Approach to managing children 2 months or older with CAP who are not improving
If the clinical features of community-acquired pneumonia (CAP) do not improve as expected with appropriate antibiotic therapy, reassess the diagnosis and seek expert advice. For children managed in the community, review disease severity and whether to admit the child to hospital.
Complications of CAP and differential diagnoses to consider (including pathogens to consider in children with immune compromise) are listed in Considerations in children 2 months or older with community-acquired pneumonia (CAP) who are not improving on empirical antibiotic therapy. If extensive microbiological testing is required, discuss the need for bronchoscopy with a respiratory physician.
Review disease severity and the results of previous investigations, including NAAT (eg PCR), if available.
Consider complications of pneumonia – lung abscess, parapneumonic effusion and thoracic empyema should be considered in children with persistent symptoms (eg fever, chest discomfort).
Consider noninfective diagnoses, such as:
- inhaled foreign body
- interstitial lung diseases
- cancer (eg thoracic neuroblastoma).
Consider testing for an undiagnosed immune system disorder.
Investigate for a broader range of pathogens, particularly in children with immune compromise. These include:
- viral pathogens that can cause pneumonia and pneumonitis, including influenza virus, parainfluenza virus, human metapneumovirus, coronavirus (eg SARS-CoV-2), RSV and cytomegalovirus
- bacterial pathogens
- anaerobes not adequately treated with standard empirical therapy – especially in a child with recurrent aspiration. See Management of aspiration pneumonia in patients who are not improving on empirical therapy for CAP or HAP for management
- atypical pathogens [NB1] (eg Mycoplasma and Chlamydophila (Chlamydia) species) – see Directed therapy for pneumonia for management
- Burkholderia pseudomallei – can cause pneumonia in tropical regions of Australia [NB2], particularly in children with risk factors [NB3]
- Pseudomonas aeruginosa – especially in children with comorbid lung disease or recent antibiotic exposure
- multidrug-resistant gram-negative bacteria – ESBL-producing Enterobacterales and carbapenemase-producing Enterobacterales are uncommon causes of CAP; if suspected or confirmed, consult an infectious diseases physician, clinical microbiologist, or local protocols (if available). See also Enterobacterales pneumonia
- Nocardia species
- mycobacterial pathogens
- Mycobacterium tuberculosis – especially in children from high-prevalence areas with prolonged symptoms
- nontuberculous mycobacteria
- fungal pathogens
- Strongyloides stercoralis in patients with past or present epidemiological risk of acquiring S. stercoralis (ie those who were born, live in or visit endemic regions).
ESBL = extended-spectrum beta-lactamase; NAAT = nucleic acid amplification testing; PCR = polymerase chain reaction; RSV = respiratory syncytial virus; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2
NB1: There is no universally accepted definition of atypical pathogens. The term is used to describe bacteria that are intrinsically resistant to beta lactams and not identifiable by standard blood or sputum culturesGarin, 2022.
NB2: Tropical regions of Australia refer to regions north of 20°S latitude. This includes areas of Queensland north of Mackay, the Northern Territory north of Tennant Creek, and Western Australia north of Port Hedland.
NB3: Risk factors for B. pseudomallei include diabetes, chronic kidney disease, chronic respiratory disease (especially cystic fibrosis) and immunosuppressive therapy.