31 August 2026Chapter 2: Respiratory diseasesPDF page 94Source update: November 2022
Acute pneumonia
Comprehensive clinical guide to acute pneumonia assessment, severity signs, age-specific antibiotics, oxygen, hydration, complications, and follow-up.
This guide supports clinical education and care navigation. It does not replace bedside judgement, emergency care, specialist advice, or local treatment protocol.
Seek urgent care
- Chest indrawing, blue lips or nails, oxygen saturation below 90%, nasal flaring, grunting, stridor, or altered consciousness.
- Refusal to drink or feed, severe malnutrition, age under 2 months, or worsening after treatment has started.
- Breathlessness, chest pain, confusion, or signs of shock in an older child or adult.
Definition and likely pathogens
Acute pneumonia is infection of the lung alveoli. It may be viral, bacterial, or parasitic, and severity depends on age, nutrition, oxygenation, comorbidity, and complications.
In children under 5 years, common causes include respiratory viruses, pneumococcus, and Haemophilus influenzae. In older children and adults, viruses, pneumococcus, and Mycoplasma pneumoniae are frequent causes.
Always assess for alternative or additional diagnoses such as malaria, tuberculosis, pneumocystosis in HIV, bronchiolitis in infants, asthma, aspiration, sepsis, heart failure, and pleural disease.
Clinical features in children under 5 years
- Typical presentation is cough or difficult breathing with fever that may be high, mild, or absent.
- Count respiratory rate for a full minute when the child is calm. Crying, agitation, fever, and recent feeding can alter the count.
- Auscultation may reveal dullness to percussion, reduced breath sounds, crepitations, bronchial breathing, or may be normal early in disease.
- Staphylococcal pneumonia should be suspected with rapid deterioration, shock, skin infection, post-measles pneumonia, empyema, pneumothorax, painful abdominal distension, or diarrhoea with severe respiratory illness.
| Age | Respiratory rate suggesting pneumonia |
|---|---|
| Under 1 month | 60 breaths/minute or more |
| 1 to 11 months | 50 breaths/minute or more |
| 12 months to 5 years | 40 breaths/minute or more |
| Severe acute malnutrition | Use a threshold about 5 breaths/minute lower than the age threshold. |
Severity assessment
- Children under 5 years have severe pneumonia if they have chest indrawing, cyanosis or SpO2 below 90%, nasal flaring, altered consciousness, stridor, grunting, refusal to drink or feed, age under 2 months, or severe malnutrition.
- Chest indrawing should be persistent and visible. Mild lower chest movement can be normal in very young infants; soft tissue retraction alone is not the same as chest indrawing.
- Older children and adults with cyanosis, nasal flaring, intercostal or subclavial indrawing, respiratory rate above 30/minute, heart rate above 125/minute, altered consciousness, shock signs, or major comorbidity need urgent inpatient assessment.
- High-risk adults include older patients and those with heart failure, sickle cell disease, severe chronic bronchitis, severe acute malnutrition, HIV with low CD4 count, or other immunosuppression.
Severe pneumonia: children under 2 months
Admit all children under 2 months with suspected pneumonia and treat as severe disease.
- IV ampicillin is preferred when access is available; IM may be used when needed.
- If ampicillin is unavailable, cefotaxime or ceftriaxone may be used according to local neonatal policy.
- If there is no improvement after 48 hours, add cloxacillin and reassess for staphylococcal pneumonia, complications, resistant organisms, and tuberculosis.
| Age and weight | Ampicillin | Gentamicin |
|---|---|---|
| 0 to 7 days, under 2 kg | 50 mg/kg IV or IM every 12 hours for 10 days | 3 mg/kg IM or slow IV once daily for 5 days |
| 0 to 7 days, 2 kg or more | 50 mg/kg IV or IM every 8 hours for 10 days | 5 mg/kg IM or slow IV once daily for 5 days |
| 8 days to under 1 month | 50 mg/kg IV or IM every 8 hours for 10 days | 5 mg/kg IM or slow IV once daily for 5 days |
| 1 month to under 2 months | 50 mg/kg IV or IM every 6 hours for 10 days | 6 mg/kg IM or slow IV once daily for 5 days |
Severe pneumonia: children 2 months to 5 years
- If clinical response follows addition of cloxacillin, switch to co-amoxiclav when improved and afebrile for 3 days, completing 10 to 14 days total. Large empyema may require a longer course and drainage.
- If ceftriaxone plus cloxacillin fails after 48 hours and TB is unlikely, add azithromycin for possible atypical pneumonia.
| Option | Dose and duration |
|---|---|
| Ceftriaxone | 50 mg/kg IM or slow IV once daily. Give parenteral therapy for at least 3 days, then switch to oral amoxicillin when improved and able to drink, completing 10 days total. |
| Ampicillin plus gentamicin | Ampicillin 50 mg/kg every 6 hours plus gentamicin 6 mg/kg once daily. Step down to amoxicillin 30 mg/kg PO three times daily when improved, completing 10 days total. |
| Poor response after 48 hours | Add cloxacillin 25 to 50 mg/kg IV every 6 hours and reassess for staphylococcal pneumonia, empyema, TB, pneumocystosis, or atypical pneumonia. |
Non-severe pneumonia outpatient treatment
- Give clear return instructions for faster breathing, chest indrawing, poor feeding, fever persistence, drowsiness, cyanosis, dehydration, chest pain, or worsening despite treatment.
- Infants under 2 months should not be managed as routine outpatient pneumonia.
| Patient group | Treatment and reassessment |
|---|---|
| Children 2 months to 5 years without severe signs | Amoxicillin 30 mg/kg PO three times daily for 5 days. Review after 48 to 72 hours, or sooner if worse. |
| Children over 5 years and adults without severe signs | Amoxicillin 30 mg/kg PO three times daily, maximum 3 g/day, for 5 days; adults commonly receive 1 g PO three times daily for 5 days. |
| No improvement after 3 days | Reassess adherence, diagnosis, complications, and severity. Add azithromycin if atypical pneumonia is likely and admit if the patient deteriorates. |
Older children and adults with severe pneumonia
| Situation | Treatment |
|---|---|
| Initial severe pneumonia | Ceftriaxone 50 mg/kg once daily in children or 1 g once daily in adults, or ampicillin 50 mg/kg every 6 hours in children and 1 g every 6 to 8 hours in adults. Continue parenteral therapy at least 3 days, then step down to amoxicillin to complete 7 to 10 days. |
| Deterioration or no improvement after 48 hours | Use ceftriaxone plus cloxacillin and evaluate for staphylococcal pneumonia, pleural complications, TB, pneumocystosis, and resistant pathogens. |
| Step-down after suspected staphylococcal disease | When improved, afebrile, and able to take oral medicine, switch to co-amoxiclav to complete 10 to 14 days, or longer for large empyema according to drainage and clinical course. |
Persistent, atypical, and staphylococcal pneumonia
| Medicine | Dose |
|---|---|
| Azithromycin | Children: 10 mg/kg once daily, maximum 500 mg, for 5 days. Adults: 500 mg on day 1, then 250 mg once daily on days 2 to 5. |
| Erythromycin | Children: 10 mg/kg, maximum 500 mg, four times daily for 10 to 14 days. Adults: 500 mg four times daily for 10 to 14 days. |
| Doxycycline | Eligible children under 45 kg: 2 to 2.2 mg/kg twice daily, maximum 100 mg twice daily, for 10 to 14 days. Children 45 kg and over and adults: 100 mg twice daily for 10 to 14 days. Avoid in pregnancy, breastfeeding when contraindicated, and young children according to local policy. |
| Component | Clinical approach |
|---|---|
| Antibiotics | Urgent hospital treatment with ceftriaxone plus cloxacillin; clindamycin is an alternative in selected settings. Step down to co-amoxiclav after clear improvement and adequate drainage when needed. |
| Complications | Look actively for empyema, pneumothorax, lung abscess, shock, and sepsis. A facility treating this condition should have pleural drainage capacity. |
Supportive care, prevention, and handover
- Give oxygen to keep SpO2 at least 90% where oxygen saturation monitoring is available, or for clinical cyanosis, severe respiratory distress, or inability to feed in settings without oximetry.
- Position infants and breathless patients semi-sitting when tolerated. Clear nasal obstruction with saline and gentle suction when it interferes with feeding or breathing.
- Maintain hydration without fluid overload. Severe respiratory distress may require IV fluid at reduced maintenance volume until oral intake is safe; resume breastfeeding, milk, food, and water as soon as possible.
- Use paracetamol for fever or pain when needed. Keep young infants warm and monitor temperature.
- Prevention includes Hib and pneumococcal vaccination where available, measles vaccination, reduced indoor smoke exposure, breastfeeding, nutrition support, HIV care, and prompt care for danger signs.
- Handover should include age, weight, respiratory rate, SpO2, severe signs, hydration and feeding status, HIV/TB/malnutrition risk, antibiotic start times, oxygen and fluids, response at 48 hours, suspected complications, and follow-up plan.
Medicines in this guide
Amoxicillin oralFirst-line outpatient treatment and oral step-down therapy for many pneumonia pathways.Ampicillin injectableParenteral treatment option for severe pneumonia, especially in young children.Gentamicin injectableCombined with ampicillin for severe pneumonia in neonates and young infants.Ceftriaxone injectableParenteral option for severe pneumonia and staphylococcal pneumonia combinations.Cloxacillin injectableAdded when staphylococcal pneumonia is suspected or response is poor.Co-amoxiclav oralOral continuation option after improvement in suspected staphylococcal pneumonia.Azithromycin oralUsed for persistent pneumonia or suspected atypical bacterial pneumonia.Erythromycin oralAlternative macrolide for atypical pneumonia when azithromycin is unavailable.Doxycycline oralAlternative atypical pneumonia treatment in eligible older children and adults.Clindamycin injectableAlternative treatment option for staphylococcal pneumonia where appropriate.Paracetamol = acetaminophen oralSymptomatic fever or pain management.Sodium chloride 0.9%Fluid and medicine-dilution option when clinically indicated.
Source
MSF Clinical guidelines - Diagnosis and treatment manual (December 2024)
This page is a paraphrased clinician-oriented guide derived from the source topic on PDF page 94. Medicine-specific details should be checked against local protocol and the linked drug-information pages.