What are the treatment guidelines for pediatric pneumonia?

Treatment Guidelines for Pediatric Pneumonia

For pediatric community-acquired pneumonia (CAP), amoxicillin is the first-line treatment for outpatient management, while hospitalized patients require age-appropriate parenteral therapy based on likely pathogens. 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
• For children 5 years and older with presumed bacterial pneumonia: oral amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) 3, 2
• For children 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, 4
• For penicillin-allergic patients: oral clindamycin (40 mg/kg/day in 3 doses) 1, 5

Inpatient Management

• For fully immunized children with no risk factors for resistant organisms: ampicillin or penicillin G 3, 1
• For children with incomplete immunization 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) 3, 1
• Addition of vancomycin or clindamycin for suspected community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) 3

Pathogen-Specific Treatment

Streptococcus pneumoniae

• Outpatient: oral amoxicillin (90 mg/kg/day in 2 doses) 1, 2
• Inpatient (susceptible strains): ampicillin or penicillin G 1
• Inpatient (resistant strains): ceftriaxone or cefotaxime 1

Mycoplasma pneumoniae/Chlamydophila pneumoniae

• Preferred: oral azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5) 3, 1
• Alternatives: clarithromycin (15 mg/kg/day in 2 doses) or oral erythromycin (40 mg/kg/day in 4 doses) 3
• For children >7 years old: doxycycline (2-4 mg/kg/day in 2 doses) 3

Staphylococcus aureus

• Methicillin-susceptible: cefazolin (150 mg/kg/day every 8 hours) or oxacillin (150-200 mg/kg/day every 6-8 hours) 3, 1
• Methicillin-resistant, clindamycin-susceptible: vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin (40 mg/kg/day every 6-8 hours) 3, 1
• Methicillin-resistant, clindamycin-resistant: vancomycin (40-60 mg/kg/day every 6-8 hours) 3

Haemophilus influenzae

• β-lactamase negative: amoxicillin (75-100 mg/kg/day in 3 doses) 3, 1
• β-lactamase producing: amoxicillin-clavulanate (amoxicillin component 45-90 mg/kg/day) 3, 1

Duration of Treatment

• For uncomplicated pneumonia: 5-7 days of antibiotics 2, 6
• For pneumonia with parapneumonic effusion: 2-4 weeks of antibiotics, depending on drainage adequacy and clinical response 2

Treatment Response Assessment

• Patients should show clinical improvement within 48-72 hours of starting appropriate antibiotics 2
• If no improvement within 48-72 hours, reassess diagnosis and consider alternative pathogens or complications 2

Common Pitfalls to Avoid

• Underdosing amoxicillin (using standard doses of 40-45 mg/kg/day rather than the recommended higher doses of 90 mg/kg/day for pneumonia), which may lead to treatment failure due to resistant pneumococci 2, 7
• Inappropriate use of macrolides as first-line therapy for presumed bacterial pneumonia in young children 2
• Failure to consider atypical pathogens in children over 5 years of age when response to β-lactam therapy is inadequate 2
• Not completing the full course of antibiotics even if symptoms improve rapidly 6

Special Considerations

• For severe pneumonia with parapneumonic effusions, drainage options should be considered based on respiratory compromise 2
• Recent studies have shown that home treatment with high-dose oral amoxicillin can be equivalent to hospitalization with parenteral antibiotics for children with severe pneumonia without underlying complications 8
• The choice of antibiotics should take into account local resistance patterns, particularly for S. pneumoniae 7