Antibiotic Regimens for Community-Acquired Pneumonia in Pediatric Patients
For pediatric community-acquired pneumonia (CAP), amoxicillin is the first-line treatment for outpatient management, with macrolides recommended for atypical pathogens, while hospitalized patients require age-appropriate parenteral therapy based on likely pathogens. 1
Outpatient Management
First-line therapy:
- Amoxicillin 90 mg/kg/day divided in three doses (or two doses to improve compliance) for children who are immunized against Haemophilus influenzae type b 2
- Treatment duration of 5 days is recommended for uncomplicated CAP 1, 3, 4
- Clinical reassessment should occur approximately 72 hours after starting antibiotics to evaluate symptom resolution 2
Alternative regimens:
- Amoxicillin-clavulanate or second/third-generation cephalosporins for children with incomplete immunization against H. influenzae type b and Streptococcus pneumoniae 2
- For penicillin-allergic patients, oral clindamycin (40 mg/kg/day in 3 doses) is an alternative 1, 5
Atypical pathogens:
- For children >5 years with suspected atypical pneumonia or persistent symptoms after 48 hours of beta-lactam therapy, add azithromycin 2
- Azithromycin dosing: 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 1, 6
Inpatient Management
Mild to moderate CAP requiring hospitalization:
- Ampicillin or penicillin G for fully immunized children with no risk factors for resistant organisms 1
- Ceftriaxone (50-100 mg/kg/day every 12-24 hours) or cefotaxime (150 mg/kg/day every 8 hours) for children with incomplete immunization or in areas with high prevalence of resistant pneumococci 1
Severe CAP or suspected Staphylococcus aureus infection:
- For methicillin-susceptible S. aureus: cefazolin (150 mg/kg/day every 8 hours) or oxacillin (150-200 mg/kg/day every 6-8 hours) 1, 7
- For methicillin-resistant S. aureus (MRSA) susceptible to clindamycin: vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin (40 mg/kg/day every 6-8 hours) 1, 5
- For MRSA resistant to clindamycin: vancomycin (40-60 mg/kg/day every 6-8 hours) or linezolid (30 mg/kg/day every 8 hours for children <12 years; 20 mg/kg/day every 12 hours for children ≥12 years) 1
Pathogen-Specific Considerations
Streptococcus pneumoniae:
- Amoxicillin remains the drug of choice for outpatient treatment 1, 3
- For parenteral therapy: ampicillin or penicillin G for susceptible strains; ceftriaxone or cefotaxime for resistant strains 1
Mycoplasma pneumoniae/Chlamydophila pneumoniae:
- Azithromycin is the preferred agent (dosing as above) 1, 6
- Alternatives: clarithromycin (15 mg/kg/day in 2 doses) or for children >7 years, doxycycline (2-4 mg/kg/day in 2 doses) 1
Haemophilus influenzae:
- Amoxicillin (75-100 mg/kg/day in 3 doses) for β-lactamase negative strains 1
- Amoxicillin-clavulanate (amoxicillin component 45-90 mg/kg/day) for β-lactamase producing strains 1
Transition from Inpatient to Outpatient Therapy
- Switch from parenteral to oral antibiotics when the child is clinically improving and able to tolerate oral intake 4
- Complete a total 5-day course for uncomplicated CAP 3, 4
- For complicated pneumonia or specific pathogens like S. aureus, longer courses may be needed 1
Important Clinical Considerations
- Limiting antibiotic exposure whenever possible is preferred to minimize development of resistance 1
- Using the proper dosage to achieve minimal effective concentration at the infection site is crucial 1
- Recent evidence suggests that shorter courses (5 days) are as effective as longer courses (10 days) for uncomplicated CAP, with the benefit of improved compliance and reduced antimicrobial resistance 3, 8
- Clinical improvement should be evident within 48-72 hours of starting appropriate therapy; failure to improve warrants reassessment 2, 4