What are the guidelines for inpatient treatment of Community-Acquired Pneumonia (CAP) in children?

From the Guidelines

Inpatient treatment of community-acquired pneumonia (CAP) in children should be guided by empiric antibiotic therapy based on the child's age and severity of illness, with ampicillin or penicillin G as first-line therapy for fully immunized children with minimal local penicillin resistance, and ceftriaxone or cefotaxime for those not fully immunized or with significant penicillin resistance, as recommended by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America 1.

Key Considerations

• For hospitalized children with uncomplicated CAP, ampicillin or penicillin G is recommended as first-line therapy (ampicillin 150-200 mg/kg/day divided every 6 hours; penicillin G 250,000-400,000 units/kg/day divided every 4-6 hours) 1.
• For children with complicated pneumonia or those with risk factors for resistant organisms, broader coverage with a third-generation cephalosporin like ceftriaxone (50-100 mg/kg/day divided every 12-24 hours) or cefotaxime (150 mg/kg/day divided every 8 hours) is appropriate 1.
• In areas with high prevalence of MRSA, consider adding vancomycin (40-60 mg/kg/day divided every 6-8 hours) or clindamycin (30-40 mg/kg/day divided every 6-8 hours) 1.
• Treatment duration typically ranges from 7-10 days for uncomplicated cases and may extend to 14-21 days for complicated cases with pleural effusions or empyema 1.
• Supportive care includes oxygen therapy to maintain saturation ≥92%, appropriate fluid management, and antipyretics for fever and pain 1.
• Reassessment within 48-72 hours is essential to evaluate treatment response and consider narrowing antibiotic coverage based on culture results 1.

Special Considerations

• Children with a history of possible, nonserious allergic reactions to amoxicillin require individualized treatment, with options including a trial of amoxicillin under medical observation, a trial of an oral cephalosporin, or treatment with levofloxacin, linezolid, clindamycin, or a macrolide 1.
• For children with bacteremic pneumococcal pneumonia, particular caution should be exercised in selecting alternatives to amoxicillin, given the potential for secondary sites of infection, including meningitis 1.

From the FDA Drug Label

Community-Acquired Pneumonia The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with community-acquired pneumonia is 10 mg/kg as a single dose on the first day followed by 5 mg/kg on Days 2 through 5.

PEDIATRIC DOSAGE GUIDELINES FOR OTITIS MEDIA, ACUTE BACTERIAL SINUSITIS AND COMMUNITY-ACQUIRED PNEUMONIA (Age 6 months and above, see PRECAUTIONS—Pediatric Use.)

Based on Body Weight OTITIS MEDIA AND COMMUNITY-ACQUIRED PNEUMONIA: (5-Day Regimen) * Dosing Calculated on 10 mg/kg/day Day 1 and 5 mg/kg/day Days 2 to 5.

The recommended dose of azithromycin for inpatient treatment of Community-Acquired Pneumonia (CAP) in children is 10 mg/kg as a single dose on the first day followed by 5 mg/kg on Days 2 through 5.

• The dosage guidelines are based on the child's weight and age (6 months and above).
• The treatment course is a 5-day regimen.
• The dosage is calculated as 10 mg/kg/day on Day 1 and 5 mg/kg/day on Days 2 to 5. 2

From the Research

Inpatient Treatment of Community-Acquired Pneumonia (CAP) in Children

• The treatment of CAP in children is empirical, based on the knowledge of the etiology of CAP at different ages 3.
• Recent studies have provided insights regarding the use of oral antibiotics in children with mild to moderate CAP, and severe CAP with lower chest retractions but no hypoxia 4.
• The choice of antibiotics for ambulatory treatment of CAP is oral amoxicillin with a duration of 3-5 days 4.
• Children with CAP with lower chest retractions but no hypoxia can be treated with oral amoxicillin 4.
• Severe pneumonia can be treated with intravenous antibiotics consisting of penicillin/ampicillin with or without an aminoglycoside 4.

Antibiotic Treatment Duration

• Most guidelines recommend antibacterials for 7-10 days (except azithromycin, which has a recommended treatment duration of 5 days) 3.
• A systematic review of randomized controlled trials found that the efficacy of short duration oral antibiotic treatment for non-severe CAP in children has not been established in developed countries 5.
• A randomized clinical trial found that a 5-day antibiotic strategy was superior to a 10-day strategy in children responding to initial treatment for outpatient CAP, resulting in similar clinical response and antibiotic-associated adverse effects, while reducing antibiotic exposure and resistance 6.

Hospitalized Patients

• In hospitalized patients who need parenteral therapy for CAP, cefuroxime (or penicillin G) is the drug of choice 3.
• Macrolides should be administered concomitantly if Mycoplasma pneumoniae or Chlamydia pneumoniae infection is suspected 3.
• An international survey of pediatric infectious diseases consultants found that increased disease severity was significantly associated with broader-spectrum and combination empiric and targeted antibiotic treatment, empiric methicillin-resistant Staphylococcus aureus (MRSA) coverage, and both longer intravenous and total duration of antibiotic treatment 7.