Clinical recommendations for the inpatient management of lower respiratory tract infections in children and adolescents with severe neurological impairment in Germany—2026 Update

Abstract Children and adolescents with severe neurological impairment (SNI) require specialized care due to their complex medical needs. These patients often experience severe, recurrent lower respiratory tract infections (LRTIs). These infections, of both viral and bacterial etiology, pose a significant risk to these patients, often resulting in respiratory insufficiency and long-term impairments. Based on expert consensus and newly available data, we have updated the previous 2024 clinical recommendations on the management of LRTIs in children and adolescents with SNI in Germany. This update now also addresses multidrug-resistant organism colonization, respiratory support, discharge planning, and prophylactic strategies. The recommendations emphasize comprehensive multidisciplinary care, antimicrobial stewardship, and a stepwise, risk-stratified approach to antibiotic therapy. Initial treatment should involve symptomatic care, including hydration, antipyretics, oxygen therapy, secretion management, and respiratory as well as cough support. In suspected bacterial LRTIs, antibiotic treatment (ABT) should be guided by clinical severity, previous microbiological findings, and treatment response, with an aminopenicillin plus a beta-lactamase inhibitor recommended for community-acquired LRTIs and piperacillin-tazobactam reserved for selected high-risk patients. Ongoing management includes regular reassessment, adjustment of ABT based on pathogen identification, and optimization of supportive care. Conclusion : The updated recommendations provide a practical, multidisciplinary framework for the inpatient management of LRTIs in children and adolescents with SNI, combining optimized supportive care with antimicrobial stewardship and a stepwise, risk-stratified approach to antibiotic treatment. What is Known: • Children and adolescents with severe neurological impairment are particularly affected by severe and recurrent lower respiratory tract infections (LRTI) • The indication and choice of antibiotic therapy for bacterial LRTI is often difficult because there are no evidence-based treatment recommendations for this heterogeneous but vulnerable patient population • The frequent overuse of broad-spectrum or reserve antibiotics in this patient population increases selection pressure for multidrug-resistant pathogens What is New: • Compared with the 2024 recommendations, this update provides more detailed guidance on secretion management and respiratory and cough support, introduces explicit discharge criteria, and expands decision-making for patients colonized with multidrug-resistant organisms. The antibiotic strategy has been further specified regarding broad-spectrum antibiotic therapy, while preventive recommendations have been expanded and updated.