MDM Templates

PNA — Outpatient

Child presents with cough, fever, and focal findings on auscultation. Well appearing, no respiratory distress, oxygen saturation ≥95% on room air, tolerating oral intake. No signs of effusion or complicated disease.

Presentation consistent with uncomplicated community-acquired pneumonia. CXR is not routinely indicated for uncomplicated outpatient CAP in an immunized child per IDSA 2011 guidelines. Not consistent with foreign body aspiration, reactive airway disease, or cardiac disease.^[1]

Plan: High-dose amoxicillin 90 mg/kg/day divided BID (max 4 g/day). Discharge with PCP follow-up in 48-72 hours. Return for worsening respiratory distress, inability to tolerate PO, persistent high fever despite antibiotics, or signs of systemic toxicity.

If >5 years with atypical features (gradual onset, prominent cough, no focal findings): Consider azithromycin for Mycoplasma coverage.

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PNA — Admit

Child presents with clinical pneumonia and meets admission criteria — hypoxemia (SpO2 <95%), moderate-severe respiratory distress, inability to tolerate oral intake, or high-risk features (age ❤ months, immunocompromised, sickle cell disease).

Severity of illness warrants inpatient management. Differential includes bacterial pneumonia, viral pneumonia, and mixed infection. CXR obtained to assess extent and evaluate for effusion or complicated disease.^[1]

Plan: IV antibiotics (ampicillin for most immunized children; ceftriaxone if unimmunized or concern for resistant organisms). Supplemental oxygen to maintain SpO2 ≥95%. IV fluids if not tolerating PO. Blood culture obtained prior to antibiotics. Transition to oral therapy when afebrile and tolerating PO.

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PNA — Complicated / Empyema Concern

Child with pneumonia presenting with persistent fever beyond 72 hours of appropriate antibiotics, or initial presentation with large pleural effusion on CXR. Clinical deterioration despite treatment raises concern for parapneumonic effusion or empyema.

Complicated pneumonia requires evaluation for effusion and possible drainage. Not consistent with treatment failure from antibiotic resistance alone given the degree of clinical worsening and imaging findings.^[1]

Plan: Chest ultrasound to characterize effusion (simple vs complex/loculated). If significant effusion with septations or clinical worsening, pediatric surgery or interventional radiology consulted for drainage (chest tube or pigtail catheter). Broaden antibiotics to cover resistant organisms. Admit for IV antibiotics, serial imaging, and monitoring of clinical response.

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Clinical Education

Diagnosis

Pediatric CAP is primarily a clinical diagnosis. CXR is NOT routinely recommended for uncomplicated outpatient CAP per IDSA 2011 guidelines. Obtain CXR if: diagnosis uncertain, child requires admission, hypoxemia present, or concern for complicated disease (effusion, abscess).^[1]

Tachypnea is the most sensitive clinical finding for pneumonia in children. WHO criteria: >60 breaths/min (<2 months), >50 (<12 months), >40 (1-5 years), >20 (>5 years). Focal crackles, decreased breath sounds, and dullness to percussion increase specificity.

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Age-Based Pathogens and Antibiotics

Age	Common Pathogens	First-Line Antibiotic
❤ months	GBS, E. coli, Listeria	Ampicillin + gentamicin (admit all)
3 mo – 5 yr	Viruses (RSV, influenza), S. pneumoniae	High-dose amoxicillin 90 mg/kg/day
>5 years	S. pneumoniae, Mycoplasma	Amoxicillin; add azithromycin if atypical
MRSA concern	S. aureus (necrotizing PNA, empyema)	Vancomycin or clindamycin

Amoxicillin is first-line for immunized children per IDSA 2011, replacing prior broader-spectrum empiric regimens. This reflects antimicrobial stewardship principles while maintaining excellent clinical outcomes.^[1]

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Viral vs Bacterial

Viral respiratory panel (RVP) does not exclude bacterial coinfection. Approximately 23% of children with bacterial CAP also have concurrent viral infection. A positive RVP should not delay antibiotics in a child with clinical pneumonia. Use RVP results to inform de-escalation, not to withhold treatment.^[2]

Features favoring bacterial over pure viral: focal consolidation on CXR, high fever (>39°C), elevated WBC or CRP, toxic appearance. Viral pneumonia more likely with diffuse bilateral infiltrates, wheezing, and gradual onset during viral season.

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Parapneumonic Effusion and Empyema

Effusions occur in up to 30% of pneumonias. Simple parapneumonic effusion resolves with antibiotics alone. Empyema (infected, loculated fluid) requires drainage plus antibiotics. Ultrasound is the imaging modality of choice — look for septations, loculations, and complex echogenicity.^[1]

Suspect empyema when: persistent fever beyond 72 hours of appropriate antibiotics, large effusion (>2 cm on ultrasound), or clinical deterioration. Drainage via chest tube or pigtail catheter, with total antibiotic course of 3-4 weeks (IV to oral transition).

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Disposition

Admit: Hypoxemia (SpO2 <95%). Moderate-severe respiratory distress. Unable to tolerate PO. Age ❤ months. Immunocompromised or high-risk comorbidities (sickle cell, asplenia). Complicated PNA with effusion. Failed outpatient therapy.

Discharge: Well appearing, SpO2 ≥95%, tolerating PO, reliable follow-up in 48-72 hours. Return for worsening breathing, inability to drink, persistent high fever, or chest pain.

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References

1. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the PIDS and IDSA. Clin Infect Dis. 2011;53(7):e25-e76. PubMed
2. Jain S, Williams DJ, Arnold SR, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med. 2015;372(9):835-845. PubMed