What is the recommended treatment for community-acquired pneumonia in pediatrics?

Treatment for Community-Acquired Pneumonia in Pediatrics

Amoxicillin is the first-line treatment for community-acquired pneumonia (CAP) in children older than 3 months, with specific dosing based on age and severity of illness. 1, 2

Treatment Algorithm Based on Setting and Severity

Outpatient Treatment (Mild CAP)

• For children <5 years old:

  • Preferred: Oral amoxicillin 90 mg/kg/day divided in 2 doses for 5-7 days 1, 2
  • Alternative: Oral amoxicillin 45 mg/kg/day in 3 doses for 5-7 days 1

• For children ≥5 years old:

  • Preferred: Oral amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) 1
  • If atypical pneumonia suspected (Mycoplasma/Chlamydia): Add azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 (maximum 500 mg on day 1,250 mg on days 2-5) 1, 3

Inpatient Treatment (Moderate to Severe CAP)

• Fully immunized children:

  • Preferred: IV ampicillin (150-200 mg/kg/day every 6 hours) or penicillin G 1
  • Alternative: IV ceftriaxone (50-100 mg/kg/day every 12-24 hours) or cefotaxime (150 mg/kg/day every 8 hours) 1

• Not fully immunized or high local penicillin resistance:

  • Preferred: IV ceftriaxone or cefotaxime 1
  • If MRSA suspected: Add vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin if susceptible 1, 2

• If atypical pneumonia suspected:

  • Add IV azithromycin (10 mg/kg on days 1 and 2) 1

Pathogen-Specific Treatment

Streptococcus pneumoniae

• Penicillin-susceptible:

  • IV: Penicillin G or ampicillin
  • Oral: Amoxicillin 90 mg/kg/day in 2 doses 1

• Penicillin-resistant (MIC ≥4.0 μg/mL):

  • IV: Ceftriaxone 100 mg/kg/day
  • Oral: Levofloxacin (if susceptible) or linezolid 1

Mycoplasma pneumoniae/Chlamydophila pneumoniae

• Preferred: Azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 1, 3
• Alternative: Clarithromycin 15 mg/kg/day in 2 doses 1

Group A Streptococcus

• IV: Penicillin G or ampicillin
• Oral: Amoxicillin 50-75 mg/kg/day in 2 doses 1, 2

Haemophilus influenzae

• β-lactamase negative:
  • IV: Ampicillin 150-200 mg/kg/day
  • Oral: Amoxicillin 75-100 mg/kg/day in 3 doses 1
• β-lactamase positive:
  • IV: Ceftriaxone or cefotaxime
  • Oral: Amoxicillin-clavulanate (amoxicillin component 45-90 mg/kg/day) 1, 2

Staphylococcus aureus

• MSSA:
  • IV: Oxacillin or cefazolin
  • Oral: Cephalexin 75-100 mg/kg/day 1
• MRSA:
  • IV: Vancomycin or clindamycin (if susceptible)
  • Oral: Clindamycin (if susceptible) or linezolid 1

Duration of Therapy

Recent evidence suggests shorter courses may be as effective as longer courses:

• Mild to moderate CAP: 5-day course is as effective as 10-day course 4, 5
• Severe CAP: 7-day course typically recommended 1

Important Clinical Considerations

• Risk factors for treatment failure: Infancy (3-11 months), very fast breathing, and hypoxia 6
• Twice-daily dosing of amoxicillin is as effective as three-times-daily dosing and may improve adherence 7
• Step-down therapy: When clinical improvement occurs, transition from IV to appropriate oral therapy 1
• Monitoring: Assess for clinical response within 48-72 hours; failure to improve warrants reevaluation 1

Caveats and Pitfalls

• Always consider local antimicrobial resistance patterns when selecting therapy
• For children with penicillin allergy, alternatives should be selected based on allergy severity and suspected pathogen
• Avoid fluoroquinolones in children unless benefits outweigh risks
• Ensure appropriate weight-based dosing to maximize efficacy while minimizing resistance