Management

The initial treatment of children with pneumonia, but with no obvious pathology such as immune suppression, the most common cause of a bacterial pneumonia is Streptococcus pneumoniae and this is usually sensitive to penicillin. Therefore the antibiotic of choice is amoxicillin (if not penicillin allergic).

In children who are allergic to penicillin or if Mycoplasma pneumoniae is thought to be the causative organism (e.g. in the older school-aged child and adolescent) a macrolide such as clarithromycin is the first choice.

Failure to respond to this should raise the possibility of other factors:

• mycoplasma - if used penicillin as first-line agent
• structural anomaly, including a foreign body
• tuberculosis

NICE have outlined guidance with respect to community acquired pneumonia in the community (1)

Note

• Non-severe community-acquired pneumonia (CAP) in a previously healthy child can be safely managed in the community. (2) ​​​
• Hospital admission is indicated for any child with severe pneumonia or CAP with suspected complications. (2) Base the assessment of severity on symptoms, signs, and risk factors for severe disease.
• Supplemental oxygen and/or intravenous fluid therapy may be needed, according to vital signs. (2) Any child who requires assisted ventilation or has oxygen saturation <92% despite supplemental oxygen requires an escalation of care to the intensive care unit (ICU).​
• Parenteral antibiotic therapy is recommended for any child admitted to hospital for management of CAP, starting with an empirical regimen and switching to a targeted antibiotic if a pathogen is identified by microbiological investigation. (2)
• Antivirals may have a role for specified subgroups of children with suspected or confirmed influenza-associated CAP, although the balance of benefits versus adverse effects remains the subject of debate. Oseltamivir is the antiviral of choice, and treatment initiated within 48 hours of symptom onset provides the optimum benefit.(2) If used, the antiviral is typically given alongside antibiotics because co-infection is common.
• Any child receiving appropriate antimicrobial therapy should start to show clinical and laboratory signs of improvement within 48-72 hours. (2) Arrange prompt reassessment, and consider further investigations and an escalation of care setting, if this is not the case.

Reference

1. NICE. Pneumonia: diagnosis and management. NICE guideline NG250. Published September 2025
2. Harris M, Clark J, Coote N, et al; British Thoracic Society Standards of Care Committee. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax. 2011 Oct;66 Suppl 2:ii1-23.