What are the treatment guidelines and medication dosages for pediatric pneumonia of moderate risk?

Treatment Guidelines and Medication Dosages for Pediatric Pneumonia of Moderate Risk

For pediatric patients with moderate-risk community-acquired pneumonia (CAP), oral amoxicillin at 90 mg/kg/day divided in 2 doses is the first-line treatment for presumed bacterial pneumonia in outpatient settings. 1

Outpatient Management

Age-Based Empiric Therapy

• Children <5 years old (preschool):

  • Presumed bacterial pneumonia: Amoxicillin oral (90 mg/kg/day in 2 doses); alternative: amoxicillin-clavulanate (amoxicillin component, 90 mg/kg/day in 2 doses) 1
  • Presumed atypical pneumonia: Azithromycin oral (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2–5) 1, 2

• Children ≥5 years old:

  • Presumed bacterial pneumonia: Oral amoxicillin (90 mg/kg/day in 2 doses to maximum of 4 g/day) 1
  • For children with presumed bacterial CAP without clear distinction from atypical CAP, a macrolide can be added to a β-lactam antibiotic 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

Duration of Therapy

• A 5-day course of antibiotics is generally sufficient for uncomplicated moderate-risk pneumonia 3, 4
• Clinical reassessment should be performed approximately 72 hours after initiating antibiotics to evaluate symptom resolution 5

Inpatient Management

Empiric Therapy Based on Vaccination Status

• Fully immunized with conjugate vaccines for H. influenzae type b and S. pneumoniae:

  • Ampicillin or penicillin G; alternatives: ceftriaxone or cefotaxime 1
  • Addition of vancomycin or clindamycin for suspected CA-MRSA 1
  • Add azithromycin if atypical pneumonia is suspected 1

• Not fully immunized for H. influenzae type b and S. pneumoniae:

  • Ceftriaxone or cefotaxime 1
  • Addition of vancomycin or clindamycin for suspected CA-MRSA 1
  • Add azithromycin if atypical pneumonia is suspected 1

Specific Medication Dosages

Amoxicillin

• 90 mg/kg/day in 2 doses (maximum 4 g/day) 1
• Can be divided into 3 doses (45 mg/kg/day per dose) for better coverage 1

Ceftriaxone

• For moderate-risk pneumonia: 50-100 mg/kg/day given once daily or divided every 12-24 hours 1, 6
• For pneumococcal pneumonia with penicillin resistance: 100 mg/kg/day given every 12-24 hours 6

Azithromycin

• Children: 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2–5 1, 2
• For children ≥40 kg: 500 mg on day 1, followed by 250 mg on days 2-5 2

Ampicillin

• 150-200 mg/kg/day divided every 6 hours 1
• For penicillin-resistant S. pneumoniae: 300-400 mg/kg/day every 6 hours 1

Clindamycin (for suspected MRSA)

• 40 mg/kg/day divided every 6-8 hours (IV) 1
• 30-40 mg/kg/day in 3 doses (oral) 1

Vancomycin (for suspected MRSA)

• 40-60 mg/kg/day divided every 6-8 hours 1

Pathogen-Specific Considerations

S. pneumoniae

• For penicillin-susceptible strains: Amoxicillin (90 mg/kg/day in 2 doses or 45 mg/kg/day in 3 doses) 1
• For penicillin-resistant strains (MICs ≥4.0 μg/mL): Ceftriaxone (100 mg/kg/day every 12-24 hours) 1

Atypical Pathogens (M. pneumoniae, C. pneumoniae)

• Empiric combination therapy with a macrolide in addition to a β-lactam antibiotic should be prescribed when atypical pathogens are suspected 1

Monitoring and Follow-up

• Children should show clinical and laboratory signs of improvement within 48-72 hours 1
• For children whose condition deteriorates after admission and initiation of antimicrobial therapy or who show no improvement within 48-72 hours, further investigation should be performed 1

Special Considerations

• For children with drug allergies to recommended therapy, treatment options should be modified accordingly 1
• For children with bacteremic pneumococcal pneumonia, particular caution should be exercised in selecting alternatives to amoxicillin 1
• Parapneumonic effusions should be identified using chest radiography and managed appropriately 1