
critical outcome is very
uncertain.
Weak recommendation
High-quality evidence Desirable effects closely Consistent evidence from well- The best action may differ
balanced with undesirable performed RCTs or exceptionally depending on circumstances
effects strong evidence from unbiased or patients or societal values;
observational studies further research is unlikely to
change our confidence in the
estimate of effect.
Moderate-quality evidence Desirable effects closely Evidence from RCTs with important Alternative approaches are likely
balanced with undesirable limitations (inconsistent results, to be better for some patients
effects methodologic flaws, indirect, or under some circumstances;
imprecise) or exceptionally strong further research (if performed)
evidence from unbiased is likely to have an important
observational studies impact on our confidence in
the estimate of effect and
may change the estimate.
Low-quality evidence Uncertainty in the estimates of Evidence for $1 critical outcome Other alternatives may be equally
desirable effects, harms, and from observational studies, from reasonable; further research is
burden; desirable effects, RCTs with serious flaws or indirect very likely to have an important
harms, and burden may be evidence impact on our confidence in the
closely balanced estimate of effect and is likely
to change the estimate.
Very low-quality evidence Major uncertainty in estimates Evidence for $1 critical outcome from Other alternatives may be equally
of desirable effects, harms, unsystematic clinical observations or reasonable; any estimate of
and burden; desirable effects 2very indirect evidence effect, for at $1 critical
may or may not be balanced outcome, is very uncertain.
with undesirable effects
may be closely balanced
a
RCTs, randomized controlled trials.

Pediatric Community Pneumonia Guidelines d CID 2011:53 (1 October) d 619

Table 2. Complications Associated With Community-Acquired Sputum Gram Stain and Culture
Pneumonia
18. Sputum samples for culture and Gram stain should be
Pulmonary obtained in hospitalized children who can produce sputum.
Pleural effusion or empyema (weak recommendation; low-quality evidence)
Pneumothorax
Urinary Antigen Detection Tests
Lung abscess
Bronchopleural fistula 19. Urinary antigen detection tests are not recommended
Necrotizing pneumonia for the diagnosis of pneumococcal pneumonia in children;
Acute respiratory failure false-positive tests are common. (strong recommendation; high-
Metastatic
quality evidence)
Meningitis
Central nervous system abscess Testing For Viral Pathogens
Pericarditis
Endocarditis
20. Sensitive and specific tests for the rapid diagnosis of
Osteomyelitis influenza virus and other respiratory viruses should be used in
Septic arthritis the evaluation of children with CAP. A positive influenza test
Systemic may decrease both the need for additional diagnostic studies
Systemic inflammatory response syndrome or sepsis and antibiotic use, while guiding appropriate use of antiviral
Hemolytic uremic syndrome agents in both outpatient and inpatient settings. (strong
recommendation; high-quality evidence)
susceptibility results pending should not routinely preclude 21. Antibacterial therapy is not necessary for children, either
discharge of that patient with appropriate oral or intravenous outpatients or inpatients, with a positive test for influenza virus
antimicrobial therapy. The patient can be discharged if close in the absence of clinical, laboratory, or radiographic findings
follow-up is assured. (weak recommendation; low-quality evidence) that suggest bacterial coinfection. (strong recommendation;
high-quality evidence).
Follow-up Blood Cultures
22. Testing for respiratory viruses other than influenza virus
16. Repeated blood cultures in children with clear clinical can modify clinical decision making in children with suspected
improvement are not necessary to document resolution of pneumonia, because antibacterial therapy will not routinely be
pneumococcal bacteremia. (weak recommendation; low-quality required for these children in the absence of clinical, laboratory,
evidence) or radiographic findings that suggest bacterial coinfection.
17. Repeated blood cultures to document resolution of (weak recommendation; low-quality evidence)
bacteremia should be obtained in children with bacteremia
Testing for Atypical Bacteria
caused by S. aureus, regardless of clinical status. (strong
recommendation; low-quality evidence) 23. Children with signs and symptoms suspicious for
Mycoplasma pneumoniae should be tested to help guide
antibiotic selection. (weak recommendation; moderate-quality
Table 3. Criteria for Respiratory Distress in Children With evidence)
Pneumonia 24. Diagnostic testing for Chlamydophila pneumoniae is not
recommended as reliable and readily available diagnostic tests
Signs of Respiratory Distress
do not currently exist. (strong recommendation; high-quality
1. Tachypnea, respiratory rate, breaths/mina
evidence)
Age 02 months: .60
Age 212 months: .50 Ancillary Diagnostic Testing
Age 15 Years: .40 Complete Blood Cell Count
Age .5 Years: .20
2. Dyspnea 25. Routine measurement of the complete blood cell count is
3. Retractions (suprasternal, intercostals, or subcostal) not necessary in all children with suspected CAP managed in the
4. Grunting outpatient setting, but in those with more serious disease it may
5. Nasal flaring provide useful information for clinical management in the
6. Apnea context of the clinical examination and other laboratory and
7. Altered mental status imaging studies. (weak recommendation; low-quality evidence)
8. Pulse oximetry measurement ,90% on room air 26. A complete blood cell count should be obtained for
a
Adapted from World Health Organization criteria. patients with severe pneumonia, to be interpreted in the context

620 d CID 2011:53 (1 October) d Bradley et al

of the clinical examination and other laboratory and imaging Table 4. Criteria for CAP Severity of Illness in Children with
studies. (weak recommendation; low-quality evidence) Community-Acquired Pneumonia

Acute-Phase Reactants Criteria

27. Acute-phase reactants, such as the erythrocyte Major criteria

sedimentation rate (ESR), C-reactive protein (CRP) Invasive mechanical ventilation
concentration, or serum procalcitonin concentration, cannot Fluid refractory shock
Acute need for NIPPV
be used as the sole determinant to distinguish between viral and
hypoxemia requiring FiO2 greater than inspired concentration or
bacterial causes of CAP. (strong recommendation; high-quality flow feasible in general care area
evidence) Minor criteria
28. Acute-phase reactants need not be routinely measured Respiratory rate higher than WHO classification for age
in fully immunized children with CAP who are managed as Apnea
outpatients, although for more serious disease, acute-phase Increased work of breathing (eg, retractions, dyspnea, nasal flaring,
grunting)
reactants may provide useful information for clinical
PaO2/FiO2 ratio ,250
management. (strong recommendation; low-quality evidence)
Multilobar infiltrates
29. In patients with more serious disease, such as those
PEWS score .6
requiring hospitalization or those with pneumonia-associated
Altered mental status
complications, acute-phase reactants may be used in Hypotension
conjunction with clinical findings to assess response to Presence of effusion
therapy. (weak recommendation; low-quality evidence) Comorbid conditions (eg, HgbSS, immunosuppression,
immunodeficiency)
Pulse Oximetry Unexplained metabolic acidosis

30. Pulse oximetry should be performed in all children with Modified from Infectious Diseases Society of America/American Thoracic
Society consensus guidelines on the management of community-acquired
pneumonia and suspected hypoxemia. The presence of pneumonia in adults [27, table 4]. Clinician should consider care in an intensive
hypoxemia should guide decisions regarding site of care and care unit or a unit with continuous cardiorespiratory monitoring for the child
having $1 major or $2 minor criteria.
further diagnostic testing. (strong recommendation; moderate- Abbreviations: FiO2, fraction of inspired oxygen; HgbSS, Hemoglobin SS
quality evidence) disease; NIPPV, noninvasive positive pressure ventilation; PaO2, arterial
oxygen pressure; PEWS, Pediatric Early Warning Score [70].
Chest Radiography
Initial Chest Radiographs: Outpatient

31. Routine chest radiographs are not necessary for the Follow-up Chest Radiograph
confirmation of suspected CAP in patients well enough to be 34. Repeated chest radiographs are not routinely required in
treated in the outpatient setting (after evaluation in the children who recover uneventfully from an episode of CAP.
office, clinic, or emergency department setting). (strong (strong recommendation; moderate-quality evidence)
recommendation; high-quality evidence) 35. Repeated chest radiographs should be obtained in
32. Chest radiographs, posteroanterior and lateral, should be children who fail to demonstrate clinical improvement and
obtained in patients with suspected or documented hypoxemia in those who have progressive symptoms or clinical
or significant respiratory distress (Table 3) and in those with deterioration within 4872 hours after initiation of
failed initial antibiotic therapy to verify the presence or absence antibiotic therapy. (strong recommendation; moderate-quality
of complications of pneumonia, including parapneumonic evidence)
effusions, necrotizing pneumonia, and pneumothorax. (strong 36. Routine daily chest radiography is not recommended
recommendation; moderate-quality evidence) in children with pneumonia complicated by parapneumonic
effusion after chest tube placement or after video-
Initial Chest Radiographs: Inpatient
assisted thoracoscopic surgery (VATS), if they remain
33. Chest radiographs (posteroanterior and lateral) should be clinically stable. (strong recommendation; low-quality
obtained in all patients hospitalized for management of CAP to evidence)
document the presence, size, and character of parenchymal 37. Follow-up chest radiographs should be obtained in
infiltrates and identify complications of pneumonia that may patients with complicated pneumonia with worsening
lead to interventions beyond antimicrobial agents and supportive respiratory distress or clinical instability, or in those with
medical therapy. (strong recommendation; moderate-quality persistent fever that is not responding to therapy over 48-72
evidence) hours. (strong recommendation; low-quality evidence)

Pediatric Community Pneumonia Guidelines d CID 2011:53 (1 October) d 621

 38. Repeated chest radiographs 46 weeks after the 44. Macrolide antibiotics should be prescribed for treatment
diagnosis of CAP should be obtained in patients with of children (primarily school-aged children and adolescents)
recurrent pneumonia involving the same lobe and in evaluated in an outpatient setting with findings compatible
patients with lobar collapse at initial chest radiography with CAP caused by atypical pathogens. Laboratory testing for
with suspicion of an anatomic anomaly, chest mass, or M. pneumoniae should be performed if available in a clinically
foreign body aspiration. (strong recommendation; moderate- relevant time frame. Table 5 lists preferred and alternative agents
quality evidence) for atypical pathogens. (weak recommendation; moderate-quality
evidence)
IV. What Additional Diagnostic Tests Should Be Used in a Child 45. Influenza antiviral therapy (Table 6) should be
With Severe or Life-Threatening CAP? administered as soon as possible to children with moderate
Recommendations to severe CAP consistent with influenza virus infection during
widespread local circulation of influenza viruses, particularly
39. The clinician should obtain tracheal aspirates for Gram
for those with clinically worsening disease documented at the
stain and culture, as well as clinically and epidemiologically
time of an outpatient visit. Because early antiviral treatment has
guided testing for viral pathogens, including influenza virus, at
been shown to provide maximal benefit, treatment should not be
the time of initial endotracheal tube placement in children
delayed until confirmation of positive influenza test results.
requiring mechanical ventilation. (strong recommendation; low-
Negative results of influenza diagnostic tests do not conclusively
quality evidence)
exclude influenza disease. Treatment after 48 hours of
40. Bronchoscopic or blind protected specimen brush
symptomatic infection may still provide clinical benefit to those
sampling, bronchoalveolar lavage (BAL), percutaneous lung
with more severe disease. (strong recommendation; moderate-
aspiration, or open lung biopsy should be reserved for the
quality evidence)
immunocompetent child with severe CAP if initial diagnostic tests
are not positive. (weak recommendation; low-quality evidence)
Inpatients

46. Ampicillin or penicillin G should be administered to the

ANTI-INFECTIVE TREATMENT fully immunized infant or school-aged child admitted to
a hospital ward with CAP when local epidemiologic data
V. Which Anti-Infective Therapy Should Be Provided to a Child
document lack of substantial high-level penicillin resistance for
With Suspected CAP in Both Outpatient and Inpatient Settings?
invasive S. pneumoniae. Other antimicrobial agents for empiric
Recommendations
therapy are provided in Table 7. (strong recommendation;
Outpatients
moderate-quality evidence)
41. Antimicrobial therapy is not routinely required for 47. Empiric therapy with a third-generation parenteral
preschool-aged children with CAP, because viral pathogens are cephalosporin (ceftriaxone or cefotaxime) should be
responsible for the great majority of clinical disease. (strong prescribed for hospitalized infants and children who are
recommendation; high-quality evidence) not fully immunized, in regions where local epidemiology of
42. Amoxicillin should be used as first-line therapy for invasive pneumococcal strains documents high-level penicillin
previously healthy, appropriately immunized infants and resistance, or for infants and children with life-threatening
preschool children with mild to moderate CAP suspected to infection, including those with empyema (Table 7). Non
be of bacterial origin. Amoxicillin provides appropriate b-lactam agents, such as vancomycin, have not been shown to
coverage for Streptococcus pneumoniae, the most prominent be more effective than third-generation cephalosporins in
invasive bacterial pathogen. Table 5 lists preferred agents and the treatment of pneumococcal pneumonia for the degree
alternative agents for children allergic to amoxicillin (strong of resistance noted currently in North America. (weak
recommendation; moderate-quality evidence) recommendation; moderate-quality evidence)
43. Amoxicillin should be used as first-line therapy for 48. Empiric combination therapy with a macrolide (oral or
previously healthy appropriately immunized school-aged parenteral), in addition to a b-lactam antibiotic, should be
children and adolescents with mild to moderate CAP for prescribed for the hospitalized child for whom M. pneumoniae
S. pneumoniae, the most prominent invasive bacterial and C. pneumoniae are significant considerations; diagnostic
pathogen. Atypical bacterial pathogens (eg, M. pneumoniae), testing should be performed if available in a clinically relevant
and less common lower respiratory tract bacterial pathogens, as time frame (Table 7). (weak recommendation; moderate-quality
discussed in the Evidence Summary, should also be considered in evidence)
management decisions. (strong recommendation; moderate- 49. Vancomycin or clindamycin (based on local susceptibility
quality evidence) data) should be provided in addition to b-lactam therapy if

622 d CID 2011:53 (1 October) d Bradley et al

Table 5. Selection of Antimicrobial Therapy for Specific Pathogens

Oral therapy (step-down therapy

Pathogen Parenteral therapy or mild infection)
Streptococcus pneumoniae with Preferred: ampicillin (150200 mg/kg/day every Preferred: amoxicillin (90 mg/kg/day in
MICs for penicillin #2.0 lg/mL 6 hours) or penicillin (200 000250 000 U/kg/day 2 doses or 45 mg/kg/day in 3 doses);
every 46 h);
Alternatives: second- or third-generation
Alternatives: ceftriaxone cephalosporin (cefpodoxime, cefuroxime,
(50100 mg/kg/day every 1224 hours) (preferred cefprozil); oral levofloxacin, if susceptible
for parenteral outpatient therapy) or cefotaxime (1620 mg/kg/day in 2 doses for children
(150 mg/kg/day every 8 hours); may also be 6 months to 5 years old and 810 mg/kg/day
effective: clindamycin (40 mg/kg/day every once daily for children 5 to 16 years old;
68 hours) or vancomycin (4060 mg/kg/day every maximum daily dose, 750 mg) or oral
68 hours) linezolid (30 mg/kg/day in 3 doses for
children ,12 years old and 20 mg/kg/day
in 2 doses for children $12 years old)
S. pneumoniae resistant to Preferred: ceftriaxone (100 mg/kg/day every Preferred: oral levofloxacin (1620 mg/kg/day
penicillin, with MICs 1224 hours); in 2 doses for children 6 months to 5 years
$4.0 lg/mL and 810 mg/kg/day once daily for children
Alternatives: ampicillin 516 years, maximum daily dose, 750 mg),
(300400 mg/kg/day every 6 hours), levofloxacin if susceptible, or oral linezolid (30 mg/kg/day
(1620 mg/kg/day every 12 hours for children in 3 doses for children ,12 years and
6 months to 5 years old and 810 mg/kg/day 20 mg/kg/day in 2 doses for children
once daily for children 516 years old; maximum $12 years);
daily dose, 750 mg), or linezolid (30 mg/kg/day
every 8 hours for children ,12 years old and Alternative: oral clindamycina
20 mg/kg/day every 12 hours for children $12 years (3040 mg/kg/day in 3 doses)
old); may also be effective: clindamycina
(40 mg/kg/day every 68 hours) or vancomycin
(4060 mg/kg/day every 68 hours)
Group A Streptococcus Preferred: intravenous penicillin (100 000250 000 Preferred: amoxicillin (5075 mg/kg/day in
U/kg/day every 46 hours) or ampicillin 2 doses), or penicillin V (5075 mg/kg/day in
(200 mg/kg/day every 6 hours); 3 or 4 doses);

Alternatives: ceftriaxone (50100 mg/kg/day every Alternative: oral clindamycina

1224 hours) or cefotaxime (150 mg/kg/day every (40 mg/kg/day in 3 doses)
8 hours); may also be effective: clindamycin, if
susceptible (40 mg/kg/day every 68 hours) or
vancomycinb (4060 mg/kg/day every 68 hours)
Stapyhylococcus aureus, Preferred: cefazolin (150 mg/kg/day every 8 hours) or Preferred: oral cephalexin (75100 mg/kg/day
methicillin susceptible semisynthetic penicillin, eg oxacillin in 3 or 4 doses);
(combination therapy not (150200 mg/kg/day every 68 hours);
well studied) Alternative: oral clindamycina
Alternatives: clindamycina (40 mg/kg/day every (3040 mg/kg/day in 3 or 4 doses)
68 hours) or >vancomycin (4060 mg/kg/day
every 68 hours)
S. aureus, methicillin resistant, Preferred: vancomycin (4060 mg/kg/day every Preferred: oral clindamycin (3040 mg/kg/day
susceptible to clindamycin 68 hours or dosing to achieve an AUC/MIC ratio of in 3 or 4 doses);
(combination therapy not .400) or clindamycin (40 mg/kg/day every 68 hours);
well-studied) Alternatives: oral linezolid
Alternatives: linezolid (30 mg/kg/day every 8 hours (30 mg/kg/day in 3 doses for children
for children ,12 years old and 20 mg/kg/day every ,12 years and 20 mg/kg/day in 2 doses
12 hours for children $12 years old) for children $12 years)
S. aureus, methicillin resistant, Preferred: vancomycin (4060 mg/kg/day every Preferred: oral linezolid (30 mg/kg/day in
resistant to clindamycin 6-8 hours or dosing to achieve an AUC/MIC ratio of 3 doses for children ,12 years and
(combination therapy not .400); 20 mg/kg/day in 2 doses for children
well studied) $12 years old);
Alternatives: linezolid (30 mg/kg/day every
8 hours for children ,12 years old and 20 mg/kg/day Alternatives: none; entire treatment course with
every 12 hours for children $12 years old) parenteral therapy may be required

Pediatric Community Pneumonia Guidelines d CID 2011:53 (1 October) d 623

Table 5. (Continued)
Oral therapy (step-down therapy
Pathogen Parenteral therapy or mild infection)

Haemophilus influenza, typeable Preferred: intravenous ampicillin (150-200 mg/kg/day Preferred: amoxicillin (75-100 mg/kg/day in
(A-F) or nontypeable every 6 hours) if b-lactamase negative, ceftriaxone 3 doses) if b-lactamase negative) or
(50100 mg/kg/day every 12-24 hours) if b-lactamase amoxicillin clavulanate (amoxicillin
producing, or cefotaxime (150 mg/kg/day every component, 45 mg/kg/day in 3 doses or
8 hours); 90 mg/kg/day in 2 doses) if b-lactamase
producing;
Alternatives: intravenous ciprofloxacin (30 mg/kg/day
every 12 hours) or intravenous levofloxacin Alternatives: cefdinir, cefixime,
(16-20 mg/kg/day every 12 hours for cefpodoxime, or ceftibuten
children 6 months to 5 years old
and 8-10 mg/kg/day once daily for children 5 to
16 years old; maximum daily dose, 750 mg)
Mycoplasma pneumoniae Preferred: intravenous azithromycin Preferred: azithromycin (10 mg/kg on day 1,
(10 mg/kg on days 1 and 2 of therapy; followed by 5 mg/kg/day once daily on
transition to oral therapy if possible); days 25);

Alternatives: intravenous erythromycin lactobionate Alternatives: clarithromycin

(20 mg/kg/day every 6 hours) or levofloxacin (15 mg/kg/day in 2 doses) or oral
(16-20 mg/kg/day every 12 hours; maximum daily erythromycin (40 mg/kg/day in 4 doses);
dose, 750 mg) for children .7 years old, doxycycline
(24 mg/kg/day in 2 doses; for adolescents
with skeletal maturity, levofloxacin
(500 mg once daily) or moxifloxacin
(400 mg once daily)
Chlamydia trachomatis or Preferred: intravenous azithromycin Preferred: azithromycin (10 mg/kg on day 1,
Chlamydophila pneumoniae (10 mg/kg on days 1 and 2 of therapy; followed by 5 mg/kg/day once daily
transition to oral therapy if possible); days 25);

Alternatives: intravenous erythromycin lactobionate Alternatives: clarithromycin

(20 mg/kg/day every 6 hours) or levofloxacin (15 mg/kg/day in 2 doses) or oral
(16-20 mg/kg/day in 2 doses for children 6 months erythromycin (40 mg/kg/day in 4 doses);
to 5 years old and 8-10 mg/kg/day once daily for for children .7 years old, doxycycline
children 5 to 16 years old; maximum daily dose, (2-4 mg/kg/day in 2 doses); for adolescents
750 mg) with skeletal maturity, levofloxacin
(500 mg once daily) or moxifloxacin
(400 mg once daily)

Doses for oral therapy should not exceed adult doses.

Abbreviations: AUC, area under the time vs. serum concentration curve; MIC, minimum inhibitory concentration.
a
Clindamycin resistance appears to be increasing in certain geographic areas among S. pneumoniae and S. aureus infections.
b
For b-lactamallergic children.

clinical, laboratory, or imaging characteristics are consistent 53. Treatment for the shortest effective duration will
with infection caused by S. aureus (Table 7). (strong minimize exposure of both pathogens and normal microbiota
recommendation; low-quality evidence) to antimicrobials and minimize the selection for resistance.
(strong recommendation; low-quality evidence)
VI. How Can Resistance to Antimicrobials Be Minimized?
Recommendations VII. What Is the Appropriate Duration of Antimicrobial Therapy
for CAP?
50. Antibiotic exposure selects for antibiotic resistance;
Recommendations
therefore, limiting exposure to any antibiotic, whenever possible,
is preferred. (strong recommendation; moderate-quality evidence) 54. Treatment courses of 10 days have been best studied,
51. Limiting the spectrum of activity of antimicrobials to although shorter courses may be just as effective, particularly
that specifically required to treat the identified pathogen is for more mild disease managed on an outpatient basis. (strong
preferred. (strong recommendation; low-quality evidence) recommendation; moderate-quality evidence)
52. Using the proper dosage of antimicrobial to be able to 55. Infections caused by certain pathogens, notably CA-
achieve a minimal effective concentration at the site of infection MRSA, may require longer treatment than those caused by
is important to decrease the development of resistance. (strong S. pneumoniae. (strong recommendation; moderate-quality
recommendation; low-quality evidence) evidence)

624 d CID 2011:53 (1 October) d Bradley et al

Table 6. Influenza Antiviral Therapy

Dosing recommendations
Treatment Prophylaxisa
Drug Formulation Children Adults Children Adults
Oseltamivir 75-mg capsule; $24 months old: 150 mg/day in #15 kg: 30 mg/day; .15 to 75 mg/day
(Tamiflu) 60 mg/5 mL 4 mg/kg/day in 2 doses for 23 kg: 45 mg/day; .23 to once daily
Suspension 2 doses, for a 5 days 40 kg: 60 mg/day; .40 kg:
5-day treatment 75 mg/day (once daily in
course each group)
#15 kg: 60 mg/day;
.15 to 23 kg:
90 mg/day; .23 to
40 kg: 120 mg/day;
.40 kg: 150 mg/day
(divided into 2 doses
for each group)
923 months old: 923 months old: 3.5 mg/kg
7 mg/kg/day in once daily; 38 months old:
2 doses; 08 months 3 mg/kg once daily; not
old: 6 mg/kg/day in routinely recommended for
2 doses; premature infants ,3 months old
infants: 2 mg/kg/day owing to limited data in
in 2 doses this age group
Zanamivir 5 mg per inhalation, $7 years old: 2 inhalations 2 inhalations $5 years old: 2 inhalations 2 inhalations
(Relenza) using a Diskhaler (10 mg total per dose), (10 mg total per (10 mg total per dose), (10 mg total
twice daily for 5 days dose), twice daily once daily for 10 days per dose),
for 5 days once daily
for 10 days
Amantadine 100-mg tablet; 19 years old: 58 mg/kg/day 200 mg/day, as 19 years old: Same as
(Symmetrel)b 50 mg/5 mL as single daily dose or in single daily dose same as treatment
suspension 2 doses, not to exceed or in 2 doses treatment dose; dose
150 mg/day; 912 years old: 912 years old:
200 mg/day in 2 doses (not same as
studied as single daily dose) treatment dose
Rimantadine 100-mg tablet; Not FDA approved for 200 mg/day, either FDA approved for prophylaxis 200 mg/day,
(Flumadine)b 50 mg/5 mL treatment in children, but as a single daily down to 12 months of age. as single
suspension published data exist on safety dose, or divided 19 years old: 5 mg/kg/day daily dose
and efficacy in children; into 2 doses once daily, not to exceed or in
suspension: 19 years old: 150 mg; $10 years old: 2 doses
6.6 mg/kg/day (maximum 200 mg/day as single daily
150 mg/kg/day) in 2 doses; dose or in 2 doses
$10 years old: 200 mg/day, as
single daily dose or in 2 doses

NOTE. Check Centers for Disease Control and Prevention Website (http://www.flu.gov/) for current susceptibility data.
a
In children for whom prophylaxis is indicated, antiviral drugs should be continued for the duration of known influenza activity in the community because of the
potential for repeated and unknown exposures or until immunity can be achieved after immunization.
b
Amantadine and rimantadine should be used for treatment and prophylaxis only in winter seasons during which a majority of influenza A virus strains
isolated are adamantine susceptible; the adamantanes should not be used for primary therapy because of the rapid emergence of resistance. However,
for patients requiring adamantane therapy, a treatment course of 7 days is suggested, or until 2448 hours after the disappearance of signs and
symptoms.

VIII. How Should the Clinician Follow the Child With CAP for the ADJUNCTIVE SURGICAL AND NON
Expected Response to Therapy? ANTI-INFECTIVE THERAPY FOR PEDIATRIC CAP
Recommendation
IX. How Should a Parapneumonic Effusion Be Identified?
56. Children on adequate therapy should demonstrate clinical
Recommendation
and laboratory signs of improvement within 4872 hours. For
children whose condition deteriorates after admission and 57. History and physical examination may be suggestive of
initiation of antimicrobial therapy or who show no parapneumonic effusion in children suspected of having CAP, but
improvement within 4872 hours, further investigation should chest radiography should be used to confirm the presence of
be performed. (strong recommendation; moderate-quality evidence) pleural fluid. If the chest radiograph is not conclusive, then

Pediatric Community Pneumonia Guidelines d CID 2011:53 (1 October) d 625

Table 7. Empiric Therapy for Pediatric Community-Acquired Pneumonia (CAP)

Empiric therapy
Presumed bacterial Presumed atypical Presumed influenza
Site of care pneumonia pneumonia pneumoniaa
Outpatient
,5 years old (preschool) Amoxicillin, oral (90 mg/kg/day in Azithromycin oral (10 mg/kg on day 1, Oseltamivir
2 dosesb); alternative: oral followed by 5 mg/kg/day once daily
amoxicillin clavulanate (amoxicillin on days 25); alternatives: oral
component, 90 mg/kg/day in clarithromycin (15 mg/kg/day in 2
2 dosesb) doses for 7-14 days) or oral
erythromycin (40 mg/kg/day in 4 doses)
$5 years old Oral amoxicillin (90 mg/kg/day in Oral azithromycin (10 mg/kg on Oseltamivir or zanamivir
2 dosesb to a maximum of 4 g/dayc); day 1, followed by 5 mg/kg/day (for children 7 years
for children with presumed bacterial once daily on days 25 to a and older); alternatives:
CAP who do not have clinical, maximum of 500 mg on day 1, peramivir, oseltamivir
laboratory, or radiographic evidence followed by 250 mg on days 25); and zanamivir
that distinguishes bacterial CAP from alternatives: oral clarithromycin (all intravenous) are
atypical CAP, a macrolide can be (15 mg/kg/day in 2 doses to a under clinical
added to a b-lactam antibiotic for maximum of 1 g/day); investigation in children;
empiric therapy; alternative: oral erythromycin, doxycycline for intravenous zanamivir
amoxicillin clavulanate (amoxicillin children .7 years old available for
component, 90 mg/kg/day in 2 dosesb compassionate use
to a maximum dose of 4000 mg/day,
eg, one 2000-mg tablet twice dailyb)
Inpatient (all ages)d
Fully immunized with Ampicillin or penicillin G; alternatives: Azithromycin (in addition to b-lactam, if Oseltamivir or zanamivir
conjugate vaccines for ceftriaxone or cefotaxime; addition diagnosis of atypical pneumonia is in (for children $7 years old;
Haemophilus influenzae of vancomycin or clindamycin for doubt); alternatives: clarithromycin alternatives: peramivir,
type b and Streptococcus suspected CA-MRSA or erythromycin; doxycycline for oseltamivir and zanamivir
pneumoniae; local children .7 years old; levofloxacin (all intravenous) are under
penicillin resistance in for children who have reached clinical investigation in
invasive strains of growth maturity, or who cannot children; intravenous
pneumococcus is minimal tolerate macrolides zanamivir available for
compassionate use
Not fully immunized for H, Ceftriaxone or cefotaxime; addition of Azithromycin (in addition to b-lactam, As above
influenzae type b and vancomycin or clindamycin for if diagnosis in doubt); alternatives:
S. pneumoniae; local suspected CA-MRSA; alternative: clarithromycin or erythromycin;
penicillin resistance in levofloxacin; addition of vancomycin doxycycline for children .7 years
invasive strains of or clindamycin for suspected old; levofloxacin for children who
pneumococcus is CA-MRSA have reached growth maturity or
significant who cannot tolerate macrolides

For children with drug allergy to recommended therapy, see Evidence Summary for Section V. Anti-Infective Therapy. For children with a history of possible, nonserious
allergic reactions to amoxicillin, treatment is not well defined and should be individualized. Options include a trial of amoxicillin under medical observation; a trial of an oral
cephalosporin that has substantial activity against S. pneumoniae, such as cefpodoxime, cefprozil, or cefuroxime, provided under medical supervision; treatment with
levofloxacin; treatment with linezolid; treatment with clindamycin (if susceptible); or treatment with a macrolide (if susceptible). For children with bacteremic pneumococcal
pneumonia, particular caution should be exercised in selecting alternatives to amoxicillin, given the potential for secondary sites of infection, including meningitis.
Abbreviation: CA-MRSA, community-associated methicillin-resistant Staphylococcus aureus.
a
See Table 6 for dosages.
b
See text for discussion of dosage recommendations based on local susceptibility data. Twice daily dosing of amoxicillin or amoxicillin clavulanate may be
effective for pneumococci that are susceptible to penicillin.
c
Not evaluated prospectively for safety.
d
See Table 5 for dosages.

further imaging with chest ultrasound or computed tomography 59. The childs degree of respiratory compromise is an
(CT) is recommended. (strong recommendation; high-quality important factor that determines management of parapneumonic
evidence) effusions (Table 8, Figure 1) (strong recommendation; moderate-
quality evidence)
X. What Factors Are Important in Determining Whether Drainage
of the Parapneumonic Effusion Is Required? XI. What Laboratory Testing Should Be Performed on Pleural Fluid?
Recommendations Recommendation
58. The size of the effusion is an important factor that 60. Gram stain and bacterial culture of pleural fluid should
determines management (Table 8, Figure 1). (strong be performed whenever a pleural fluid specimen is obtained.
recommendation; moderate-quality evidence) (strong recommendation; high-quality evidence)

626 d CID 2011:53 (1 October) d Bradley et al

Table 8. Factors Associated with Outcomes and Indication for Drainage of Parapneumonic Effusions

Risk of poor Tube drainage with or

Size of effusion Bacteriology outcome without fibrinolysis or VATSa
Small: ,10 mm on lateral Bacterial culture and Gram Low No; sampling of pleural fluid is not
decubitus radiograph or stain results unknown or routinely required
opacifies less than negative
one-fourth of hemithorax
Moderate: .10-mm rim of Bacterial culture and/or Gram Low to moderate No if the patient has no respiratory compromise
fluid but opacifies less than stain results negative or and the pleural fluid is not consistent with
half of the hemithorax positive (empyema) empyema (sampling of pleural fluid by simple
thoracentesis may help determine presence
or absence of empyema and need for a
drainage procedure, and sampling with a
drainage catheter may provide both
diagnostic and therapeutic benefit);
Yes, if the patient has respiratory
compromise or if pleural fluid is consistent
with empyema if the patient has respiratory
compromise or if pleural fluid is consistent
with empyema
Large: opacifies more than Bacterial culture and/or Gram High Yes in most cases
half of the hemithorax stain results positive
(empyema)
a
VATS, video-assisted thoracoscopic surgery.

61. Antigen testing or nucleic acid amplification through are free flowing (no loculations), placement of a chest tube
polymerase chain reaction (PCR) increase the detection of without fibrinolytic agents is a reasonable first option. (strong
pathogens in pleural fluid and may be useful for management. recommendation; high-quality evidence)
(strong recommendation; moderate-quality evidence)
62. Analysis of pleural fluid parameters, such as pH and XIII. When Should VATS or Open Decortication Be Considered in
levels of glucose, protein, and lactate dehydrogenase, rarely Patients Who Have Had Chest Tube Drainage, With or Without
change patient management and are not recommended. (weak Fibrinolytic Therapy?
recommendation; very low-quality evidence) Recommendation
63. Analysis of the pleural fluid white blood cell (WBC) count, 67. VATS should be performed when there is persistence of
with cell differential analysis, is recommended primarily to help moderate-large effusions and ongoing respiratory compromise
differentiate bacterial from mycobacterial etiologies and from despite 23 days of management with a chest tube and
malignancy. (weak recommendation; moderate-quality evidence) completion of fibrinolytic therapy. Open chest debridement
with decortication represents another option for management
of these children but is associated with higher morbidity rates.
XII. What Are the Drainage Options for Parapneumonic Effusions?
(strong recommendation; low-quality evidence)
Recommendations
64. Small, uncomplicated parapneumonic effusions XIV. When Should a Chest Tube Be Removed Either After Primary
should not routinely be drained and can be treated with Drainage or VATS?
antibiotic therapy alone. (strong recommendation; moderate- 68. A chest tube can be removed in the absence of an
quality evidence) intrathoracic air leak and when pleural fluid drainage is
65. Moderate parapneumonic effusions associated with ,1 mL/kg/24 h, usually calculated over the last 12 hours.
respiratory distress, large parapneumonic effusions, or (strong recommendation; very low-quality evidence)
documented purulent effusions should be drained. (strong
recommendation; moderate-quality evidence) XV. What Antibiotic Therapy and Duration Is Indicated for the
66. Both chest thoracostomy tube drainage with the addition Treatment of Parapneumonic Effusion/Empyema?
of fibrinolytic agents and VATS have been demonstrated to be Recommendations
effective methods of treatment. The choice of drainage procedure 69. When the blood or pleural fluid bacterial culture identifies
depends on local expertise. Both of these methods are associated a pathogenic isolate, antibiotic susceptibility should be used to
with decreased morbidity compared with chest tube drainage determine the antibiotic regimen. (strong recommendation; high-
alone. However, in patients with moderate-to-large effusions that quality evidence)

Pediatric Community Pneumonia Guidelines d CID 2011:53 (1 October) d 627

Figure 1. Management of pneumonia with parapneumonic effusion; abx, antibiotics; CT, computed tomography; dx, diagnosis; IV, intravenous; US,
ultrasound; VATS, video-assisted thoracoscopic surgery.

70. In the case of culture-negative parapneumonic effusions, a. Clinical and laboratory assessment of the current
antibiotic selection should be based on the treatment severity of illness and anticipated progression in order to
recommendations for patients hospitalized with CAP (see determine whether higher levels of care or support are
Evidence Summary for Recommendations 4649). (strong required. (strong recommendation; low-quality evidence)
recommendation; moderate-quality evidence) b. Imaging evaluation to assess the extent and progression
71. The duration of antibiotic treatment depends on the of the pneumonic or parapneumonic process. (weak
adequacy of drainage and on the clinical response recommendation; low-quality evidence)
demonstrated for each patient. In most children, antibiotic c. Further investigation to identify whether the original
treatment for 24 weeks is adequate. (strong recommendation; pathogen persists, the original pathogen has developed
low-quality evidence) resistance to the agent used, or there is a new secondary
infecting agent. (weak recommendation; low-quality
MANAGEMENT OF THE CHILD NOT evidence)
RESPONDING TO TREATMENT 73. A BAL specimen should be obtained for Gram stain and
culture for the mechanically ventilated child. (strong
XVI. What Is the Appropriate Management of a Child Who Is Not
recommendation; moderate-quality evidence)
Responding to Treatment for CAP?
74. A percutaneous lung aspirate should be obtained for Gram
Recommendation
stain and culture in the persistently and seriously ill child for
72. Children who are not responding to initial therapy after whom previous investigations have not yielded a microbiologic
4872 hours should be managed by one or more of the following: diagnosis. (weak recommendation; low-quality evidence)

628 d CID 2011:53 (1 October) d Bradley et al

 75. An open lung biopsy for Gram stain and culture should if a chest radiograph, obtained for clinical concerns, shows
be obtained in the persistently and critically ill, mechanically no significant reaccumulation of a parapneumonic effusion
ventilated child in whom previous investigations have not or pneumothorax. (strong recommendation; very low-quality
yielded a microbiologic diagnosis. (weak recommendation; evidence)
low-quality evidence) 84. In infants and children with barriers to care, including
concern about careful observation at home, inability to comply
XVII. How Should Nonresponders With Pulmonary Abscess or with therapy, or lack of availability for follow-up, these issues
Necrotizing Pneumonia Be Managed? should be identified and addressed before discharge. (weak
Recommendation recommendation; very low-quality evidence)

76. A pulmonary abscess or necrotizing pneumonia identified

in a nonresponding patient can be initially treated with XIX. When Is Parenteral Outpatient Therapy Indicated, In
intravenous antibiotics. Well-defined peripheral abscesses Contrast to Oral Step-Down Therapy?
without connection to the bronchial tree may be drained under Recommendations
imaging-guided procedures either by aspiration or with a drainage 85. Outpatient parenteral antibiotic therapy should be
catheter that remains in place, but most abscesses will drain offered to families of children no longer requiring skilled
through the bronchial tree and heal without surgical or invasive nursing care in an acute care facility but with a demonstrated
intervention. (weak recommendation; very low-quality evidence) need for ongoing parenteral therapy. (weak recommendation;
moderate-quality evidence)
86. Outpatient parenteral antibiotic therapy should be
DISCHARGE CRITERIA offered through a skilled pediatric home nursing program
or through daily intramuscular injections at an appropriate
XVIII. When Can a Hospitalized Child With CAP Be Safely
pediatric outpatient facility. (weak recommendation; low-quality
Discharged?
evidence)
Recommendations
87. Conversion to oral outpatient step-down therapy when
77. Patients are eligible for discharge when they have possible, is preferred to parenteral outpatient therapy. (strong
documented overall clinical improvement, including level of recommendation; low-quality evidence)
activity, appetite, and decreased fever for at least 1224 hours.
(strong recommendation; very low-quality evidence)
78. Patients are eligible for discharge when they demonstrate PREVENTION
consistent pulse oximetry measurements .90% in room air
XX. Can Pediatric CAP Be Prevented?
for at least 1224 hours. (strong recommendation; moderate-
Recommendations
quality evidence)
79. Patients are eligible for discharge only if they demonstrate 88. Children should be immunized with vaccines for bacterial
stable and/or baseline mental status. (strong recommendation; pathogens, including S. pneumoniae, Haemophilus influenzae
very low-quality evidence) type b, and pertussis to prevent CAP. (strong recommendation;
80. Patients are not eligible for discharge if they have high-quality evidence)
substantially increased work of breathing or sustained tachypnea 89. All infants $6 months of age and all children and
or tachycardia (strong recommendation; high-quality evidence) adolescents should be immunized annually with vaccines for
81. Patients should have documentation that they can tolerate influenza virus to prevent CAP. (strong recommendation; high-
their home anti-infective regimen, whether oral or intravenous, quality evidence)
and home oxygen regimen, if applicable, before hospital 90. Parents and caretakers of infants ,6 months of age,
discharge. (strong recommendation; low-quality evidence) including pregnant adolescents, should be immunized with
82. For infants or young children requiring outpatient oral vaccines for influenza virus and pertussis to protect the infants
antibiotic therapy, clinicians should demonstrate that parents from exposure. (strong recommendation; weak-quality evidence)
are able to administer and children are able to comply 91. Pneumococcal CAP after influenza virus infection is
adequately with taking those antibiotics before discharge. decreased by immunization against influenza virus. (strong
(weak recommendation; very low-quality evidence) recommendation; weak-quality evidence)
83. For children who have had a chest tube and meet the 92. High-risk infants should be provided immune prophylaxis
requirements listed above, hospital discharge is appropriate with respiratory syncytial virus (RSV)specific monoclonal anti-
after the chest tube has been removed for 1224 hours, either body to decrease the risk of severe pneumonia and hospitalization
if there is no clinical evidence of deterioration since removal or caused by RSV. (strong recommendation; high-quality evidence)

Pediatric Community Pneumonia Guidelines d CID 2011:53 (1 October) d 629

Notes S. S. S. receives research support from the National Institutes of Health and
the Robert Wood Johnson Foundation. He received past research support
Acknowledgments. The members of the panel wish to express their from Wyeth Pharmaceuticals (completed September 2009); the funding was
gratitude to Drs Joseph St Geme, Richard L. Hodinka, Michael Light, and to his employer. All other authors: No reported conflicts.
Karen L. McGowan for their thoughtful review of earlier drafts of the All authors have submitted the ICMJE Form for Disclosure of Potential
manuscript. In addition, the panel is greatly indebted to Jennifer Padberg, Conflicts of Interest. Conflicts that the editors consider relevant to the
MPH (IDSA), and Christy Phillips, MSA (PIDS), for exceptional organiza- content of the manuscript have been disclosed.
tional skills in coordinating meetings, conference calls and several drafts of
the guidelines manuscript conforming to the new GRADE (Grades of Rec-
ommendation, Assessment, Development, and Evaluation) method of as- References
signing a strength to the recommendations and the quality of the evidence.
The recommendations in this report do not represent an official doc- 1. Dean NC, Bateman KA, Donnelly SM, et al. Improved clinical outcomes
ument of the Centers for Disease Control and Prevention. with utilization of a community-acquired pneumonia guideline. Chest
Financial support. This work was supported by the IDSA. 2006; 130:7949.
Potential conflicts of interest. J. S. B. has received no pharmaceutical 2. McCabe C, Kirchner C, Zhang H, et al. Guideline-concordant therapy
funding or support during the past 36 months for management of pediatric and reduced mortality and length of stay in adults with community-
CAP. C. L. B. served as principal investigator on Wyeth/Pfizer clinical trials of acquired pneumonia: playing by the rules. Arch Intern Med 2009;
PCV13; the funding was to her employer, the University of Utah. C. H. has 169:152531.
received honoraria from Sanofi Pasteur, and his employer has received grant 3. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus
funds for research performed by C. H. from Johnson & Johnson Pharma- on rating quality of evidence and strength of recommendations. BMJ
ceuticals, Cubist, Merck, Sanofi Pasteur, Astellas, and GlaxoSmithKline. 2008; 336:9246.
S. L. K. has served as a consultant for Pfizer, GlaxoSmithKline, and Novartis. 27. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases
S. E. M. has served as principal investigator on a Gebauer clinical trial for Society of America/American Thoracic Society consensus guidelines on
vapocoolant and a clinical site investigator for a multicenter Baxter Hylenex the management of community-acquired pneumonia in adults. Clin
clinical trial, the funding for both trials was to her employer, the Cleveland Infect Dis 2007; 44(Suppl 2):S2772.
Clinic; she has also served as consultant for Baxter Health Care, Halozyme 70. Duncan H, Hutchison J, Parshuram CS. The Pediatric Early Warning
Therapeutics, Pricara (Ortho-McNeil-Janssen), Rox-888, and Venasite. System score: a severity of illness score to predict urgent medical need
J. A. S. has given expert testimony for Finley, Alt, Smith, and Schamberg. in hospitalized children. J Crit Care 2006; 21:2718.

630 d CID 2011:53 (1 October) d Bradley et al