What is the management of pneumonia in an 8-year-old child?

Management of Pneumonia in an 8-Year-Old Child

For an 8-year-old child with community-acquired pneumonia (CAP), high-dose oral amoxicillin (90 mg/kg/day in 2 doses, maximum 4 g/day) is the first-line treatment for presumed bacterial pneumonia in the outpatient setting, with consideration of adding a macrolide if atypical pneumonia is suspected. 1

Outpatient Management

Assessment and Classification

• Determine severity based on clinical presentation, respiratory status, and ability to maintain oral intake 1
• Assess vaccination status for Haemophilus influenzae type b and Streptococcus pneumoniae, as this affects antibiotic selection 1
• Consider local patterns of antimicrobial resistance in your community 1

Antibiotic Selection for Outpatient Treatment

• For presumed bacterial pneumonia:

  • First-line: Oral amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) 1
  • Alternative: Oral amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) 1
  • Duration: 5-7 days is typically sufficient for uncomplicated cases 2, 3

• For presumed atypical pneumonia (Mycoplasma pneumoniae, Chlamydophila pneumoniae):

  • First-line: Oral azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5, maximum 500 mg on day 1, followed by 250 mg on days 2-5) 1, 4
  • Alternatives: Oral clarithromycin (15 mg/kg/day in 2 doses, maximum 1 g/day) or doxycycline for children >7 years old 1

• For mixed/uncertain etiology:

  • Consider combination therapy with a β-lactam (amoxicillin) plus a macrolide if clinical, laboratory, or radiographic findings don't clearly distinguish between bacterial and atypical pneumonia 1

Inpatient Management

Indications for Hospitalization

• Respiratory distress, hypoxemia, inability to maintain oral hydration, or failed outpatient therapy 1
• Complicated pneumonia (empyema, large pleural effusion) 1

Antibiotic Selection for Hospitalized Patients

• For fully immunized children with minimal local penicillin resistance:

  • First-line: Ampicillin or penicillin G 1
  • Alternatives: Ceftriaxone or cefotaxime 1

• For not fully immunized children or areas with significant penicillin resistance:

  • First-line: Ceftriaxone (50-100 mg/kg/day) or cefotaxime (150 mg/kg/day) 1
  • Add vancomycin or clindamycin if MRSA is suspected 1

• For suspected atypical pneumonia in hospitalized patients:

  • Add azithromycin to β-lactam therapy 1

Special Considerations

Suspected Staphylococcal Pneumonia

• Add vancomycin or clindamycin to β-lactam therapy if clinical, laboratory, or imaging characteristics suggest Staphylococcus aureus infection 1
• For MRSA, vancomycin (40-60 mg/kg/day) or clindamycin (if susceptible) is recommended 1

Influenza-Associated Pneumonia

• Add oseltamivir if influenza is suspected or confirmed 1
• Continue appropriate antibacterial coverage for secondary bacterial pneumonia 1

Parapneumonic Effusion

• Chest radiography should be used to confirm the presence of pleural fluid 1
• Consider chest ultrasound or CT for further characterization if needed 1
• Gram stain and bacterial culture of pleural fluid should be performed when obtained 1

Duration of Therapy

• For mild to moderate outpatient pneumonia, 5 days of appropriate antibiotic therapy is generally sufficient 2, 3
• For more severe cases or complicated pneumonia, longer courses (7-10 days) may be needed 1
• Recent evidence suggests shorter courses (3-5 days) may be as effective as longer courses (7-10 days) for uncomplicated CAP 5, 3

Common Pitfalls to Avoid

• Overuse of broad-spectrum antibiotics when narrow-spectrum options would be effective 5, 6
• Failure to consider atypical pathogens in children >5 years old 1
• Inadequate dosing of amoxicillin (lower doses may be insufficient for penicillin-resistant pneumococci) 7
• Not adjusting therapy based on clinical response within 48-72 hours 1

Follow-up

• Clinical improvement should be expected within 48-72 hours of starting appropriate therapy 1
• Consider alternative diagnoses or resistant organisms if no improvement occurs 1
• Routine follow-up chest radiographs are not necessary for patients who recover uneventfully 1