American Academy of Pediatrics – Committee on Infectious Diseases and the Pediatric Infectious Diseases Society

View all recommendations from this society

November 12, 2018

Don’t treat uncomplicated community-acquired pneumonia in otherwise healthy, immunized, hospitalized patients with antibiotic therapy broader than ampicillin.

Community-acquired pneumonia (CAP) accounts for a significant percentage of antibiotic use in children. Unnecessary use of broadspectrum antibiotics, including cephalosporins such as ceftriaxone, have been shown to contribute to antibiotic resistance and C. difficile infection. The most common cause of CAP in healthy, immunized children is Streptococcus pneumoniae, of which most strains are highly susceptible to penicillin/ampicillin. As ampicillin achieves high levels in the lung and is narrow in spectrum, it should be used as a first-line drug for inpatient management of most children with uncomplicated pediatric CAP. In cases with more resistant local epidemiology, or complicated CAP including empyema, antibiotics with a broader spectrum may be needed.

This list from the American Academy of Pediatrics is developed with judicious use of antimicrobials in mind, however, when a patient has suddenly and inexplicably become severely ill, the short-term, empiric use of broad-spectrum antibiotics is warranted, and should be left to the discretion of the medical team.

How The List Was Created

The American Academy of Pediatrics Committee on Infectious Diseases’ Subcommittee on Antimicrobial Resistance and Stewardship identified the need to promote the judicious use of antibiotics in the inpatient setting at their strategic planning session held in October 2015. A workgroup of pediatric experts was formed with representatives from the Academy’s Committee on Infectious Diseases, Committee on Fetus and Newborn, Section on Infectious Diseases, and external partners from the Pediatric Infectious Diseases Society. A modified Delphi process was used to create the list for Choosing Wisely. Experts from the workgroup were asked to create an initial list of what practices may be included– 15 practices for inpatient antimicrobial stewardship were identified through email and conference calls.

The workgroup reviewed and ranked via survey which practices within the list of 15 were the most important to include. The survey also asked for any additional suggestions for inpatient AS practices that were not included on the list. This survey was then simultaneously sent to the Antimicrobial Resistance Stewardship workgroup, as well as, internally, to the following Executive Committees: 1. Committee on Hospital Care, 2. Committee on Fetus and Newborn, 3. Committee on Pediatric Emergency Medicine, Section on Critical Care, Section on Emergency Medicine, Section on Infectious Diseases, and Section on Neonatal-Perinatal Medicine and externally to the Pediatric Infectious Diseases Society Executive Committee and their antimicrobial stewardship workgroup. The list was edited based on the feedback received and narrowed down to a new top ten list. The workgroup reviewed the list and voted on their top five based on the following criteria: 1. Feasibility, 2. Supported by Evidence, 3. Not Duplicative, 4. Free from Harm, and 5. Truly Necessary. The list was peer reviewed by relevant expert Committee, Council and Section leadership. The AAP Executive Committee approved this publication of the list.

AAP’s disclosure and conflict of interest policy can be found at


Bradley, J. S., Byington, C. L., Shah, S. S., Alverson, B., Carter, E. R., Harrison, C., et al. (2011, October). The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. Oxford University Press.

Newman, R. E., Hedican, E. B., Herigon, J. C., Williams, D. D., Williams, A. R., & Newland, J. G. (2012). Impact of a Guideline on Management of Children Hospitalized With Community-Acquired Pneumonia. Pediatrics, 129(3), e597–e604.

Harrison CJ, Woods C, Stout G, et al. Susceptibilities of Haemophilus influenzae, Streptococcus pneumoniae, including serotype 19A, and Moraxella catarrhalis paediatric isolates from 2005 to 2007 to commonly used antibiotics. J Antimicrob Chemother 2009; 63:511–9.

Kyaw MH, Lynfield R, Schaffner W, et al. Effect of introduction of the pneumococcal conjugate vaccine on drug-resistant Streptococcus pneumoniae. N Engl J Med 2006; 354:1455–63.