What are the first-line antibiotic recommendations for pediatric outpatients with pneumonia?

First-Line Antibiotic Recommendations for Pediatric Outpatients with Pneumonia

For pediatric outpatients with community-acquired pneumonia (CAP), amoxicillin is the first-line antibiotic of choice, with specific dosing based on age and presumed pathogen. 1

Age-Based Treatment Recommendations

Children <5 Years Old (Preschool)

• Presumed bacterial pneumonia: Oral amoxicillin 90 mg/kg/day in 2 doses 1
  • Alternative: Oral amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) 1
• Presumed atypical pneumonia: Oral azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 1
  • Alternatives: Oral clarithromycin (15 mg/kg/day in 2 doses for 7-14 days) or oral erythromycin (40 mg/kg/day in 4 doses) 1

Children ≥5 Years Old

• Presumed bacterial pneumonia: 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 to maximum 4000 mg/day) 1
• Presumed atypical pneumonia: 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, 2
  • Alternatives: Oral clarithromycin (15 mg/kg/day in 2 doses to maximum 1 g/day), erythromycin, or doxycycline for children >7 years old 1
• Mixed/indeterminate etiology: For children with presumed bacterial CAP who do not have clear evidence distinguishing bacterial from atypical CAP, a macrolide can be added to a β-lactam antibiotic for empiric therapy 1

Pathogen-Specific Considerations

Streptococcus pneumoniae (penicillin-susceptible)

• Oral amoxicillin (90 mg/kg/day in 2 doses or 45 mg/kg/day in 3 doses) 1
• Alternatives for penicillin allergy: Second- or third-generation cephalosporin (cefpodoxime, cefuroxime, cefprozil) 1

Mycoplasma pneumoniae or Chlamydophila pneumoniae

• Oral azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5) 1
• Alternatives: Clarithromycin (15 mg/kg/day in 2 doses) or oral erythromycin (40 mg/kg/day in 4 doses) 1
• For children >7 years old: Doxycycline (2-4 mg/kg/day in 2 doses) 1

Duration of Therapy

• Standard duration: 5-7 days for most uncomplicated cases 3, 4
• 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 3, 5
• A 3-day course may be associated with higher failure rates and is not recommended 6

Special Considerations

Penicillin Allergy

For children with a history of possible, non-serious allergic reactions to amoxicillin, options include:

• Trial of amoxicillin under medical observation 1
• Trial of an oral cephalosporin with substantial activity against S. pneumoniae (cefpodoxime, cefprozil, or cefuroxime) under medical supervision 1
• Treatment with levofloxacin, linezolid, clindamycin (if susceptible), or a macrolide (if susceptible) 1

Monitoring Response

• Children on adequate therapy should demonstrate clinical and laboratory signs of improvement within 48-72 hours 1
• If the child's condition deteriorates or shows no improvement within 48-72 hours, further investigation should be performed 1

Community-Associated MRSA Considerations

• If community-associated MRSA is suspected, consider adding clindamycin (30-40 mg/kg/day in 3-4 doses) 1, 7

Key Pitfalls to Avoid

• Underdosing amoxicillin: Using standard doses (40-45 mg/kg/day) rather than the recommended higher doses (90 mg/kg/day) for pneumonia may lead to treatment failure due to resistant pneumococci 1
• Inappropriate use of macrolides as first-line therapy for presumed bacterial pneumonia: Macrolides should be reserved for atypical pneumonia or as add-on therapy 1
• Too-short treatment courses: While 5 days appears adequate, 3-day courses have shown unacceptable failure rates 6
• Failure to reassess: Children not improving within 48-72 hours require reevaluation 1