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pulm.cap.peds.v1PRODUCTION
pulm.cap.peds.v1

Pediatric community-acquired pneumonia

pediatricssubacuteacutepediatricneonatal
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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 — community onset (not HAP/VAP, not bronchiolitis, not aspiration/foreign-body, not active TB); set age tier (neonate <28 d / 1-3 mo / 3 mo-<5 yr / ≥5 yr). Neonate/young infant defaults to the sepsis pathway (route id.sepsis.core.v1) (IDSA/PIDS 2011 PMID 21880587)

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Community acquisition + age tier confirmed

Patient inputs (22)

Age tier is the PRIMARY pathogen prior: neonate GBS/E.coli/Listeria; <5 yr viral-predominant + S. pneumoniae; ≥5 yr Mycoplasma rises (EPIC Jain NEJM 2015 PMID 25714161 — RSV <5 yr 37% vs ≥5 yr 8%; IDSA/PIDS 2011 PMID 21880587)

Fever pattern + height; neonate/<3 mo with T ≥38°C mandates full sepsis workup (route id.sepsis.core.v1)

WHO age-band tachypnea thresholds: ≥60 (<2 mo), ≥50 (2-12 mo), ≥40 (1-5 yr), ≥30 (≥5 yr) — replaces CURB-65 RR criterion (WHO IMCI; IDSA/PIDS 2011 PMID 21880587)

SpO2 <90-92% on room air → admit; hypoxia is the strongest single severity marker in pediatric CAP (IDSA/PIDS 2011 PMID 21880587)

Tachycardia + perfusion assessment for sepsis/shock overlap (Surviving Sepsis Pediatrics 2020)

Retractions/grunting/nasal flaring/head-bobbing — WHO severity classification (WHO IMCI)

Inability to feed/drink in a young child = WHO SEVERE pneumonia → admit (WHO IMCI)

PCV13/PCV15/PCV20 + Hib + influenza coverage shifts the pathogen prior — under-immunised → empiric ceftriaxone for non-vaccine serotypes/Hib (Griffin NEJM 2013 PMID 23841730 — PCV cut <2 yr pneumonia hospitalisation 551.1/100,000; IDSA/PIDS 2011 PMID 21880587)

β-lactam allergy (clarify severity before avoiding), baseline meds, recent antibiotics (IDSA/PIDS 2011 PMID 21880587)

Lethargy / irritability / convulsions = WHO severe / impending failure (WHO IMCI)

ALL pediatric antibiotic dosing is weight-based (mg/kg/day) with age-banded max caps (IDSA/PIDS 2011 PMID 21880587; CAP-IT PMID 34726708)

Lung/pleural ultrasound — sensitive for consolidation + parapneumonic effusion/empyema; preferred to define drainable collection (IDSA/PIDS 2011 PMID 21880587)

Resistant-pathogen risk; HAP differential if hospitalised in last 90 d (route pulm.cap.core.v1 / HAP) (IDSA/PIDS 2011 PMID 21880587)

CF/bronchiectasis (Pseudomonas), neuromuscular/aspiration risk, BPD, asthma — changes empiric coverage and the differential (IDSA/PIDS 2011 PMID 21880587)

Sickle cell (acute chest syndrome — distinct entity, route heme.sickle-cell.core.v1), HIV, transplant, malignancy, asplenia → broaden coverage + atypical (IDSA/PIDS 2011 PMID 21880587)

Malnutrition / HIV / LMIC setting raises WHO-pathway severity-mortality CONDITIONAL on the same WHO severity grade — do not read severity in isolation in the malnourished child (WHO IMCI; APPIS Addo-Yobo Lancet 2004 PMID 15451221)

Bandemia + leukocytosis pattern; severity adjunct, NOT pathogen-specific (IDSA/PIDS 2011 PMID 21880587)

Recommended in severe / hospitalised CAP and complicated pneumonia per IDSA/PIDS 2011 (PMID 21880587)

Severity adjunct; not for routine outpatient mild CAP (IDSA/PIDS 2011 PMID 21880587)

Bacterial-vs-viral probability + duration-shortening adjunct; selective use, does NOT override clinical judgment in radiographic CAP (IDSA/PIDS 2011 PMID 21880587)

RSV/influenza/SARS-CoV-2/parainfluenza/hMPV — viral predominance under 5 yr; positive viral panel + no toxicity may support narrowing/withholding antibiotics (EPIC Jain NEJM 2015 PMID 25714161 — viruses 73% > bacteria 15%)

Confirms pneumonia in moderate-severe/hospitalised; NOT required for outpatient mild CAP (IDSA/PIDS 2011 PMID 21880587)

* = 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 / cold or warm shock features
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningapnoea_or_grunting_in_infant
    Apnoea, grunting, or extreme bradypnea in an infant with CAP (esp. RSV / pertussis co-presentation)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverespo2_under_90_92_peds_cap
    SpO2 <90-92% on room air in pediatric CAP — strongest single severity marker; admission threshold
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverewho_severe_pneumonia_chest_indrawing_feeding
    WHO SEVERE pneumonia — chest indrawing, inability to feed/drink, cyanosis, lethargy/AMS, or convulsions
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverewho_severity_conditional_on_malnutrition_hiv
    Same WHO severity grade carries HIGHER mortality in the malnourished / HIV-infected / LMIC child — severity-mortality is CONDITIONAL on nutritional/immune status (do-not-read-in-isolation)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereparapneumonic_effusion_or_empyema_peds
    Moderate-large parapneumonic effusion or empyema on ultrasound/CT (loculation, thick fluid, persistent fever despite appropriate antibiotics)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenecrotising_pneumonia_peds
    Cavitation on imaging or persistent fever/toxicity despite adequate antibiotics
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereneonate_or_young_infant_fever_sepsis_default
    Neonate <28 d (or young infant <3 mo with toxicity) with fever and respiratory signs
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresickle_cell_acute_chest_syndrome_overlap
    Sickle cell disease child with fever + cough + new infiltrate + chest pain ± hypoxia — acute chest syndrome, a DISTINCT entity that mimics/overlaps pediatric CAP
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefail_outpatient_at_48_72h
    No improvement at 48-72 h on first-line outpatient antibiotic
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

IDSA/PIDS pediatric CAP — weight-based ladder (outpatient → ward → PICU); age-tiered; short-course-evidenced
axis: peds_cap_empirics_by_setting_agestep neonate_young_infant_sepsis_overlap - Neonate (<28 d) / young infant (<3 mo) — sepsis-overlap broad coverage
Selected step "Neonate (<28 d) / young infant (<3 mo) — sepsis-overlap broad coverage" — Age <28 d (or <3 mo with toxicity/fever) — GBS / E. coli / Listeria / gram-negatives; default to sepsis pathway
  • ampicillin
    first line
    aminopenicillin
    Neonate 150-300 mg/kg/day IV divided q6-8h (age/weight-banded); covers GBS + Listeria • IV • q6-8h (max: 12 g/day)
    triggers: neonate, young_infant_toxic
    GBS + Listeria coverage in the neonatal CAP/sepsis overlap; pair with an aminoglycoside or 3GC. RxCUI 733 = ampicillin RxNav-verified IN 2026-05-16
    rxcui 733
  • gentamicin
    first line
    aminoglycoside
    Neonate 4-5 mg/kg/dose IV (gestational-age/postnatal-age interval) • IV • q24-36h by GA/PNA
    triggers: neonate, gram_negative_coverage
    Gram-negative synergy with ampicillin in neonatal sepsis/pneumonia (route id.sepsis.core.v1). RxCUI 4128 = gentamicin RxNav-verified IN 2026-05-16
    rxcui 1596450
  • ceftriaxone
    second line
    cephalosporin_3rd
    50-75 mg/kg/day IV (AVOID <28 d if hyperbilirubinemia or calcium-containing IV — use cefotaxime) • IV • daily
    triggers: infant_1_to_3_mo, gentamicin_avoid
    Alternative gram-negative cover beyond the neonatal period; ceftriaxone bilirubin/calcium caution in neonates. RxCUI 2193 = ceftriaxone RxNav-verified IN 2026-05-16
    rxcui 2193

outpatient playbook — drug actions (4)

  1. 1. amoxicillin
    90 mg/kg/day divided BID-TID (max 4 g/day); 40-50 mg/kg/day non-inferior (CAP-IT) • PO • q8-12h × 5 days (3 d NI to 7 d in non-severe)
    trigger: Outpatient CAP age ≥3 mo, immunised
    IDSA/PIDS 2011 first-line; CAP-IT PMID 34726708 + SAFER PMID 33683325 short-course
  2. 2. azithromycin
    10 mg/kg day 1 (max 500 mg) then 5 mg/kg/day (max 250 mg) • PO • daily × 5 days
    trigger: Atypical (Mycoplasma) ≥5 yr or severe β-lactam allergy
    Atypical coverage rises ≥5 yr (EPIC age-conditioned prior)
  3. 3. amoxicillin-clavulanate
    90 mg/kg/day amoxicillin component divided BID • PO • q12h × 5 days
    trigger: Under-immunised (Hib) or aspiration overlap
    β-lactamase-stable + oral anaerobe cover
  4. 4. oseltamivir
    Weight-banded BID • PO • q12h × 5 days
    trigger: Influenza season + flu-positive/strongly suspected
    Reduces duration + bacterial superinfection

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Fever + cough + age-band tachypnea in a child (IDSA/PIDS 2011 PMID 21880587); Retractions, nasal flaring, grunting, accessory-muscle use, head-bobbing (WHO IMCI severity); New infiltrate on CXR or consolidation on lung ultrasound (IDSA/PIDS 2011 PMID 21880587).

Objective

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

Assessment

**Pediatric community-acquired pneumonia** (pulm.cap.peds.v1).
Phenotype framing: Age-conditioned: neonate GBS/E.coli/Listeria; infant <5 yr RSV/influenza/hMPV/parainfluenza + S. pneumoniae (viral-predominant — EPIC RSV <5 yr 37%); school-age ≥5 yr S. pneumoniae + Mycoplasma/Chlamydophila rising. Mimics: bronchiolitis (<2 yr first wheeze + URI prodrome), viral URI/wheeze, asthma exacerbation, aspiration/foreign-body (focal/recurrent same-lobe), TB (chronic + contact + weight loss), empyema/necrotising (persistent fever + effusion) (Jain NEJM 2015 PMID 25714161; IDSA/PIDS 2011 PMID 21880587)
Scope: Confirm pediatric CAP scope — community onset (not HAP/VAP, not bronchiolitis, not aspiration/foreign-body, not active TB); set age tier (neonate <28 d / 1-3 mo / 3 mo-<5 yr / ≥5 yr). Neonate/young infant defaults to the sepsis pathway (route id.sepsis.core.v1) (IDSA/PIDS 2011 PMID 21880587)

No severity triggers fired against current inputs.

Plan

Regimen axis: **IDSA/PIDS pediatric CAP — weight-based ladder (outpatient → ward → PICU); age-tiered; short-course-evidenced** — step "Neonate (<28 d) / young infant (<3 mo) — sepsis-overlap broad coverage".
1. ampicillin Neonate 150-300 mg/kg/day IV divided q6-8h (age/weight-banded); covers GBS + Listeria IV q6-8h (aminopenicillin, first line) — GBS + Listeria coverage in the neonatal CAP/sepsis overlap; pair with an aminoglycoside or 3GC. RxCUI 733 = ampicillin RxNav-verified IN 2026-05-16
2. gentamicin Neonate 4-5 mg/kg/dose IV (gestational-age/postnatal-age interval) IV q24-36h by GA/PNA (aminoglycoside, first line) — Gram-negative synergy with ampicillin in neonatal sepsis/pneumonia (route id.sepsis.core.v1). RxCUI 4128 = gentamicin RxNav-verified IN 2026-05-16
3. ceftriaxone 50-75 mg/kg/day IV (AVOID <28 d if hyperbilirubinemia or calcium-containing IV — use cefotaxime) IV daily (cephalosporin_3rd, second line) — Alternative gram-negative cover beyond the neonatal period; ceftriaxone bilirubin/calcium caution in neonates. RxCUI 2193 = ceftriaxone RxNav-verified IN 2026-05-16

Setting playbook (outpatient) — Treat mild pediatric CAP with weight-based first-line oral amoxicillin (short-course evidenced) and define failure/complication return triggers (IDSA/PIDS 2011 PMID 21880587; CAP-IT PMID 34726708)
4. amoxicillin 90 mg/kg/day divided BID-TID (max 4 g/day); 40-50 mg/kg/day non-inferior (CAP-IT) PO q8-12h × 5 days (3 d NI to 7 d in non-severe) — Outpatient CAP age ≥3 mo, immunised (IDSA/PIDS 2011 first-line; CAP-IT PMID 34726708 + SAFER PMID 33683325 short-course)
5. azithromycin 10 mg/kg day 1 (max 500 mg) then 5 mg/kg/day (max 250 mg) PO daily × 5 days — Atypical (Mycoplasma) ≥5 yr or severe β-lactam allergy (Atypical coverage rises ≥5 yr (EPIC age-conditioned prior))
6. amoxicillin-clavulanate 90 mg/kg/day amoxicillin component divided BID PO q12h × 5 days — Under-immunised (Hib) or aspiration overlap (β-lactamase-stable + oral anaerobe cover)
7. oseltamivir Weight-banded BID PO q12h × 5 days — Influenza season + flu-positive/strongly suspected (Reduces duration + bacterial superinfection)

Non-pharmacologic actions:
- Antipyretics for comfort + hydration counselling
- Return precautions: worsening dyspnea, cyanosis, decreased PO, lethargy, persistent fever >48-72 h
- Caregiver education on adherence + short-course completion
- Influenza/PCV/Hib catch-up when recovered (Griffin NEJM 2013 PMID 23841730)

AVOID / contraindication checks:
-  macrolide QTc — baseline ECG if congenital long QT or QT prolonging co meds (IDSA/PIDS 2011 PMID 21880587)
-  doxycycline short courses acceptable at any age per AAP 2018 Red Book (no clinically significant staining for ≤21 d courses)
-  fluoroquinolones AVOIDED in pediatric CAP unless no alternative (cartilage/tendon/musculoskeletal — AAP)
-  ceftriaxone AVOID in neonates <28 d with hyperbilirubinemia or concurrent calcium containing IV (use cefotaxime); biliary sludging with prolonged use
-  vancomycin AUC24 target 400 600, monitor SCr q48h and during PICU use (IDSA/PIDS 2011 PMID 21880587)
-  aminoglycoside (gentamicin) renal + ototoxicity — level monitoring; neonatal GA/PNA banded dosing
-  β lactam allergy — clarify severity (rash vs anaphylaxis) before avoiding; most can receive a cephalosporin (IDSA/PIDS 2011 PMID 21880587)
-  oseltamivir renal dose adjust; neuropsychiatric monitoring per labelling
- Dosing: ALL agents weight based mg/kg/day with age banded max caps — never fixed adult doses (CAP IT PMID 34726708; IDSA/PIDS 2011 PMID 21880587)

Monitoring

Regimen monitoring:
- clinical response at 48-72 h — defervescence, WOB, oxygen wean, feeding (IDSA/PIDS 2011 PMID 21880587)
- IV→PO switch when afebrile ≥24 h + tolerating PO + improving (IDSA/PIDS 2011 PMID 21880587)
- duration: 5 d non-inferior to 10 d uncomplicated (SAFER Pernica PMID 33683325); 3 d non-inferior to 7 d in non-severe (CAP-IT Bielicki PMID 34726708)
- duration: 10-21 d for complicated pneumonia (empyema / necrotising / abscess) (IDSA/PIDS 2011 PMID 21880587)
- vancomycin Bayesian AUC24 400-600 + SCr if MRSA cover in PICU (IDSA/PIDS 2011 PMID 21880587)
- non-response at 72 h → reassess for resistance, atypical, complication, foreign-body, TB, or non-CAP mimic
- CXR follow-up at 4-6 wk ONLY for round/lobar/necrotising or non-resolving pneumonia — not routine if resolved (IDSA/PIDS 2011 PMID 21880587)

Setting (outpatient) monitoring:
- Reassess at 48-72 h by phone or clinic (IDSA/PIDS 2011 PMID 21880587)
- CXR at 4-6 wk only if round/lobar/non-resolving (IDSA/PIDS 2011 PMID 21880587)

Follow-up plan: Pneumococcal (PCV) + Hib + influenza + COVID catch-up immunisation review (Griffin PMID 23841730 — PCV materially cut hospitalisation); household smoke-exposure cessation; immunodeficiency / aspiration / structural workup if recurrent or non-resolving pneumonia; CXR follow-up at 4-6 wk ONLY for round/lobar/necrotising or non-resolving pneumonia — not routine if clinically resolved (IDSA/PIDS 2011 PMID 21880587)
- Close-out criterion: Follow-up scheduled and prevention/recurrence addressed

Monitoring phase: Clinical response at 48-72 h; if not improving → reassess for resistance, atypical, complication (effusion/empyema/necrotising), or alternative diagnosis (bronchiolitis/asthma/foreign-body/TB). IV→PO switch once afebrile ≥24 h + tolerating PO + improving WOB/oxygen weaned; complete short course (5 d uncomplicated per SAFER; 10-21 d if complicated) (SAFER PMID 33683325; IDSA/PIDS 2011 PMID 21880587)

Disposition

Current setting: outpatient — Treat mild pediatric CAP with weight-based first-line oral amoxicillin (short-course evidenced) and define failure/complication return triggers (IDSA/PIDS 2011 PMID 21880587; CAP-IT PMID 34726708)

Disposition criteria:
- Continue outpatient if afebrile/improving by 48-72 h
- Switch/escalate if not improving (resistance, atypical, complication, or non-CAP mimic)

Escalation triggers (move to higher acuity):
- SpO2 <90-92% → admit (IDSA/PIDS 2011 PMID 21880587)
- Inability to tolerate PO / dehydration → admit
- No improvement at 48-72 h on first-line → admit / step up
- Neonate/<3 mo with fever → ED + sepsis workup (route id.sepsis.core.v1)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Pediatric CAP with sepsis-induced hypotension / cold or warm shock features
- [LIFE_THREATENING] Apnoea, grunting, or extreme bradypnea in an infant with CAP (esp. RSV / pertussis co-presentation)
- [SEVERE] SpO2 <90-92% on room air in pediatric CAP — strongest single severity marker; admission threshold

Citations

- IDSA/PIDS 2011 Pediatric CAP Guideline (Bradley, Clin Infect Dis 2011;53(7):e25-76; PMID 21880587; DOI 10.1093/cid/cir531) + CAP-IT (Bielicki JAMA 2021) + SAFER (Pernica JAMA Peds 2021) short-course evidence + WHO IMCI severity pathway + Surviving Sepsis Pediatrics 2020 [PMID:21880587](https://pubmed.ncbi.nlm.nih.gov/21880587/)
- Cited evidence (PMID 34726708) [PMID:34726708](https://pubmed.ncbi.nlm.nih.gov/34726708/)
- Cited evidence (PMID 33683325) [PMID:33683325](https://pubmed.ncbi.nlm.nih.gov/33683325/)
- Cited evidence (PMID 25714161) [PMID:25714161](https://pubmed.ncbi.nlm.nih.gov/25714161/)
- Cited evidence (PMID 23841730) [PMID:23841730](https://pubmed.ncbi.nlm.nih.gov/23841730/)

Last reconciled with current guidelines: 2026-05-16.
References
  • IDSA/PIDS 2011 Pediatric CAP Guideline (Bradley, Clin Infect Dis 2011;53(7):e25-76; PMID 21880587; DOI 10.1093/cid/cir531) + CAP-IT (Bielicki JAMA 2021) + SAFER (Pernica JAMA Peds 2021) short-course evidence + WHO IMCI severity pathway + Surviving Sepsis Pediatrics 2020 — PMID:21880587
  • Cited evidence (PMID 34726708) — PMID:34726708
  • Cited evidence (PMID 33683325) — PMID:33683325
  • Cited evidence (PMID 25714161) — PMID:25714161
  • Cited evidence (PMID 23841730) — PMID:23841730