What is the initial management for community-acquired pneumonia (CAP) in a 12-year-old?

Initial Management of Community-Acquired Pneumonia in a 12-Year-Old

For a 12-year-old with community-acquired pneumonia (CAP), high-dose oral amoxicillin (90 mg/kg/day in 2 doses, maximum 4g/day) is the first-line treatment for presumed bacterial pneumonia in the outpatient setting, with consideration of adding a macrolide if atypical pneumonia is suspected. 1

Assessment and Diagnosis

• Determine severity based on clinical presentation, respiratory status, and ability to maintain oral intake 1
• Assess for signs of respiratory distress, hypoxemia (oxygen saturation <92%), inability to maintain oral hydration, which would indicate need for hospitalization 1, 2
• Check vaccination status for Haemophilus influenzae type b and Streptococcus pneumoniae, as this affects antibiotic selection 1
• Consider local patterns of antimicrobial resistance in your community 1

Outpatient Management

• For mild to moderate CAP in a fully immunized 12-year-old:

  • First-line: High-dose oral amoxicillin (90 mg/kg/day in 2 doses, maximum 4g/day) 1
  • Duration: 5-7 days, depending on clinical response 1
  • If atypical pneumonia is suspected (gradual onset, prominent cough, minimal respiratory distress):
    • Add azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5) 2, 3

• For penicillin-allergic patients:

  • Non-anaphylactic allergy: Consider cephalosporin (cefdinir, cefpodoxime) 2
  • Anaphylactic allergy: Azithromycin alone or clindamycin (30-40 mg/kg/day in 3-4 doses) 2

Inpatient Management (if required)

• Indications for hospitalization:

  • Respiratory distress, hypoxemia (O₂ saturation <92%), inability to maintain oral hydration, or failed outpatient therapy 2, 1
  • Complicated pneumonia (empyema, large pleural effusion) 2

• For hospitalized patients:

  • First-line: Ampicillin (150-200 mg/kg/day every 6 hours) for fully immunized children with minimal local penicillin resistance 2, 1
  • Alternative: Ceftriaxone (50-100 mg/kg/day) or cefotaxime (150 mg/kg/day) for not fully immunized children or areas with significant penicillin resistance 2, 1
  • If MRSA is suspected: Add vancomycin (40-60 mg/kg/day) or clindamycin (if susceptible) 2, 1
  • If Mycoplasma pneumoniae is suspected: Add azithromycin (10 mg/kg on days 1 and 2, followed by 5 mg/kg/day once daily on days 3-5) 2

Monitoring and Follow-up

• Clinical improvement should be expected within 48-72 hours of starting appropriate therapy 1, 4
• If no improvement occurs within 48-72 hours, consider:
  • Clinical and laboratory reassessment of illness severity 2
  • Imaging evaluation to assess progression 2
  • Investigation for resistant organisms or alternative diagnoses 2, 4
• Patients are eligible for discharge when they have 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 is required before discharge 2
• Routine follow-up chest radiographs are not necessary for patients who recover uneventfully 1

Special Considerations

• Recent epidemiological trends show a shift toward viral pathogens as the predominant cause of CAP in children due to widespread vaccination against S. pneumoniae and H. influenzae type b 5
• For parapneumonic effusions, antibiotic selection should follow the recommendations for hospitalized CAP patients 2
• Duration of antibiotic treatment for complicated pneumonia depends on the adequacy of drainage and clinical response, typically 2-4 weeks 2
• If influenza is suspected or confirmed, add oseltamivir while continuing appropriate antibacterial coverage for possible secondary bacterial pneumonia 1