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peds.cap.v1PRODUCTION
peds.cap.v1

Pediatric community-acquired pneumonia (CAP)

pediatricsacutepediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm pediatric CAP scope (age 3 mo to 18 yr; community-onset within 48 h of presentation); exclude HAP / aspiration / foreign body / TB / bronchiolitis (PIDS/IDSA 2011 Bradley; WHO IMCI 2025)

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CAP framing confirmed; neonatal / bronchiolitis / aspiration / FB pathways excluded

Patient inputs (26)

Age tier drives pathogen probability + antibiotic selection (<3 mo neonatal pathway; 3 mo to <5 yr S. pneumoniae predominant; ≥5 yr Mycoplasma rises) (PIDS/IDSA 2011)

Fever pattern + magnitude; <3 mo + fever ≥38°C → route to peds.febrile-infant.core.v1 (AAP 2021 Pantell)

Age-band tachypnea per WHO IMCI 2025: ≥60 (<2 mo), ≥50 (2-12 mo), ≥40 (1-5 yr), ≥30 (≥5 yr); LR+ ~3-4 for radiographic pneumonia (Shah JAMA 2017)

SpO2 <92% → admission threshold per PIDS/IDSA 2011; LR+ ~3-5 for severe disease

Tachycardia + perfusion assessment for sepsis (SSC Pediatrics 2020)

Retractions / grunting / nasal flaring / head bobbing — severity (WHO IMCI 2025; BTS 2024)

Inability to feed / drink in young child = WHO IMCI severe pneumonia

PCV13/PCV15/PCV20, Hib, influenza, COVID coverage drives pathogen risk + empiric choice (PIDS/IDSA 2011; ACIP 2025)

β-lactam allergy severity drives macrolide vs alternative; baseline meds for interactions (PIDS/IDSA 2011)

Focal crackles + bronchial breathing + decreased breath sounds — LR+ ~ 5-7 for radiographic pneumonia vs viral bronchiolitis (Wingerter 2012)

Lethargy / irritability / AMS = severe disease marker (WHO IMCI 2025; SSC Pediatrics 2020)

All antibiotic + fluid dosing is weight-based (mg/kg/day; mL/kg) (PIDS/IDSA 2011)

Atypical screen ≥5 yr or extrapulmonary features (PIDS/IDSA 2011)

Moderate-large effusion → diagnostic + therapeutic drainage (PIDS/IDSA 2011; BTS 2024)

CT chest for non-resolving / complicated pneumonia (necrosis / abscess / fistula) (PIDS/IDSA 2011)

Resistant pathogen risk; HAP overlay if hospitalized in last 90 d (PIDS/IDSA 2011)

CF / neuromuscular / BPD / asthma raise risk + change empiric coverage (PIDS/IDSA 2011)

Sickle cell / HIV / transplant / malignancy / chronic steroid — broaden coverage + consider atypical pathogens (PIDS/IDSA 2011)

TB / pertussis / COVID household contact alters differential + workup (WHO 2024 TB peds; Red Book 2021)

WBC + bandemia pattern — severity adjunct, not specific (PIDS/IDSA 2011)

CRP >40-100 mg/L + procalcitonin >0.5-1 ng/mL raises bacterial probability — LR+ ~2-3 for bacterial CAP (NICE 2019)

PCT <0.25 ng/mL → bacterial CAP unlikely (LR− ~0.3); selective use to shorten duration (NICE 2019; CAP-IT 2021)

Required if hospitalized / severe / complicated CAP per PIDS/IDSA 2011; low yield ~ 1-7% in uncomplicated CAP (Myers 2013)

RSV / influenza / SARS-CoV-2 / parainfluenza / adenovirus — viral predominance under 5 yr (PIDS/IDSA 2011)

Required for moderate-severe / hospitalized / complicated CAP; NOT routine for outpatient mild (PIDS/IDSA 2011; BTS 2024)

Sensitive for consolidation + effusion; replaces or supplements CXR in many centers (BTS 2024; Pereda Pediatrics 2015)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningseptic_shock_peds_cap
    Pediatric CAP with sepsis-induced hypotension / shock features — abnormal capillary refill / mottled / cold extremities / altered mental status / hypotension for age (SSC Pediatrics 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningapnea_in_infant_with_cap
    Apnea / extreme bradypnea in an infant with CAP — particularly RSV / pertussis co-infection (PIDS/IDSA 2011; AAP 2014 Ralston)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverespo2_under_92_peds_cap
    SpO2 <92% on room air in pediatric CAP — PIDS/IDSA 2011 admission threshold; LR+ ~3-5 for severe disease
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereparapneumonic_effusion_or_empyema
    Moderate-large parapneumonic effusion or empyema on CXR / ultrasound / CT — complicated CAP (PIDS/IDSA 2011; BTS 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenecrotizing_pneumonia_peds_cap
    Cavitation / pneumatocele / necrotizing features on imaging or persistent fever despite appropriate abx (PIDS/IDSA 2011; BTS 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereage_under_3_months_with_fever_and_resp_symptoms
    Age <3 mo with fever ≥38°C rectal and respiratory illness — route to peds.febrile-infant.core.v1 sepsis pathway (AAP 2021 Pantell)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverewho_imci_severe_pneumonia
    WHO IMCI severe pneumonia — central cyanosis OR inability to feed/drink OR persistent vomiting OR AMS / convulsions / lethargy OR severe respiratory distress (head nodding, grunting, severe chest indrawing) (WHO IMCI 2025)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecomplicated_cap_lung_abscess
    Lung abscess on imaging — cavitary lesion with air-fluid level (PIDS/IDSA 2011; BTS 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateoutpatient_failure_at_48_72h
    No improvement at 48-72 h on first-line outpatient antibiotic — persistent fever, worsening WOB, new hypoxemia, decreased PO (PIDS/IDSA 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_or_non_resolving_cap
    Recurrent pneumonia (≥2 episodes in 1 year OR ≥3 lifetime) OR non-resolving pneumonia (persistent infiltrate >4 weeks) — workup for underlying structural / immune / aspiration cause (PIDS/IDSA 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

PIDS/IDSA pediatric CAP empiric antibiotics — outpatient → ward → PICU; age + immunization + severity-tiered (PIDS/IDSA 2011 Bradley + 2024 update; WHO IMCI 2025; BTS 2024)
axis: peds_cap_empiric_antibioticsstep outpatient_3mo_to_5yr_immunized - Outpatient — age 3 mo to <5 yr — fully immunized — typical bacterial coverage
Selected step "Outpatient — age 3 mo to <5 yr — fully immunized — typical bacterial coverage" — Outpatient CAP, age ≥3 mo to <5 yr, fully immunized (PCV13/15/20 + Hib), SpO2 ≥92%, tolerating PO, mild-moderate WOB
  • amoxicillin
    first line
    aminopenicillin
    90 mg/kg/day PO divided BID or TID (max 4 g/day) • PO • q8-12h × 5 days
    triggers: outpatient_cap_3mo_to_5yr_immunized
    PIDS/IDSA 2011 first-line; high-dose covers DRSP; CAP-IT 2021 validated 3-day course in mild, 5-day standard
    rxcui 723
  • azithromycin
    second line
    macrolide
    10 mg/kg PO day 1 (max 500 mg) then 5 mg/kg/day (max 250 mg) days 2-5 • PO • daily × 5 days
    triggers: severe_beta_lactam_allergy, atypical_suspected
    Reserved for severe β-lactam allergy or atypical concern; macrolide resistance up to 10-20% in some regions
    rxcui 18631

outpatient playbook — drug actions (3)

  1. 1. amoxicillin
    rxcui 723
    90 mg/kg/day divided BID or TID (max 4 g/day) • PO • q8-12h × 5 days
    trigger: Outpatient CAP age ≥3 mo, immunized, SpO2 ≥92%, tolerating PO
    PIDS/IDSA 2011 first-line; CAP-IT 2021 validated short course
  2. 2. azithromycin
    rxcui 18631
    10 mg/kg day 1 (max 500 mg) then 5 mg/kg/day (max 250 mg) days 2-5 • PO • daily × 5 days
    trigger: Atypical (Mycoplasma) ≥5 yr OR severe β-lactam allergy
    Atypical coverage (PIDS/IDSA 2011)
  3. 3. oseltamivir
    rxcui 260101
    Weight-based BID • PO • q12h × 5 days
    trigger: Influenza season + influenza-positive or strongly suspected
    CDC + IDSA 2018 — reduces complications (Louie 2009)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Fever + cough + age-band tachypnea in a child (PIDS/IDSA 2011 Bradley; WHO IMCI 2025); Retractions / nasal flaring / grunting / accessory muscle use (WHO IMCI 2025; BTS 2024); SpO2 <92% in a child with respiratory illness (PIDS/IDSA 2011; BTS 2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric community-acquired pneumonia (CAP)** (peds.cap.v1).
Phenotype framing: Bacterial typical (S. pneumoniae > H. influenzae > GAS > S. aureus including MRSA) vs atypical (Mycoplasma ≥5 yr, Chlamydophila) vs viral (RSV / influenza / SARS-CoV-2 / parainfluenza / adenovirus / hMPV) vs aspiration vs TB vs FB vs bronchiolitis (<2 yr) vs asthma exacerbation with mucus plugging (PIDS/IDSA 2011)
Scope: Confirm pediatric CAP scope (age 3 mo to 18 yr; community-onset within 48 h of presentation); exclude HAP / aspiration / foreign body / TB / bronchiolitis (PIDS/IDSA 2011 Bradley; WHO IMCI 2025)

No severity triggers fired against current inputs.

Plan

Regimen axis: **PIDS/IDSA pediatric CAP empiric antibiotics — outpatient → ward → PICU; age + immunization + severity-tiered (PIDS/IDSA 2011 Bradley + 2024 update; WHO IMCI 2025; BTS 2024)** — step "Outpatient — age 3 mo to <5 yr — fully immunized — typical bacterial coverage".
1. amoxicillin 90 mg/kg/day PO divided BID or TID (max 4 g/day) PO q8-12h × 5 days (aminopenicillin, first line) — PIDS/IDSA 2011 first-line; high-dose covers DRSP; CAP-IT 2021 validated 3-day course in mild, 5-day standard
2. azithromycin 10 mg/kg PO day 1 (max 500 mg) then 5 mg/kg/day (max 250 mg) days 2-5 PO daily × 5 days (macrolide, second line) — Reserved for severe β-lactam allergy or atypical concern; macrolide resistance up to 10-20% in some regions

Setting playbook (outpatient) — Treat mild pediatric CAP with first-line oral amoxicillin; counsel return precautions; arrange 48-72 h reassessment (PIDS/IDSA 2011; WHO IMCI 2025; BTS 2024)
3. amoxicillin 90 mg/kg/day divided BID or TID (max 4 g/day) PO q8-12h × 5 days — Outpatient CAP age ≥3 mo, immunized, SpO2 ≥92%, tolerating PO (PIDS/IDSA 2011 first-line; CAP-IT 2021 validated short course)
4. azithromycin 10 mg/kg day 1 (max 500 mg) then 5 mg/kg/day (max 250 mg) days 2-5 PO daily × 5 days — Atypical (Mycoplasma) ≥5 yr OR severe β-lactam allergy (Atypical coverage (PIDS/IDSA 2011))
5. oseltamivir Weight-based BID PO q12h × 5 days — Influenza season + influenza-positive or strongly suspected (CDC + IDSA 2018 — reduces complications (Louie 2009))

Non-pharmacologic actions:
- Antipyretics for comfort (NICE 2019)
- Hydration instructions — small frequent fluids; ORS if mild dehydration (WHO IMCI 2025)
- Return precautions — worsening dyspnea, cyanosis, decreased PO, lethargy, persistent fever beyond 48-72 h, new chest pain (PIDS/IDSA 2011; WHO IMCI 2025)
- Caregiver education on adherence + course completion (AAP)
- Immunization catch-up at convalescent visit (ACIP 2025)
- Smoke-exposure cessation counseling for household (AAP)

AVOID / contraindication checks:
- Macrolide_qt_check_in_baseline_qt_prolongation (PIDS/IDSA 2011)
- Doxycycline_short_course_any_age_acceptable (AAP 2018)
- Fluoroquinolone_avoid_in_pediatric_unless_no_alternative_cartilage_tendon_concerns (AAP)
- Vancomycin_auc_target_400_to_600_with_renal_function_check_q48h (Rybak IDSA 2020 PMID 32191793)
- Ceftriaxone_avoid_under_28d_bilirubin_displacement_calcium_iv_interaction (FDA 2009; AAP 2021 Pantell)
- Erythromycin_avoid_under_1_month_pyloric_stenosis_risk_use_azithromycin (Red Book 2021 CDC)
- Beta_lactam_allergy_clarify_severity_before_avoiding_consider_test_dose (PIDS/IDSA 2011)
- Judicious_fluid_resuscitation_avoid_over_resuscitation_in_severe_pneumonia_siadh_risk (FEAST 2011 PMID 21615299; PIDS/IDSA 2011)

Monitoring

Regimen monitoring:
- clinical response at 48 to 72h temperature wob oxygen demand feeding (PIDS/IDSA 2011)
- iv to po switch when afebrile 24h and tolerating po (PIDS/IDSA 2011)
- duration 5 days uncomplicated validated by cap it 2021 (PIDS 2024 update)
- duration 10 to 21 days for complicated pneumonia empyema necrotizing (PIDS/IDSA 2011)
- vancomycin auc 400 to 600 or trough 15 to 20 with renal function q48h (Rybak IDSA 2020)
- cxr at 4 to 6 weeks for round or lobar or complicated pneumonia (BTS 2024)
- serum sodium monitoring for siadh risk in severe cap (PIDS/IDSA 2011)

Setting (outpatient) monitoring:
- Reassess at 48-72 h by phone or clinic (PIDS/IDSA 2011)
- CXR at 4-6 weeks if round / lobar / non-resolving (BTS 2024)
- Weight gain + feeding tolerance (WHO IMCI 2025)

Follow-up plan: PCP follow-up 1-2 wk; CXR at 4-6 wk for round / lobar / non-resolving pneumonia (BTS 2024); immunization catch-up (PCV / Hib / influenza / COVID) per ACIP 2025; smoke-exposure cessation; immunology workup if recurrent / non-resolving; pulmonology referral if structural concern (PIDS/IDSA 2011; AAP Bright Futures)
- Close-out criterion: Follow-up scheduled + prevention plan + immunization catch-up documented

Monitoring phase: Clinical response at 48-72 h (afebrile, improving WOB, weaning oxygen, tolerating PO); switch IV→PO when afebrile 24 h + tolerating PO; reassess for resistance / complication / alternate diagnosis if failure; vancomycin trough or AUC if used (PIDS/IDSA 2011; BTS 2024)

Disposition

Current setting: outpatient — Treat mild pediatric CAP with first-line oral amoxicillin; counsel return precautions; arrange 48-72 h reassessment (PIDS/IDSA 2011; WHO IMCI 2025; BTS 2024)

Disposition criteria:
- Continue outpatient if afebrile / improving by 48-72 h (PIDS/IDSA 2011)
- Switch / escalate if not improving (PIDS/IDSA 2011)
- Document follow-up + return precautions + immunization plan (ACIP 2025)

Escalation triggers (move to higher acuity):
- SpO2 <92% → admit (PIDS/IDSA 2011)
- Inability to tolerate PO / dehydration → admit (PIDS/IDSA 2011)
- Worsening at 48-72 h despite first-line abx → admit / step up (PIDS/IDSA 2011)
- Age <3 mo with fever ≥38°C → ED + sepsis workup per peds.febrile-infant.core.v1 (AAP 2021 Pantell)
- Apnea / seizure / AMS → ED + admit (WHO IMCI 2025)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Pediatric CAP with sepsis-induced hypotension / shock features — abnormal capillary refill / mottled / cold extremities / altered mental status / hypotension for age (SSC Pediatrics 2020)
- [LIFE_THREATENING] Apnea / extreme bradypnea in an infant with CAP — particularly RSV / pertussis co-infection (PIDS/IDSA 2011; AAP 2014 Ralston)
- [SEVERE] SpO2 <92% on room air in pediatric CAP — PIDS/IDSA 2011 admission threshold; LR+ ~3-5 for severe disease

Citations

- PIDS/IDSA 2011 pediatric CAP guideline (Bradley) + 2024 short-course update (CAP-IT 2021) + WHO IMCI 2025 + BTS 2024 pediatric pneumonia + SSC Pediatrics 2020/2024 + AAP 2021 Pantell febrile infant (neonatal routing) [PMID:21880587](https://pubmed.ncbi.nlm.nih.gov/21880587/)
- Cited evidence (PMID 34499792) [PMID:34499792](https://pubmed.ncbi.nlm.nih.gov/34499792/)
- Cited evidence (PMID 32191793) [PMID:32191793](https://pubmed.ncbi.nlm.nih.gov/32191793/)
- Cited evidence (PMID 29562151) [PMID:29562151](https://pubmed.ncbi.nlm.nih.gov/29562151/)
- Cited evidence (PMID 21615299) [PMID:21615299](https://pubmed.ncbi.nlm.nih.gov/21615299/)

Last reconciled with current guidelines: 2026-05-15.
References
  • PIDS/IDSA 2011 pediatric CAP guideline (Bradley) + 2024 short-course update (CAP-IT 2021) + WHO IMCI 2025 + BTS 2024 pediatric pneumonia + SSC Pediatrics 2020/2024 + AAP 2021 Pantell febrile infant (neonatal routing) — PMID:21880587
  • Cited evidence (PMID 34499792) — PMID:34499792
  • Cited evidence (PMID 32191793) — PMID:32191793
  • Cited evidence (PMID 29562151) — PMID:29562151
  • Cited evidence (PMID 21615299) — PMID:21615299