What is the treatment for pneumonia in children?

Treatment of Pneumonia in Children

Amoxicillin is the first-line treatment for community-acquired pneumonia (CAP) in children, with a recommended dose of 90 mg/kg/day in two divided doses for 5-7 days in most cases. 1, 2

Treatment Based on Severity and Setting

Outpatient Management (Mild-Moderate Pneumonia)

• First-line therapy: Oral amoxicillin

  • Dosage: 90 mg/kg/day divided in 2 doses (maximum 4g/day) 2
  • Duration: 5 days for most children; extend to 7 days in areas with high HIV prevalence 1, 2, 3

• Alternative options (for penicillin allergy):

  • Non-anaphylactic allergy: Cefuroxime (30 mg/kg/day in divided doses) 2
  • Severe allergic reactions: Clindamycin (10-20 mg/kg/day in 3 divided doses) 2
  • If atypical pneumonia suspected (especially in children ≥5 years): Macrolide antibiotics 1, 2

Inpatient Management (Severe Pneumonia)

• Fully immunized children:

  • Ampicillin (150-200 mg/kg/day every 6 hours) or penicillin G (200,000-250,000 U/kg/day every 4-6 hours) 1

• Not fully immunized or high local pneumococcal resistance:

  • Third-generation cephalosporin: Ceftriaxone (50-100 mg/kg/day) or cefotaxime (150 mg/kg/day) 1

• If MRSA suspected:

  • Add vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin (40 mg/kg/day every 6-8 hours) based on local susceptibility patterns 1, 2

• If Mycoplasma or Chlamydia pneumonia suspected:

  • Add a macrolide (e.g., azithromycin) to β-lactam therapy 1

Age-Specific Considerations

Children <5 years

• Focus on coverage for Streptococcus pneumoniae with amoxicillin as first-line therapy 1, 2
• Amoxicillin is effective against the majority of pathogens causing CAP in this age group 1

Children ≥5 years

• Consider atypical pathogens (Mycoplasma pneumoniae, Chlamydia pneumoniae)
• Macrolide antibiotics may be used as first-line empirical treatment 1
• For azithromycin, the pediatric dose for CAP is 10 mg/kg on day 1, followed by 5 mg/kg on days 2-5 4

Monitoring and Follow-up

• Children treated at home should be reviewed if deteriorating or not improving after 48 hours 1
• Patients on oxygen therapy should have oxygen saturation checks at least every 4 hours 2
• Clinical improvement should be assessed within 48-72 hours, looking for:
  • Decreased respiratory rate
  • Reduced work of breathing
  • Improved oxygen saturation
  • Decreased fever
  • Improved feeding 2

Important Considerations

• Oxygen therapy: Provide supplemental oxygen for patients with oxygen saturation ≤92% to maintain levels above 92% 1
• Hydration: If IV fluids needed, give at 80% of basal levels and monitor electrolytes 1
• Avoid unnecessary interventions:
  • Chest physiotherapy is not beneficial and should not be performed 1
  • Young children with mild symptoms of lower respiratory tract infection may not need antibiotics 1

Recent Evidence on Dosing and Duration

Recent high-quality evidence from the CAP-IT trial (2021) showed that lower-dose amoxicillin (35-50 mg/kg/day) was non-inferior to higher-dose (70-90 mg/kg/day), and 3-day treatment was non-inferior to 7-day treatment for most children 3. However, time to resolution of cough was slightly longer with the 3-day course, suggesting that the traditional 5-7 day course may still be preferable for symptom management 3, 5.

Common Pitfalls to Avoid

1. Inappropriate antibiotic selection: Don't use broad-spectrum antibiotics when narrow-spectrum will suffice
2. Inadequate dosing: Underdosing amoxicillin can lead to treatment failure, especially in areas with increasing pneumococcal resistance
3. Overuse of macrolides: Reserve for suspected atypical pneumonia or as part of combination therapy
4. Delayed transition to oral therapy: Switch from IV to oral antibiotics when there is clear clinical improvement 1
5. Unnecessary hospitalization: Use severity assessment criteria to determine appropriate treatment setting

By following these evidence-based guidelines, clinicians can effectively manage pediatric pneumonia while minimizing antibiotic resistance and optimizing outcomes.