What are the preferred antibiotics for community-acquired pneumonia in pediatrics?

Preferred Antibiotics for Community-Acquired Pneumonia in Pediatrics

Amoxicillin is the first-line antibiotic of choice for community-acquired pneumonia (CAP) in children, with a recommended dosage of 90 mg/kg/day divided into two doses (maximum 4 g/day). 1

First-Line Treatment by Age Group

Children Under 5 Years

• First-line: Amoxicillin 90 mg/kg/day divided into 2 doses for 5 days 1
• Alternative (for penicillin allergy): Cefpodoxime, cefuroxime, or cefprozil 1

Children 5 Years and Older

• First-line: Amoxicillin 90 mg/kg/day divided into 2 doses (maximum 4 g/day) for 5 days 1
• Alternative (for atypical pneumonia): Macrolides such as azithromycin 1, 2

Azithromycin Dosing for Atypical Pneumonia

For suspected Mycoplasma pneumonia or other atypical pathogens:

• Dosing: 10 mg/kg on day 1 (maximum 500 mg), followed by 5 mg/kg on days 2-5 (maximum 250 mg) 1, 2
• Alternative adult dosing: 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5 2

Treatment Duration

Recent evidence suggests that shorter courses (5 days) may be as effective as longer courses (7-10 days) for uncomplicated pneumonia 1, 3. The American Academy of Pediatrics recommends:

• 5-day course for most uncomplicated CAP cases 1
• Treatment should be continued for at least 48-72 hours beyond symptom resolution 1

Hospitalization Considerations

Consider hospitalization for children with:

• Severe respiratory distress
• Oxygen saturation <92% or cyanosis
• Inability to maintain oral hydration
• Toxic appearance
• Failure to respond to outpatient management 1

For hospitalized children:

• Fully immunized: Ampicillin or penicillin G
• Not fully immunized or high local resistance: Ceftriaxone or cefotaxime 1

Monitoring Response

• Assess for clinical improvement within 48-72 hours of starting antibiotics 1
• Signs of improvement include decreased fever, improved respiratory rate, and decreased work of breathing
• If no improvement after 48-72 hours, reassess diagnosis and consider alternative antibiotics 1

Common Pitfalls to Avoid

1. Underdosing amoxicillin: Using standard adult doses rather than weight-based dosing can lead to treatment failure 1
2. Defaulting to macrolides as first-line therapy in young children with typical pneumonia 1
3. Using unnecessarily broad-spectrum antibiotics when narrow-spectrum options are effective 1
4. Defaulting to 10-day courses regardless of clinical response 1
5. Not evaluating response after 48-72 hours of therapy 1

Antibiotic Stewardship Considerations

• Avoid unnecessary broad-spectrum antibiotics to prevent antimicrobial resistance 1
• Be aware of increasing macrolide resistance in Mycoplasma pneumoniae globally 1
• Adjust therapy based on clinical response rather than defaulting to fixed durations 1

The evidence strongly supports amoxicillin as the first-line treatment for pediatric CAP, with macrolides reserved for suspected atypical pathogens. High-dose amoxicillin (90 mg/kg/day) is recommended to overcome potential resistance, and a 5-day course is typically sufficient for uncomplicated cases.