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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Community- and hospital-acquired pneumonia

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Sepsis or respiratory failure

Central cyanosis, saturation below 90%, severe recession, grunting, apnoea, exhaustion, shock, reduced consciousness or inability to drink indicates severe pneumonia or sepsis requiring immediate hospital care.

Action: Give oxygen and support ventilation, obtain intravenous or intraosseous access, check glucose and lactate, take blood culture if this does not delay treatment and give intravenous antibiotics within the sepsis pathway. Use cautious weight-based isotonic fluid with repeated reassessment, involve senior paediatrics and intensive care, and drain tension or complicated pleural disease through specialist teams.

Synopsis

Diagnose pneumonia from age-specific clinical features, identify sepsis and respiratory failure, distinguish community from healthcare-associated infection, use severity-directed imaging and microbiology, prescribe narrow first-line antibiotics with current paediatric doses, and detect effusion, empyema and treatment failure.

  • Pneumonia is infection of lung parenchyma. In children it is diagnosed clinically from fever, cough, tachypnoea, recession, crackles or bronchial breathing and systemic effect; viral and bacterial features overlap.
  • Use age-specific respiratory rate and the whole child. Hypoxaemia, work, perfusion, alertness, drinking, age and comorbidity determine severity more reliably than auscultation alone.
  • First line for non-severe community-acquired bacterial pneumonia is oral amoxicillin. Current NICE uses 3 days for most children aged 3 months–11 years when clinically stable, and 5 days for age 12–17 or more severe disease.
  • NICE age doses for 3 days: 3–11 months 125 mg three times daily; 1–4 years 250 mg three times daily; 5–11 years 500 mg three times daily. Verify BNF-C, allergy and renal function.
  • Use a macrolide when atypical pathogens are suspected or amoxicillin is unsuitable according to current guidance; do not combine routinely in mild preschool pneumonia.
  • Severe community pneumonia generally needs intravenous co-amoxiclav, adding clarithromycin if atypical infection is suspected, then oral step-down once clinically stable.
  • Do not routinely request chest radiography, blood tests or microbiology for a stable child managed in the community. Imaging does not reliably distinguish viral from bacterial infection.
  • In hospital, obtain radiography for severe disease, diagnostic uncertainty, complications or poor response. Lung ultrasound is useful for pleural fluid; ultrasound does not replace chest radiography for all parenchymal questions.
  • Hospital-acquired pneumonia begins at least 48 hours after admission and was not incubating on arrival. Select antibiotics from local resistance, prior cultures, aspiration and device exposure; send respiratory and blood cultures when feasible before treatment.
  • Review at 48–72 hours. Improvement includes reduced fever and effort, better oxygenation and drinking; cough may persist after bacterial control.
  • Complicated effusion or empyema needs respiratory and surgical input, ultrasound characterisation, pleural sampling when drained and antibiotics; do not repeatedly tap a large infected collection without a drainage plan.
  • Prevention includes vaccination, smoke avoidance, aspiration assessment, hand hygiene, oral care and minimising unnecessary ventilation and antibiotics.

    • Key red flags

    Saturation below 90%, cyanosis, grunting, severe recession, apnoea, exhaustion or altered consciousness requires urgent admission and respiratory support.

    Shock, prolonged capillary refill, hypotension, oliguria, mottling or high lactate indicates sepsis and needs time-critical treatment.

    Infant under 3 months with suspected bacterial pneumonia or fever needs same-day paediatric assessment because deterioration and bacteraemia risk is greater.

    Pleuritic pain, unilateral reduced air entry, dullness, persistent fever or scoliosis toward one side suggests parapneumonic effusion or empyema.

    Failure to improve within 48–72 hours requires review of adherence, organism, resistance, effusion, abscess, foreign body, TB and immune or structural disease.

    Hospital onset, recent ventilation, tracheostomy, aspiration or known resistant colonisation requires local microbiology advice rather than routine community antibiotics.

    Investigation priorities

    01
    First-line community assessmentFirst stepFirst line

    Diagnose clinically and decide oral treatment versus hospital referral.

    Management branches

    CommunityTreat stable disease narrowly

    A child has non-severe community-acquired pneumonia and can drink.

    1. Give oral amoxicillin using the current age dose and 3- or 5-day course.
    2. Provide fluids, antipyretic comfort and explicit breathing and hydration advice.
    3. Review if worsening at any time or not beginning to improve within 3 days.

    Key medicines

    AmoxicillinNon-severe community pneumonia: age 3–11 months 125 mg orally three times daily; 1–4 years 250 mg three times daily; 5–11 years 500 mg three times daily, usually 3 days. Age 12–17 years 500 mg three times daily for 5 days.Verify current NICE and BNF-C dosing, weight, renal function and immediate versus non-immediate penicillin allergy. Review if not improving within 3 days; do not apply short courses to severe or complicated disease.
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    Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • NICE NG250 pneumonia recommendationsCurrent 2025 diagnosis, severity, antibiotic choice and paediatric course length.
    • NICE NG250 tools and resourcesCurrent visual summaries include age-specific community pneumonia antibiotic doses and durations.
    • NICE NG51 sepsis recommendationsAge-specific sepsis recognition, cultures, antibiotics and fluid reassessment.
    • British Thoracic Society pleural infection in children guidelineUK specialist investigation and drainage of parapneumonic effusion and empyema.

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom