What is the first-line treatment for pneumonia in a 6-year-old child weighing 15 kilograms (kg)?

First-Line Treatment for Pneumonia in a 6-Year-Old Child Weighing 15 kg

For a 6-year-old child weighing 15 kg with community-acquired pneumonia, oral amoxicillin at a dose of 90 mg/kg/day divided into 2 doses for 5 days is the recommended first-line treatment. 1

Assessment for Severity and Need for Hospitalization

Before initiating treatment, assess for indicators requiring hospital admission:

• Oxygen saturation <92% or cyanosis
• Respiratory rate >50 breaths/min
• Difficulty breathing or grunting
• Signs of dehydration
• Family unable to provide appropriate observation 2

Antibiotic Selection Algorithm

For Outpatient Management (Non-Severe Pneumonia):

1. First-line treatment: Amoxicillin

   • Dosage: 90 mg/kg/day in 2 divided doses (maximum 4 g/day) 1
   • For a 15 kg child: 1350 mg/day = 675 mg twice daily
   • Duration: 5 days 2, 3

2. If Mycoplasma or atypical pneumonia is suspected (especially in children ≥5 years):

   • Add a macrolide antibiotic such as azithromycin 2, 1
   • Azithromycin dosage: 10 mg/kg (150 mg) on day 1, followed by 5 mg/kg (75 mg) daily for days 2-5 4

3. If penicillin allergy exists:

   • Macrolide antibiotics (azithromycin, clarithromycin) 2

For Inpatient Management (Severe Pneumonia):

1. First-line parenteral therapy:

   • Ampicillin: 150-200 mg/kg/day divided every 6 hours 1
   • Alternative: Ceftriaxone (50-100 mg/kg/day every 12-24 hours) or cefotaxime (150 mg/kg/day every 8 hours) 1

2. For suspected staphylococcal pneumonia:

   • Combination of flucloxacillin with amoxicillin or a macrolide 2

Supportive Care

• Ensure adequate oxygenation (maintain O₂ saturation >92%) 2
• Maintain hydration (IV fluids at 80% basal levels if needed) 2
• Provide antipyretics for fever and comfort 2
• Monitor oxygen saturation at least every 4 hours if on oxygen therapy 2, 1
• Avoid chest physiotherapy as it is not beneficial 2

Follow-up and Treatment Failure

• Review within 48 hours if not improving 2
• If the child remains febrile or unwell after 48 hours:
  1. Re-evaluate for complications 2
  2. Consider switching to a second-line antibiotic:
     • If initially on amoxicillin, consider amoxicillin-clavulanate (80-90 mg/kg/day of amoxicillin component) 2
     • Consider adding a macrolide if atypical pathogens are suspected 2, 5

Important Considerations

• Recent evidence shows that 5-day amoxicillin treatment is as effective as 10-day treatment for uncomplicated CAP in children, with similar clinical cure rates 3, 6
• Despite guidelines recommending narrow-spectrum antibiotics like amoxicillin, studies show inappropriate use of broad-spectrum antibiotics is common in practice 7
• The American Academy of Pediatrics and Infectious Diseases Society of America recommend avoiding unnecessary broad-spectrum antibiotics when narrow-spectrum options are effective 1

Common Pitfalls to Avoid

1. Using broad-spectrum antibiotics unnecessarily - Amoxicillin alone is effective against the majority of pathogens causing CAP in children 2
2. Prolonged antibiotic courses - 5 days is sufficient for uncomplicated pneumonia 3, 6
3. Failure to assess severity - Always evaluate for indicators requiring hospitalization 2
4. Overlooking supportive care - Proper hydration and oxygenation are crucial components of treatment 1
5. Not considering age-specific pathogens - Children ≥5 years have higher prevalence of Mycoplasma pneumonia, which may require macrolide coverage 2