Empiric Treatment of Pediatric Community-Acquired Pneumonia (CAP)

For pediatric community-acquired pneumonia, amoxicillin is the first-line treatment for children under 5 years, while macrolide antibiotics are recommended as first-line empirical treatment for children aged 5 and above due to the higher prevalence of Mycoplasma pneumonia in older children. 1, 2

Age-Based Treatment Approach

Children Under 5 Years (Outpatient)

Amoxicillin oral: 90 mg/kg/day in 2 doses 1
Alternative: Amoxicillin-clavulanate oral (amoxicillin component: 90 mg/kg/day in 2 doses) 1
For presumed atypical pneumonia: Azithromycin oral (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5) 1, 3

Children 5 Years and Older (Outpatient)

Oral amoxicillin (90 mg/kg/day in 2 doses to maximum of 4 g/day) 1
For presumed atypical pneumonia or when bacterial vs. atypical CAP cannot be distinguished: Add a macrolide (azithromycin, clarithromycin, or erythromycin) 1, 2
Azithromycin dosing: 10 mg/kg on day 1 (maximum 500 mg), followed by 5 mg/kg/day once daily on days 2-5 (maximum 250 mg) 1, 3

Inpatient Treatment (All Ages)

For fully immunized children with minimal local penicillin resistance:
- Ampicillin or penicillin G 1
- Alternatives: Ceftriaxone or cefotaxime 1
- Add vancomycin or clindamycin for suspected CA-MRSA 1
For not fully immunized children or areas with significant penicillin resistance:
- Ceftriaxone or cefotaxime 1
- Add vancomycin or clindamycin for suspected CA-MRSA 1
For atypical pneumonia (inpatient): Add azithromycin to β-lactam therapy 1

Pathogen-Specific Considerations

For suspected Streptococcus pneumoniae: Amoxicillin at any age 1, 2
For suspected Mycoplasma or Chlamydia pneumonia: Macrolide antibiotics 1, 2
For suspected Staphylococcus aureus: Macrolide or combination of flucloxacillin with amoxicillin 1, 2

Treatment Duration and Monitoring

A 5-day course is recommended for most cases of pediatric CAP 2, 4
Children should demonstrate clinical improvement within 48-72 hours of starting appropriate therapy 1
If no improvement occurs within 48-72 hours, further investigation should be performed 1

Special Considerations

Drug Allergies

For children with non-serious allergic reactions to amoxicillin, options include:
- Trial of amoxicillin under medical observation 1
- Oral cephalosporin with substantial activity against S. pneumoniae (cefpodoxime, cefprozil, or cefuroxime) 1
- Macrolide (if susceptible organisms) 1

Severity Assessment

Indicators for hospital admission in infants:
- Oxygen saturation <92%, cyanosis 1
- Respiratory rate >70 breaths/min 1
- Difficulty breathing, intermittent apnea, grunting 1
- Not feeding 1
- Family unable to provide appropriate observation 1
Indicators for hospital admission in older children:
- Oxygen saturation <92%, cyanosis 1
- Respiratory rate >50 breaths/min 1
- Difficulty breathing, grunting 1
- Signs of dehydration 1
- Family unable to provide appropriate observation 1

Common Pitfalls and Caveats

Young children with mild symptoms of lower respiratory tract infection may not need antibiotics 1, 2
Chest physiotherapy is not beneficial and should not be performed in children with pneumonia 1, 2
Nasogastric tubes may compromise breathing and should be avoided in severely ill children, especially infants with small nasal passages 1
For children with bacteremic pneumococcal pneumonia, caution should be exercised when selecting alternatives to amoxicillin due to potential for secondary sites of infection 1
Distinguishing between viral, atypical bacterial, and typical bacterial CAP is often challenging, and up to one-third of CAP cases may be mixed viral-bacterial or dual bacterial infections 5
Radiologic findings and C-reactive protein levels offer limited help for antibacterial selection; alveolar infiltrations and high CRP levels indicate pneumococcal pneumonia, but their absence doesn't rule out bacterial CAP 5

What is the empiric treatment for pediatric Community-Acquired Pneumonia (CAP)?

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