<p class="first" id="d6094594e139">Complicated community-acquired pneumonia in a previously
well child is a severe illness
characterised by combinations of local complications (eg, parapneumonic effusion,
empyema, necrotising pneumonia, and lung abscess) and systemic complications (eg,
bacteraemia, metastatic infection, multiorgan failure, acute respiratory distress
syndrome, disseminated intravascular coagulation, and, rarely, death). Complicated
community-acquired pneumonia should be suspected in any child with pneumonia not responding
to appropriate antibiotic treatment within 48-72 h. Common causative organisms are
Streptococcus pneumoniae and Staphylococcus aureus. Patients have initial imaging
with chest radiography and ultrasound, which can also be used to assess the lung parenchyma,
to identify pleural fluid; CT scanning is not usually indicated. Complicated pneumonia
is treated with a prolonged course of intravenous antibiotics, and then oral antibiotics.
The initial choice of antibiotic is guided by local microbiological knowledge and
by subsequent positive cultures and molecular testing, including on pleural fluid
if a drainage procedure is done. Information from pleural space imaging and drainage
should guide the decision on whether to administer intrapleural fibrinolytics. Most
patients are treated by drainage and more extensive surgery is rarely needed; in any
event, in low-income and middle-income countries, resources for extensive surgeries
are scarce. The clinical course of complicated community-acquired pneumonia can be
prolonged, especially when patients have necrotising pneumonia, but complete recovery
is the usual outcome.
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