What is the recommended treatment for pneumonia in children?

Treatment of Pneumonia in Children

Amoxicillin is the first-line treatment for typical bacterial pneumonia in children, while macrolides such as azithromycin are recommended for atypical pneumonia, particularly in school-aged children and adolescents. 1, 2

Treatment Algorithm Based on Age and Suspected Pathogen

Children <5 years old

• First-line therapy: Amoxicillin 90 mg/kg/day in 2 doses (maximum 4g/day) 2
  • Duration: 5-day course is as effective as longer regimens 2, 3
  • Dosing frequency: Twice daily dosing is as effective as thrice daily 4
• Alternative: Amoxicillin-clavulanate if β-lactamase producing organisms are suspected 2

Children ≥5 years old

• For typical bacterial pneumonia: Amoxicillin 90 mg/kg/day in 2 doses 2
• For suspected atypical pneumonia: Azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 1, 2, 5
• Alternative macrolides: Clarithromycin (15 mg/kg/day in 2 doses) or erythromycin (40 mg/kg/day in 4 doses) 1
• For children >7 years with atypical pneumonia: Doxycycline (2-4 mg/kg/day in 2 doses) may be used 1, 2

Hospitalized Children

For fully immunized children:

• Preferred: Ampicillin (200 mg/kg/day every 6 hours) or penicillin G (100,000-250,000 U/kg/day every 4-6 hours) 1, 2
• Add macrolide if atypical pneumonia is suspected 2

For non-fully immunized children or in areas with high pneumococcal resistance:

• Preferred: Ceftriaxone (50-100 mg/kg/day every 12-24 hours) or cefotaxime (150 mg/kg/day every 8 hours) 1, 2
• Add macrolide if atypical pneumonia is suspected 2

Pathogen-Specific Treatment

Streptococcus pneumoniae

• Penicillin-susceptible: Amoxicillin (90 mg/kg/day in 2 doses) 2
• Penicillin-resistant (MICs ≥4.0 μg/mL): Ceftriaxone (100 mg/kg/day every 12-24 hours) 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, 2
• Alternatives: Clarithromycin or erythromycin 1

Staphylococcus aureus

• MSSA: Cefazolin (150 mg/kg/day every 8 hours) or oxacillin (150-200 mg/kg/day every 6-8 hours) for parenteral; cephalexin (75-100 mg/kg/day in 3-4 doses) for oral 1
• MRSA: Vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin (40 mg/kg/day every 6-8 hours) if susceptible 1

Haemophilus influenzae

• β-lactamase negative: Ampicillin (150-200 mg/kg/day every 6 hours) for parenteral; amoxicillin (75-100 mg/kg/day in 3 doses) for oral 1
• β-lactamase producing: Ceftriaxone/cefotaxime for parenteral; amoxicillin-clavulanate for oral 1

Important Clinical Considerations

• Duration: A 5-day course is sufficient for uncomplicated cases 2, 3
• Clinical improvement should be evident within 48-72 hours of starting appropriate therapy 2
• Oral amoxicillin has been shown to be equivalent to injectable penicillin for severe pneumonia in controlled settings 6
• Treatment failure risk factors include age <12 months, very fast breathing, hypoxia, and non-adherence to medication 3, 6

Common Pitfalls to Avoid

• Overuse of antibiotics in young children with likely viral pneumonia 2
• Inappropriate use of macrolides as first-line therapy in young children (<5 years) with typical pneumonia 2
• Failure to consider macrolide resistance in patients not responding to initial therapy 2
• Inadequate dosing: Higher doses of amoxicillin do not improve outcomes but ensure appropriate weight-based dosing 7, 8
• Excessive treatment duration: Longer courses (7 days vs. 3 days) do not significantly improve outcomes but may slightly reduce time to resolution of cough 3, 8