Community-Acquired Pneumonia in Children: Rapid Evidence Review

 

Am Fam Physician. 2021 Dec ;104(6):618-625.

Author disclosure: No relevant financial affiliations.

In the United States, pneumonia is the most common cause of hospitalization in children. Even in hospitalized children, community-acquired pneumonia is most likely of viral etiology, with respiratory syncytial virus being the most common pathogen, especially in children younger than two years. Typical presenting signs and symptoms include tachypnea, cough, fever, and anorexia. Findings most strongly associated with an infiltrate on chest radiography in children with clinically suspected pneumonia are grunting, history of fever, retractions, crackles, tachypnea, and the overall clinical impression. Chest radiography should be ordered if the diagnosis is uncertain, if patients have hypoxemia or significant respiratory distress, or if patients fail to show clinical improvement within 48 to 72 hours after initiation of antibiotic therapy. Outpatient management of community-acquired pneumonia is appropriate in patients without respiratory distress who can tolerate oral antibiotics. Amoxicillin is the first-line antibiotic with coverage for Streptococcus pneumoniae for school-aged children, and treatment should not exceed seven days. Patients requiring hospitalization and empiric parenteral therapy should be transitioned to oral antibiotics once they are clinically improving and able to tolerate oral intake. Childhood and maternal immunizations against S. pneumoniae, Haemophilus influenzae type b, Bordetella pertussis, and influenza virus are the key to prevention.

Community-acquired pneumonia (CAP) is a lung infection contracted outside of the hospital. Lower respiratory tract infection includes pneumonia, bronchitis, bronchiolitis, or any combination of the three. In the United States, pneumonia is the most common cause of hospitalization in children.1

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Signs and symptoms most strongly associated with pneumonia found on chest radiography are grunting, history of fever, retractions, crackles, and the overall clinical impression.6,7

C

Prospective cohort study and a meta-analysis of diagnostic accuracy studies

Chest radiography should be ordered if the diagnosis is uncertain, if patients have hypoxemia or significant respiratory distress, or if patients fail to show clinical improvement within 48 to 72 hours after initiation of antibiotic therapy.11

C

Consensus guidelines

Chest ultrasonography can be used in place of chest radiography for accurate diagnosis of pneumonia in children.14

B

Single randomized controlled trial

Amoxicillin is the treatment of choice for community-acquired pneumonia in school-aged children in the outpatient setting.23

A

Systematic review showing improved patient-oriented outcomes

Childhood and maternal immunizations against bacterial and viral pathogens decrease the risk of pneumonia.11

B

High-quality cohort studies showing improved morbidity


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Signs and symptoms most strongly associated with pneumonia found on chest radiography are grunting, history of fever, retractions, crackles, and the overall clinical impression.6,7

C

Prospective cohort study and a meta-analysis of diagnostic accuracy studies

Chest radiography should be ordered if the diagnosis is uncertain, if patients have hypoxemia or significant respiratory distress, or if patients fail to show clinical improvement within 48 to 72 hours after initiation of antibiotic therapy.11

C

Consensus guidelines

Chest ultrasonography can be used in place of chest radiography for accurate diagnosis of pneumonia in children.14

B

Single randomized controlled trial

Amoxicillin is the treatment of choice for community-acquired pneumonia in school-aged children in the outpatient setting.23

A

Systematic review showing improved patient-oriented outcomes

Childhood and maternal immunizations against bacterial and viral pathogens decrease the risk of pneumonia.11

B

High-quality cohort studies showing improved morbidity


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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BEST PRACTICES IN INFECTIOUS DISEASE

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Do not use broad-spectrum antibiotics such as ceftriaxone for children hospitalized with u

The Authors

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DUSTIN K. SMITH, DO, FAAFP, is program director of the Jacksonville (Fla.) Family Medicine Residency Program at Naval Hospital Jacksonville and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

DANIEL P. KUCKEL, MD, is a faculty member at the Jacksonville Family Medicine Residency Program at Naval Hospital Jacksonville and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

ANTHONY M. RECIDORO, DO, is a resident at the Jacksonville Family Medicine Residency Program at Naval Hospital Jacksonville.

Address correspondence to Dustin K. Smith, DO, FAAFP, Family Medicine Clinic, 2080 Child St., Jacksonville, FL 32214 (email: dustin.k.smith16.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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