IDSA/PIDS 2026: updated guidelines for managing pneumonia in children

Paediatrics

Community-acquired pneumonia (CAP) is a significant cause of morbidity and hospitalisation among infants and children. Although most cases resolve with appropriate antimicrobial treatment, complicated pneumonia can progress to parapneumonic effusion and empyema, resulting in respiratory compromise and prolonged hospitalisation. Timely identification of pleural complications and appropriate intervention are therefore essential to minimise disease-related morbidity.The 2026 clinical practice guidelines developed by the Infectious Diseases Society of America (IDSA) and the Pediatric Infectious Diseases Society (PIDS) provide updated recommendations for managing CAP and its complications in infants and children older than 3 months. Particular emphasis has been placed on the assessment and management of parapneumonic effusions and empyema, including imaging modalities, indications for pleural drainage, chest tube selection and intrapleural fibrinolytic therapy.Imaging assessment of parapneumonic effusionParapneumonic effusion, which develops when fluid accumulates in the pleural space secondary to pneumonia, can progress to complicated effusion or empyema. Accurate assessment of effusion size and complexity is essential for determining the appropriate management strategyFor children with radiographic evidence of moderate-to-large parapneumonic effusions, chest ultrasonography has been suggested over computed tomography (CT) or magnetic resonance imaging (MRI) to characterise the size and complexity of the effusion. Ultrasound allows pleural fluid collections to be assessed and can help identify loculations and septations that may influence drainage decisionsCompared with CT and MRI, chest ultrasound offers the advantages of avoiding ionising radiation, being relatively accessible and allowing bedside assessment. It can also be used during follow-up to monitor changes in pleural fluid collections and assess treatment responsePleural fluid drainage versus observationThe decision to undertake pleural drainage is guided by effusion size, clinical presentation, respiratory status and evidence of purulent fluid. Not all parapneumonic effusions require invasive intervention, and management is recommended to be individualised according to disease severityFor children with small, uncomplicated parapneumonic effusions, observation has been conditionally suggested over pleural drainage. Clinical monitoring is essential to identify progression, persistent fever or respiratory deterioration that may necessitate interventionIn contrast, pleural drainage is recommended in children presenting with any of the following:Moderate parapneumonic effusion accompanied by respiratory distressLarge parapneumonic effusionDocumented purulent pleural effusionDrainage is particularly important when substantial fluid accumulation compromises lung expansion or when infected pleural collections require source control. The selection of an appropriate drainage technique should be guided by clinical stability and the extent of pleural involvement.Chest tube drainage with intrapleural fibrinolytics versus surgical debridementIn children and adolescents aged 3 months to 18 years with pneumonia-associated empyema requiring pleural drainage, chest tube placement combined with intrapleural fibrinolytic therapy has been suggested as the preferred first-line approach over surgical debridement in most casesEmpyema is characterised by the accumulation of infected or purulent fluid within the pleural cavity, often accompanied by fibrin deposition, septation and loculation. These changes can restrict lung expansion and complicate fluid evacuation. Intrapleural fibrinolytic agents facilitate drainage by breaking down fibrinous septations and improving communication between loculated pleural collectionsThis minimally invasive approach may help achieve adequate pleural drainage while avoiding the need for more invasive surgical procedures. However, surgical intervention may still be considered when adequate drainage cannot be achieved or when clinical improvement is not observed following initial managementSelection of chest tube sizeFor children aged 3 months to 18 years with parapneumonic effusion or empyema requiring drainage, the use of small-bore chest tubes (≤12 French [Fr]) has been suggested over large-bore tubes (≥14 Fr)Small-bore chest tubes offer a less invasive drainage option and may reduce procedural discomfort while facilitating effective evacuation of pleural collections. Their use, particularly when combined with intrapleural fibrinolytic therapy, is supported as an appropriate approach to managing paediatric empyemaThe choice of chest tube should nevertheless be guided by the characteristics of the pleural collection, clinical presentation and the treating team's experienceIntrapleural tPA alone versus tPA combined with DNaseFor children aged 3 months to 18 years with pneumonia-associated empyema, the administration of tissue plasminogen activator (tPA) alone has been suggested over its combination with deoxyribonuclease (DNase) for intrapleural fibrinolysistPA promotes fibrinolysis by converting plasminogen into plasmin, which facilitates the breakdown of fibrin deposits within the pleural space. This helps disrupt septations and improves drainage of infected pleural fluidAlthough DNase has been used alongside tPA to reduce the viscosity of pleural collections by degrading extracellular DNA, additional benefit from combining both agents has not been established in the paediatric population. Accordingly, tPA monotherapy has been favoured in the updated recommendationsConclusionThe 2026 IDSA/PIDS guidelines emphasise a structured, severity-based approach to managing paediatric CAP complicated by parapneumonic effusion and empyema. Chest ultrasound is preferred for characterising moderate-to-large effusions, while observation is favoured for small, uncomplicated collections. When drainage is indicated, small-bore chest tubes combined with intrapleural fibrinolytic therapy are recommended as the preferred initial approach in most cases, with tPA monotherapy favoured over combination therapy with DNase. These recommendations support effective pleural source control while limiting unnecessary invasive interventions in children.[2]Reference(s):1. Dequin PF, Torres A, Bassetti M, et al. Severe community-acquired pneumonia: current concepts and controversies. Intensive Care Med. 2026;52(1):118-130. doi:10.1007/s00134-025-08252-x. https://pmc.ncbi.nlm.nih.gov/articles/PMC12852277/2. St Peter SD, Ampofo K, Brogan T, et al. 2026 Clinical Practice Guideline Update by the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society on The Management of Community-acquired Pneumonia in Infants and Children Older than 3 Months of Age: The Choice of Chest Tube Size. Clin Infect Dis. Published online March 17, 2026. doi:10.1093/cid/ciag190. https://www.idsociety.org/practice-guideline/community-acquired-pneumonia-in-infants-and-children/