What is the recommended treatment for pediatric pneumonia?

Pediatric Pneumonia Treatment

The recommended first-line treatment for pediatric community-acquired pneumonia is high-dose oral amoxicillin at 90 mg/kg/day divided into two doses (maximum 4 g/day) for children under 5 years. 1

Treatment Algorithm by Age and Severity

Outpatient Management (Mild-Moderate Pneumonia)

• First-line therapy:

  • Children <5 years: Amoxicillin 90 mg/kg/day in 2 divided doses 1
  • Children ≥5 years: Amoxicillin 90 mg/kg/day in 2 divided doses (maximum 4 g/day) 1
  • Duration: 5 days for uncomplicated cases 1, 2, 3

• Alternative options (for penicillin allergy):

  • Cephalosporins: cefpodoxime, cefuroxime, or cefprozil 1
  • Macrolides (if atypical pathogens suspected):
    • Azithromycin: 10 mg/kg on day 1 (max 500 mg), then 5 mg/kg on days 2-5 (max 250 mg) 1, 4

Suspected Atypical Pneumonia

• First-line for Mycoplasma pneumonia:
  • Azithromycin: 10 mg/kg on day 1 (max 500 mg), then 5 mg/kg on days 2-5 (max 250 mg) 1, 4

Inpatient Management (Severe Pneumonia)

• Fully immunized children:

  • Ampicillin or penicillin G 1

• Not fully immunized or high local resistance:

  • Ceftriaxone or cefotaxime 1
  • Consider vancomycin or clindamycin if MRSA suspected 1

Dosing Considerations

Amoxicillin Dosing

• Standard dosing: 45-50 mg/kg/day divided into 3 doses
• High-dose therapy: 90 mg/kg/day divided into 2 doses (recommended for pneumonia) 1, 5
• Maximum daily dose: 4 g/day 1

Azithromycin Dosing for Pneumonia

• Children ≥6 months: 10 mg/kg (max 500 mg) on day 1, followed by 5 mg/kg (max 250 mg) on days 2-5 1, 4

Treatment Duration

• Uncomplicated pneumonia: 5 days of therapy is as effective as longer courses (7-10 days) 1, 2, 3
• Severe pneumonia: Continue treatment for at least 48-72 hours beyond symptom resolution 1

Monitoring Response

• Assess for clinical improvement within 48-72 hours of starting antibiotics 1
• Signs of improvement include:
  • Decreased fever
  • Improved respiratory rate
  • Decreased work of breathing 1

Hospitalization Criteria

Consider hospital admission for children with:

• Severe respiratory distress
• Oxygen saturation <92% or cyanosis
• Inability to maintain oral hydration
• Toxic appearance
• Failure to respond to outpatient management
• Respiratory rate >50 breaths/min in infants
• All infants ≤8 weeks with pneumonia 1

Common Pitfalls to Avoid

1. Inadequate dosing: Using standard adult doses rather than weight-based dosing can lead to treatment failure 1
2. Excessive treatment duration: Defaulting to 10-day courses regardless of clinical response may contribute to antimicrobial resistance 1
3. Delayed reassessment: Not evaluating response after 48-72 hours can delay necessary changes in treatment 1
4. Inappropriate use of macrolides: Using macrolides as first-line therapy in young infants with typical pneumonia 1
5. Ignoring local resistance patterns: Not considering local antibiotic resistance when selecting empiric therapy 1

Evidence Quality and Considerations

Recent evidence from randomized controlled trials supports shorter courses (5 days) of amoxicillin for uncomplicated pneumonia 2, 3, 6. A multicentre equivalency study also found that oral amoxicillin is as effective as injectable penicillin for severe pneumonia in children aged 3-59 months 7, which has important implications for treatment in resource-limited settings.

The American Academy of Pediatrics and the Infectious Diseases Society of America emphasize antibiotic stewardship by recommending narrow-spectrum antibiotics when effective and avoiding unnecessary broad-spectrum antibiotics 1.