10 TABLE . Recommended Evidence-based Management for Childhood Community-acquired Pneumonia Under 5-years of Age from Different Guidelines Origin Diagnosis Severity assessment for Antimicrobial therapy Outpatient Inpatient hospitalization Outpatient Inpatient USA1 CXR not CXR necessary  Respiratory distress: tachypnea,  Antimicrobial not  Fully immunized*, necessary (anteroposterior dyspnea, retractions routinely required for low prevalence of and lateral view (suprasternal, intercostal, pre-school-aged children high-level required) subcostal), grunting, nasal unless bacterial disease pneumococcal flaring, apnea, altered mental suspected penicillin-resistance: status  Previously healthy, fully ampicillin OR  Hypoxemia (SpO2 < 90% at sea immunized*, mild to penicillin G level) moderate presentation,  Not fully immunized, bacterial disease significant prevalence suspected: amoxicillin of high level pneumococcal penicillin-resistance†: 3rd generation cephalosporin  Atypical bacteria are suspected: beta- lactam + macrolides

UK2 CXR not CXR necessary  Temperature > 38.5oC  < 2 years-old, mild  IV amoxicillin OR necessary (lateral view  Nasal flaring symptoms of lower amoxicillin- not required)  Cyanosis respiratory tract clavulanic acid OR  Grunting respiration infection: no antibiotics cefuroxime OR  Tachycardia  Clear clinical diagnosis cefotaxime OR  Capillary refill time > 2seconds of pneumonia: ceftriaxone  Hypoxemia (SpO2 < 92%) amoxicillin  In very severe disease Infants: RR >70breaths/min  Failure to first-line macrolides must be moderate-severe recession choice OR atypical added intermittent apnea bacteria are suspected at not feeding any age: macrolides to Older children: RR >50breaths/min be added severe difficulty in breathing dehydration

11 Japan3 CXR for those with fever, cough,  Tachypnea: RR> 50breaths/min 2mon-5-year-old: 2mon-5-year-old: and dyspnea along with chest in amoxicillin ± clavulanic IV amoxicillin ± findings children < 1-year-old acid sultamicillin RR> 40breaths/min in OR OR children 2-5- year-old sultamicillin piperacillin  Retractions OR OR  Nasal alar breathing broad spectrum cephem broad spectrum cephem ‡ ‡  Shoulder breathing PO IV  Grunting  Cyanosis

 Extent of infiltration > 2/3 of

one lung on CXR  SpO2 < 90%  Peripheral blood smear: 500 < neutrophils or > 10,000

Canada4 CXR is necessary  Age < 6 months 3mon-5-year-old: 3mon-5-year-old:  Toxic appearance amoxicillin OR ampicillin OR  Severe respiratory distress erythromycin OR cefuroxime  Oxygen requirement clarithromycin  Dehydration  Vomiting In Intensive Care Unit: cefuroxime +  No response to appropriate oral antimicrobial therapy erythromycin OR clarythromycin  Immunocompromised host

 Non-compliant parents

Brazil5 Tachypnea: Subcostal  Age < 2 months 2months-old onwards: 2months-old onwards: 2-11-months- retraction + For those older than 2 months: amoxicillin penicillin G OR old: > 50 CXR  Subcostal retraction ampicillin nd breaths/minute  Impaired level of consciousness 2 line: > 12 months-  Inability to drink or eat amoxicillin-clavulanic acid very severe: old: > 40  Convulsion OR ceftriaxone breaths/minute  Cyanosis cefuroxime ± + OR oxacillin  Stridor in calm child CXR + erythromycin (for > 3- ±  Nasal flaring 12 year-old) macrolides

South Africa6 >2month-old subcostal  Age < 2 months 3mon-5-year-old: 3mon-5-year-old: cough OR retraction OR For those older than 2 months: amoxicillin PO IV ampicillin OR difficult stridor OR  Impaired level of consciousness amoxicillin PO OR breathing general danger  Inability to drink or eat cefuroxime OR § WITH sign  Cyanosis amoxicillin-clavulanic tachypnea:  Stridor in calm child acid OR cefotaxime OR 2-11-months-  Severe chest-wall indrawing ceftriaxone old: > 50  SpO2 < 92% at sea level breaths/minute < 90% at higher altitudes > 12 months-  Severe malnutrition old: > 40 breaths/minute  Failure to respond to ambulatory care or clinical deterioration on treatment

WHO7, 8 Tachypnea: Tachypnea +  Age < 2 months Non-severe Very severe 2-11-months- danger signs For those older than 2 months: Tachypnea with no Ampicillin OR penicillin old: > 50 including (danger signs) subcostal retraction or + gentamicin breaths/minute subcostal  Unusually sleep or unconscious danger sign with a wheeze parenterally > 12 months- retraction  Inability to drink or eat but no fever: no antibiotics old: > 40  Convulsions but close follow-up breaths/minute  Head nodding Tachypnea without wheeze: ± amoxicillin Subcostal Failure to respond to ambulatory Severe retraction Subcostal retraction: care or clinical deterioration on nd treatment amoxicillin PO; 2 line ceftriaxone *Fully immunized with conjugate vaccines for Haemophilus influenzae type b and Streptococcus pneumonia †High level pneumococcal penicillin-resistance: Minimal Inhibitory Concentration > 4ug/mL ‡Cephem PO: cefditoren pivoxil, cefcapene pivoxil, cefteram pivoxil; IV: ceftriaxone, cefotaxime §General danger sign: inability to drink, convulsions, abnormal sleepiness, or persistent vomiting WHO: World Health Organization CXR: chest x-ray RR: respiratory rate IV: intra-venous PO: per os 13 References for Table:

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