What are the World Health Organization (WHO) guidelines for pneumonia management?

WHO Guidelines for Pneumonia Management

According to the World Health Organization (WHO) guidelines, amoxicillin is the recommended first-line treatment for childhood pneumonia, given twice daily for 3-5 days, with co-trimoxazole as an alternative in certain settings. 1

Classification and Treatment of Pediatric Pneumonia

Non-Severe Pneumonia (Outpatient Management)

• First-line treatment: Oral amoxicillin
  • Dosage: 50 mg/kg per dose, in two divided doses daily
  • Duration: 3-5 days 1
• Alternative: Co-trimoxazole (8 mg/kg trimethoprim per dose, twice daily) in settings where amoxicillin is unavailable 1
• For areas with high antimicrobial resistance to co-trimoxazole: Amoxicillin is preferred 1

Chest Indrawing Pneumonia

• Previously requiring hospitalization, now can be managed as outpatient with oral amoxicillin 1
• Important safety considerations: Children with chest indrawing pneumonia should be referred or monitored daily if they have:
  • Signs of severe respiratory distress
  • Oxygen saturation <93% (when not at high altitude)
  • Moderate malnutrition
  • Unknown HIV status in HIV-endemic settings 1

Severe Pneumonia (Inpatient Management)

• Injectable antimicrobial agents such as:
  • Ceftriaxone
  • Penicillin/gentamicin combination
  • Chloramphenicol 1

Special Considerations

Malaria Co-infection

• In malaria-endemic regions, assess children with rapid breathing for both pneumonia and malaria 1
• Children with clinical features consistent with both conditions should receive treatment for both 1
• Caution: Co-trimoxazole has some antimalarial activity but is not a first-line malaria treatment 1

HIV Co-infection

• Children in areas with high HIV prevalence should be assessed for HIV infection 1
• For children with suspected or confirmed HIV infection with non-severe pneumonia:
  • Amoxicillin is recommended regardless of co-trimoxazole prophylaxis status 1
  • If treatment fails, refer to hospital for broader spectrum parenteral antibiotics 1

Treatment Failure

Treatment failure is defined as:

• Development of signs warranting immediate referral, OR
• No decrease in respiratory rate after 48-72 hours of therapy 1

If treatment failure occurs:

1. Systematically determine possible explanations:
   • Non-adherence to therapy
   • Alternative diagnoses
2. If first-line treatment failure is suspected:
   • Second-line treatment: High-dose amoxicillin-clavulanic acid
   • For children over 3 years: Consider adding an affordable macrolide 1

Adult Pneumonia Management

For adults with community-acquired pneumonia (CAP):

Outpatient Treatment

• Recommendations vary based on comorbidities and risk factors 1

Inpatient, ICU Treatment

• A β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin or a fluoroquinolone 1
• For penicillin-allergic patients: respiratory fluoroquinolone and aztreonam 1

Implementation Considerations

• Pulse oximetry screening should be performed at the earliest point in the care pathway 1
• When referral is not possible but indicated, careful daily monitoring is essential 1
• For hospitalized patients, the first antibiotic dose should be administered while still in the emergency department 1
• Patients should be switched from intravenous to oral therapy when they are hemodynamically stable, improving clinically, and able to ingest medications 1

Duration of Therapy

• Minimum treatment duration for CAP is 5 days 1
• Patients should be afebrile for 48-72 hours and have no more than one CAP-associated sign of clinical instability before discontinuing therapy 1
• Recent evidence suggests that a 5-day course of amoxicillin is as effective as a 10-day course for uncomplicated CAP in children under 10 years old 2

The WHO pneumonia management guidelines emphasize early appropriate antibiotic therapy targeting the most likely pathogens, with consideration for local resistance patterns and special populations such as those with HIV or in malaria-endemic regions.