What is the recommended treatment for pediatric pneumonia?

Treatment for Pediatric Pneumonia

The recommended first-line treatment for pediatric community-acquired pneumonia is oral amoxicillin at 90 mg/kg/day in 2 doses for children with presumed bacterial pneumonia, and azithromycin for children with presumed atypical pneumonia. 1

Age-Based Treatment Recommendations

Outpatient Management

• For children under 5 years with presumed bacterial pneumonia:

  • Oral amoxicillin 90 mg/kg/day in 2 doses 2, 1
  • Alternative: amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) 2

• For children under 5 years with presumed atypical pneumonia:

  • Oral azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 2, 1, 3
  • Alternatives: clarithromycin (15 mg/kg/day in 2 doses) or erythromycin (40 mg/kg/day in 4 doses) 2

• For children 5 years and older with presumed bacterial pneumonia:

  • Oral amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) 2, 1
  • For children with presumed bacterial CAP who don't have clear distinction from atypical CAP, a macrolide can be added to a β-lactam antibiotic 2

• For children 5 years and older with 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) 2, 1, 3
  • Alternatives for children >7 years: doxycycline (2-4 mg/kg/day in 2 doses) 2, 1

Inpatient Management

• For fully immunized children with no risk factors for resistant organisms:

  • Ampicillin or penicillin G 2, 4
  • Add azithromycin if atypical pneumonia is suspected 2, 4

• For children not fully immunized or in areas with high prevalence of resistant pneumococci:

  • Ceftriaxone (50-100 mg/kg/day every 12-24 hours) or cefotaxime (150 mg/kg/day every 8 hours) 2, 4
  • Add vancomycin or clindamycin if MRSA is suspected 2, 4

Pathogen-Specific Considerations

• For Streptococcus pneumoniae:

  • Oral: amoxicillin (90 mg/kg/day in 2 doses) 2, 1
  • Parenteral: penicillin (100,000-250,000 U/kg/day every 4-6 hours) or ampicillin (200 mg/kg/day every 6 hours) 2
  • Alternatives: ceftriaxone or cefotaxime 2

• For 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) 2, 1
  • Parenteral: IV azithromycin (10 mg/kg on days 1 and 2) 2

• For Staphylococcus aureus (methicillin-susceptible):

  • Oral: cephalexin (75-100 mg/kg/day in 3-4 doses) 2
  • Parenteral: cefazolin (150 mg/kg/day every 8 hours) or oxacillin (150-200 mg/kg/day every 6-8 hours) 2, 5

• For MRSA (clindamycin-susceptible):

  • Oral: clindamycin (30-40 mg/kg/day in 3-4 doses) 2
  • Parenteral: vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin (40 mg/kg/day every 6-8 hours) 2

Duration of Treatment

• For uncomplicated pneumonia: 5-7 days of antibiotics is typically adequate 2, 6
• For pneumonia with parapneumonic effusion: 2-4 weeks of antibiotics, depending on drainage adequacy and clinical response 2
• For complicated pneumonia: prolonged course of IV antibiotics followed by oral antibiotics 7

Management of Parapneumonic Effusions

• Small effusions (<10mm rim): treat with antibiotics alone, no drainage needed unless respiratory compromise is high 2
• Moderate to large effusions: consider drainage options based on respiratory compromise 2:
  • Chest tube alone
  • Chest tube with fibrinolytics (preferred initial approach)
  • Video-assisted thoracoscopic surgery (VATS) if not responding to fibrinolytics (approximately 15% of patients) 2

Assessment of Treatment Response

• Patients should show clinical improvement within 48-72 hours of starting appropriate antibiotics 2, 1
• If no improvement after 48-72 hours, consider 2:
  • Clinical and laboratory reassessment for disease severity
  • Further imaging (ultrasound or CT) to assess for complications
  • Investigation for resistant pathogens or secondary infections
  • For mechanically ventilated children, obtain BAL specimen for Gram stain and culture 2

Discharge Criteria

• Documented overall clinical improvement including level of activity, appetite, and decreased fever for at least 12-24 hours 2
• Consistent pulse oximetry measurements >90% in room air for at least 12-24 hours 2

Common 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 in young children 1, 8
• Failure to reassess children not improving within 48-72 hours 2, 1
• Routine chest radiographs at the end of therapy are not recommended unless clinically indicated 6
• Overlooking the possibility of complications (empyema, lung abscess) in children not responding to appropriate therapy 6, 7