Stay informed with the latest updates on coronavirus (COVID-19). Find out more >>

Community acquired pneumonia

  • PIC logo
    PIC Endorsed
  • See also

    Pleural effusion and empyema 
    Sepsis in neonates (Neonatal eHandbook)
    Assessment of severity of respiratory conditions

    Key Points

    1. Community acquired pneumonia (CAP) can be diagnosed clinically when there are signs of a lower respiratory tract infection and wheezing syndromes have been ruled out
    2. CXR is not required for routine diagnosis or management, unless severe or complicated pneumonia is suspected
    3. Blood tests and microbiological investigations are not recommended for routine use in the diagnosis and management of CAP
    4. For non-severe pneumonia, high dose oral amoxicillin is recommended, even for inpatient use 
    5. For infants <1 month of age see Sepsis in neonates


    • Pneumonia can be defined clinically as the presence of fever, cough and tachypnoea at rest (and retractions in younger children) when clinical wheezing syndromes have been ruled out
    • “Complicated pneumonia” occurs when there is a complication such as parapneumonic effusion, empyema, lung abscess, or necrotising pneumonia 



    • Fever
    • Fast breathing at rest
    • Cough
    • Increased work of breathing/respiratory distress
    • Apnoea


    • Appears lethargic/unwell  
    • Hypoxaemia
    • Tachypnoea
    • Chest wall in-drawing, retractions, grunting, nasal flaring
    • Crackles and bronchial breathing on auscultation
    • Absent breath sounds and a dull percussion note suggest a pleural effusion  

    Assessment of severity

    Severe pneumonia should be considered if there are clinical features of pneumonia and 1 or more of:



    Investigations, including CXR, are not recommended routinely for CAP, particularly in those with mild disease who are expected to be managed as an outpatient 

    Chest X-Ray (posteroanterior view)

    • Recommended for children who require admission or if severe or complicated pneumonia is suspected
    • Consider repeating if the child fails to clinically improve after 48–72 hours of appropriate antibiotic therapy
    • Follow-up CXR is not required for those who recover uneventfully
    • Follow-up CXR is recommended after 4–6 weeks for:
      • complicated pneumonia
      • persistent signs
      • recurrent pneumonia involving the same lobe or if initial suspicion of a chest mass, anatomical abnormality or foreign body

    Severe or complicated pneumonia

    • UEC for children receiving intravenous fluids 
    • FBE and blood film 
    • Microbiological investigations 
      • Blood culture has a low yield and is more likely to be positive if empyema is present or in a child with severe/complicated pneumonia
      • Testing for influenza (nasal swab or aspirate for PCR)
      • Avoid testing for other viral pathogens (will not change management)
    • Acute phase reactants (particularly CRP and procalcitonin) cannot distinguish between a viral or bacterial cause nor indicate severity. Consider testing to monitor progress


    Admission to hospital is required for oxygenation, fluid therapy or moderate to severe work of breathing

    • Check oxygen saturations and provide supplemental oxygen if saturations are <90%  
    • If giving NG or IV fluids as maintenance therapy, limit fluids to 2/3rds of the child’s calculated fluid requirement to avoid fluid overload, with regular clinical review of fluid status
    • Advice regarding antibiotic management is summarised in the algorithm below. High dose oral amoxicillin is considered as effective as IV benzylpenicillin   
    • Most children can be managed with oral antibiotics 
    • Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines

    Child with suspected pneumonia


    Penicillin hypersensitivity

    Non-beta-lactam antibiotic alternatives include  

    • Azithromycin 10 mg/kg (max 500 mg) oral daily — instead of oral amoxicillin or
    • Doxycycline for 8–18 years, 2 mg/kg (maximum 100 mg) oral twice daily on day 1, then 2 mg/kg (maximum 100 mg) once daily — instead of oral amoxicillin. Use rounded doses:
      • <26 kg: 50 mg
      • 26 kg to 35 kg: 75 mg
      • >35 kg: 100 mg
      • Doxycycline has not been associated with tooth discolouration, enamel hypoplasia or bone deposition, even in children younger than 8 years, however, use is limited by the lack of a suitable formulation
    • Vancomycin IV (see local hospital protocol for doses) instead of benzylpenicillin or cefotaxime/ceftriaxone

    For further information refer to Therapeutic Guidelines 

    Atypical pneumonia

    • Testing for causes of atypical pneumonia (including Mycoplasma) rarely influences management, as it does not differentiate infection from asymptomatic carriage 
    • There is no proven benefit from treatment with macrolides alone or in combination with β-lactams in children with suspected or confirmed atypical pneumonia. The only exception in practice is in cases of severe pneumonia — azithromycin may be considered (as the perceived benefit is greater) 

    Consider consultation with local paediatric team when

    • Fulfills criteria for hospital admission
    • Outpatient therapy fails

    Consider transfer when

    • Severe or complicated pneumonia
    • Comorbidities such as cardiac disease, chronic respiratory disease, immune deficiency or suppression are present
    • Child requiring care above the level of comfort of the local hospital
    • Child has an O2 requirement is FiO2 of >50%

    For emergency advice and paediatric or neonatal ICU transfers, call Retrieval Services

    Consider discharge when

    Child is maintaining adequate oxygenation and oral intake. 
    Note: children managed as outpatients should have medical review in 24–48 hrs

    Parent information sheet



    Last revised February, 2020

  • Reference List

    1. Ambroggio L, Brokamp C, Mantyla R et al. Validation of the British Thoracic Society Severity Criteria for Pediatric Community-acquired Pneumonia. Pediatr Infect Dis J 2019;38:894–899
    2. Ambroggio L. Beta-lactam versus beta- lactam/macrolide therapy in pediatric outpatient pneumonia. Pediatr Pulmonol. 2016 May;51(5):541-8.
    3. Ambroggio L, Test M, Metlay JP, Graf TR, Blosky MA, Macaluso M, Shah SS Comparative Effectiveness of Beta-lactam Versus Macrolide Monotherapy in Children with Pneumonia Diagnosed in the Outpatient Setting. Pediatr Infect Dis J. 2015 Aug;34(8):839-42.
    4. Biondi E, McCulloh R, Alverson B, Klein A, Dixon A, Ralston S. Treatment of mycoplasma pneumonia: a systematic review. Pediatrics. 2014 Jun;133(6):1081-90. doi: 10.1542/peds.2013-3729
    5. Bradley, J.S., Byington, C.L., Shah, S.S. 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. Clin Infect Dis, 2011; 53:e25.
    6. Brendan J McMulla BJ, Andresen D, Blyth CC et al. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines. Lancet Infect Dis 2016; 16: e139–52
    7. Chaves GS, Freitas DA, Santino TA, et al. Chest physiotherapy for pneumonia in children. Cochrane Database Syst Rev 2019; 1:CD010277.
    8. Dean P, Florin TA. Factors Associated With Pneumonia Severity in Children: A Systematic Review. Journal of the Pediatric Infectious Diseases Society 2018;7(4):323–34
    9. Fritz CQ, Edwards KM, Self WH, et al. Prevalence, Risk Factors, and Outcomes of Bacteremic Pneumonia in Children. Pediatrics. 2019;144(1):e20183090
    10. Gardiner SJ, Gavranich JB, Chang AB. Antibiotics for community-acquired lower respiratory tract infections secondary to Mycoplasma pneumoniae in children. Cochrane Database Syst Rev. 2015 Jan 8;1:CD004875.
    11. Harris, M., Clark, J., Coote, N. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax, 2011; 66:ii1
    12. Jain S, Williams DJ, Arnold SR. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Children. N Engl J Med 2015; 372:835-845 DOI: 10.1056/NEJMoa1405870. Retrieved from:
    13. Lassi ZS, Imdad A, Bhutta ZA. Short-course versus long-course intravenous therapy with the same antibiotic for severe community-acquired pneumonia in children aged two months to 59 months. Cochrane Database Syst Rev 2017; 10:CD008032.
    14. Leyenaar JK, Shieh MS, Lagu T, Pekow PS, Lindenauer P. Comparative effectiveness of ceftriaxone in combination with a macrolide compared with ceftriaxone alone for pediatric patients hospitalized with community-acquired pneumonia. Pediatr Infect Dis J. 2014 Apr;33(4):387-92.
    15. McCrossan P, McNaughten B, Shields M, Thompson A. Is follow up chest X-ray required in children with round pneumonia? Arch Dis Child 2017; 102:1182.
    16. McCulloh, R.J. & Patel, K. Recent Developments in Pediatric Community-Acquired Pneumonia. Curr Infect Dis Rep (2016) 18: 14. Retrieved from:
    17. Nascimento-Carvalho CM; Madhi SA; O'Brien KL. Review of guidelines for evidence-based management for childhood community- acquired pneumonia in under-5 years from developed and developing countries. Pediatric Infectious Disease Journal. 2013;32(11):1281-2
    18. Shah S, Florin T, Ambroggio L. Procalcitonin in Childhood Pneumonia, Journal of the Pediatric Infectious Diseases Society, 2018;7(1): 54 – 55
    19. Stockmann C, Ampofo K, Killpack J, et al. Procalcitonin Accurately Identifies Hospitalized Children With Low Risk of Bacterial Community-Acquired Pneumonia. J Pediatric Infect Dis Soc. 2018;7(1):46–53. doi:10.1093/jpids/piw091
    20. Williams DJ, Edwards KM, Self WH et al. Effectiveness ofβ-Lactam Monotherapy vs Macrolide Combination Therapy for Children Hospitalized With Pneumonia. JAMA Pediatr. 2017;171(12):1184.
    21. Williams DJ, Zhu Y, Grijalva CG, et al. Predicting Severe Pneumonia Outcomes in Children. Pediatrics. 2016; 138(4):e20161019