This document provides clinical guidance for all staff involved in the care and management of a child >1
month old presenting to an Emergency Department (ED) in Queensland with symptoms suggestive of
Community Acquired Pneumonia (CAP).
This guideline has been developed by senior ED clinicians and Paediatricians, with input from Infection
Management team, Respiratory Service and Pharmacy department at Queensland Children’s Hospital,
Brisbane.
ALERT – For children with signs of septic shock please see the Sepsis Guideline (CHQGDL-60010).
Introduction
Community acquired pneumonia in childhood is an important cause of morbidity in both the developed and
developing world. Children with symptoms consistent with CAP present frequently to emergency
departments across Queensland. CAP is estimated to have an incidence of 5 to 8 cases per 1000 person
years in Australia.
7 The incidence is highest in children less than 5 years old, Indigenous patients and the
unimmunised population. The rate of CAP has fortunately reduced in the developed world secondary to
Hib and pneumococcal vaccination. This guideline provides guidance regarding the diagnosis, risk
stratification, investigation and management of these children.
Key points
• A CXR does not need to be routinely performed in children with mild/moderate disease who
will be managed as an outpatient if a complication of pneumonia is not clinically suspected.
• High dose oral amoxicillin 25 mg/kg (Maximum 1 g/dose) three times a day is recommended
in uncomplicated cases of mild/moderate and severe CAP even if patient is admitted if the
patient is tolerating oral intake (and not requiring ICU/HDU care).
• In childhood CAP, the benefit of empirical therapy for atypical bacteria is uncertain. In
children hospitalised with CAP, add therapy for atypical bacteria only when B.pertussis
or M.pneumonaie are clinically suspected.
• Blood and microbiological tests are not recommended for routine use in CAP.
• Viruses are the most common cause of CAP in children over 2 months old.
Assessment
ALERT – Bacterial pneumonia should be considered in children when there is persistent or
repetitive fever >38.5 degrees Celsius together with chest recession and a raised respiratory
rate
A reasonable definition of pneumonia in childhood may be a persistent or repetitive fever, cough and
tachypnoea at rest when clinical wheezing syndromes have been ruled out.
pneumonia in any child with fever and tachypnoea if there is not a clear alternate diagnosis. Radiological
changes are not required to make the clinical diagnosis as an x-ray is not required in simple pneumonia
managed as an outpatient and radiological features can lag behind clinical symptoms.
Community acquired pneumonia is defined as pneumonia occurring in a previously healthy child (or child
without respiratory comorbidities) due to an infection acquired outside hospital.
Symptoms/signs that could suggest a pneumonia include; fever, cough, tachypnoea, increased WOB,
grunting, abdominal pain, chest pain, focal or diffuse changes in air entry or crackles/crepitations on chest
auscultation, dullness to chest percussion or a new oxygen requirement.
There are multiple potential causative organisms in CAP including viruses, bacteria and atypical bacteria.
There is no reliable clinical or radiological way to distinguish between these potential causative agents.
CAP in children is usually viral, commonly Respiratory syncytial virus (RSV), Adenovirus, Parainfluenza
virus, Influenza virus and Human metapneumovirus. The most common bacterial causes are
Streptococcus pneumoniae, Staphylococcus aureus and Mycoplasma pneumoniae. Less common
pathogens include Chlamydia trachomatis and Bordetella pertussis.
The assessment of any child with pneumonia should include an assessment of the severity of the illness,
as well as an assessment for signs of complications of pneumonia including; sepsis, dehydration,
empyema, necrotising pneumonia, lung abscess or pleural effusion. Consider risk factors for more severe
disease such as younger age, indigenous status, comorbidities and immunosuppression
Atypical Bacteria
In children hospitalised with CAP, the benefit of empirical therapy for atypical bacteria is uncertain. It is
reasonable to add therapy for atypical bacteria to amoxicillin if:
• Bordetella pertussis is suspected (e.g. children who have been in contact with a pertussis case,
children with paroxysmal cough associated with cyanosis or apnoea), while awaiting the results
of PCR performed on nasopharyngeal samples
• M. pneumoniae is suspected (e.g. school-aged children with rash, children with a household
contact who has M. pneumoniae infection, chest pain14).
In children with mild to moderate CAP managed as an outpatient it is reasonable to commence
amoxicillin alone (without the need for testing) with a plan to add a macrolide (i.e. roxithromycin or
azithromycin) if symptoms are not improving after 48 hours (unless Bordetella pertussis is suspected
clinically).