TABLE 94.14 MANAGEMENT OF UNCOMPLICATED COMMUNITY-ACQUIRED PNEUMONIA IN PREVIOUSLY HEALTHY CHILDREN a Age Outpatient Inpatient b Other considerations Neonates N/A Ampicillin + thirdgeneration cephalosporin Consider empiric influenza antiviral therapy in children with moderate–severe pneumonia during influenza season, even if rapid influenza diagnostic test results are negative (these tests are insufficiently sensitive to guide empiric therapy) Infants Amoxicillin Ampicillin Preschool aged Amoxicillin Ampicillin School aged Amoxicillin + macrolide Ampicillin + macrolide Adolescents Amoxicillin + macrolide Ampicillin + macrolide The IDSA guidelines state that antimicrobial therapy may not be required routinely for preschool-aged children with community-acquired pneumonia, as the majority will have a viral etiology Laboratory parameters or radiographic findings might help determine need for antibiotics a Based upon the 2011 Infectious Diseases Society of America and the Pediatric Infectious Diseases Society guidelines for the management of community-acquired pneumonia in children Clin Infect Dis 2011;53(7):e25 Management for children with complicated pneumonia (e.g., empyema, lung abscess) is discussed elsewhere Unimmunized children should have a third-generation cephalosporin added to ampicillin, for coverage of H influenzae type B b Vancomycin or clindamycin should be added if there is clinical, laboratory, or radiographic reason to suspect staphylococcal pneumonia; critically ill children should be treated with broad-spectrum antibiotics for pneumonia (e.g., vancomycin and cefotaxime), given that rates of resistant pneumococci are increasing in many industrialized nations N/A, not applicable Lung Abscess Most lung abscesses are polymicrobial and caused by aspiration of oral flora, especially in patients with underlying neurologic disorders The predominant anaerobes are Bacteroides, Peptostreptococcus, and Prevotella Anaerobes, S aureus, pneumococcus, and nontypeable H influenzae are the most common pathogens identified in otherwise healthy children Fungal pathogens and Pseudomonas should be considered in immunocompromised children M tuberculosis will be discussed separately in the section on travel medicine The most common symptoms are fever, cough, shortness of breath, and chest pain Symptoms have often been present for up to to weeks before the child is recognized to have a lung abscess; as a consequence, weight loss is seen in some children, whereas it is an uncommon occurrence for children with community-acquired pneumonia Auscultation of the lungs is often nonfocal, particularly in young children The diagnosis usually is made by chest radiograph, which can show a thin- or thick-walled cavity with an air–fluid level Intrathoracic adenopathy can be found in more subacute causes of lung abscess (e.g., tuberculosis, fungal) CT can be of use if operative intervention is planned to better delineate the anatomy Leukocytosis with a neutrophilic predominance is common; blood cultures are positive in 10% to 15% of cases Gram stain of the sputum is rarely useful unless the abscess has ruptured into a bronchus and is communicating with the airway Percutaneous aspiration or bronchoscopy is more sensitive in yielding a microbiologic diagnosis Empiric antibiotic coverage should target S aureus, pneumococcus, and anaerobes Clindamycin and cefotaxime is one such regimen, with the advantage that it can be readily converted from a parenteral regimen to oral equivalents However, for toxic-appearing children, or in regions where cephalosporinresistant pneumococci or clindamycin-resistant staphylococci are commonly seen, vancomycin should be included