Pediatric emergency medicine trisk 2283 2283

TABLE 94.14
MANAGEMENT OF UNCOMPLICATED COMMUNITY-ACQUIRED PNEUMONIA IN PREVIOUSLY
HEALTHY CHILDREN a
Age

Outpatient

Inpatient b

Other considerations

Neonates

N/A

Ampicillin + thirdgeneration
cephalosporin

Consider empiric influenza antiviral therapy
in children with moderate–severe
pneumonia during influenza season, even
if rapid influenza diagnostic test results
are negative (these tests are insufficiently
sensitive to guide empiric therapy)

Infants

Amoxicillin

Ampicillin

Preschool aged

Amoxicillin

Ampicillin

School aged

Amoxicillin +
macrolide

Ampicillin +
macrolide

Adolescents

Amoxicillin +
macrolide

Ampicillin +
macrolide

The IDSA guidelines state that
antimicrobial therapy may not be
required routinely for preschool-aged
children with community-acquired
pneumonia, as the majority will have a
viral etiology. Laboratory parameters or
radiographic findings might help
determine need for antibiotics

a Based

upon the 2011 Infectious Diseases Society of America and the Pediatric Infectious Diseases Society guidelines for the management of
community-acquired pneumonia in children. Clin Infect Dis 2011;53(7):e25. Management for children with complicated pneumonia (e.g., empyema,
lung abscess) is discussed elsewhere. Unimmunized children should have a third-generation cephalosporin added to ampicillin, for coverage of H.
influenzae type B.
b Vancomycin or clindamycin should be added if there is clinical, laboratory, or radiographic reason to suspect staphylococcal pneumonia; critically ill
children should be treated with broad-spectrum antibiotics for pneumonia (e.g., vancomycin and cefotaxime), given that rates of resistant pneumococci
are increasing in many industrialized nations.
N/A, not applicable.

Lung Abscess
Most lung abscesses are polymicrobial and caused by aspiration of oral flora, especially in patients with underlying
neurologic disorders. The predominant anaerobes are Bacteroides, Peptostreptococcus, and Prevotella. Anaerobes,
S. aureus, pneumococcus, and nontypeable H. influenzae are the most common pathogens identified in otherwise
healthy children. Fungal pathogens and Pseudomonas should be considered in immunocompromised children. M.
tuberculosis will be discussed separately in the section on travel medicine. The most common symptoms are fever,
cough, shortness of breath, and chest pain. Symptoms have often been present for up to 2 to 3 weeks before the
child is recognized to have a lung abscess; as a consequence, weight loss is seen in some children, whereas it is an
uncommon occurrence for children with community-acquired pneumonia. Auscultation of the lungs is often
nonfocal, particularly in young children. The diagnosis usually is made by chest radiograph, which can show a
thin- or thick-walled cavity with an air–fluid level. Intrathoracic adenopathy can be found in more subacute causes
of lung abscess (e.g., tuberculosis, fungal). CT can be of use if operative intervention is planned to better delineate
the anatomy. Leukocytosis with a neutrophilic predominance is common; blood cultures are positive in 10% to
15% of cases. Gram stain of the sputum is rarely useful unless the abscess has ruptured into a bronchus and is
communicating with the airway. Percutaneous aspiration or bronchoscopy is more sensitive in yielding a
microbiologic diagnosis. Empiric antibiotic coverage should target S. aureus, pneumococcus, and anaerobes.
Clindamycin and cefotaxime is one such regimen, with the advantage that it can be readily converted from a
parenteral regimen to oral equivalents. However, for toxic-appearing children, or in regions where cephalosporinresistant pneumococci or clindamycin-resistant staphylococci are commonly seen, vancomycin should be included