What are the current treatment guidelines for community-acquired pneumonia (CAP) in pediatrics?

Treatment Guidelines for Community-Acquired Pneumonia in Pediatrics

Amoxicillin is the first-line antibiotic treatment for community-acquired pneumonia (CAP) in previously healthy, appropriately immunized children with mild to moderate disease suspected to be of bacterial origin. 1

Diagnostic Approach

• Routine chest radiographs are not necessary for confirmation of suspected CAP in patients well enough to be treated in the outpatient setting 1
• Chest radiographs should be obtained in patients with suspected hypoxemia, significant respiratory distress, or those with failed initial antibiotic therapy 1
• Pulse oximetry should be performed in all children with pneumonia to assess for hypoxemia and guide decisions regarding site of care 1
• For children requiring mechanical ventilation, tracheal aspirates should be obtained for Gram stain, culture, and viral pathogen testing at the time of endotracheal tube placement 1

Treatment Algorithm by Age and Setting

Outpatient Treatment

• Preschool-aged children (< 5 years):

  • Antimicrobial therapy is not routinely required as viral pathogens are responsible for the majority of clinical disease 1
  • When bacterial pneumonia is suspected: oral amoxicillin 90 mg/kg/day in 2 doses 2
  • For atypical pneumonia: oral azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 1, 2

• School-aged children and adolescents (≥ 5 years):

  • For suspected bacterial pneumonia: oral amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) 1, 2
  • For suspected atypical pneumonia (M. pneumoniae or C. pneumoniae): oral azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 1, 2
  • For children > 7 years with atypical pneumonia: doxycycline (2-4 mg/kg/day in 2 doses) is an alternative 1, 2

Inpatient Treatment

• For fully immunized children admitted to a hospital ward:

  • Ampicillin or penicillin G when local epidemiologic data show lack of substantial high-level penicillin resistance for invasive S. pneumoniae 1
  • For severe pneumonia or in regions with high-level penicillin resistance: third-generation cephalosporin (ceftriaxone or cefotaxime) 1

• For children with penicillin allergy:

  • Non-type I hypersensitivity: certain cephalosporins may be considered 3
  • Type I (immediate) hypersensitivity: fluoroquinolones or macrolides 3

Treatment Duration

• For uncomplicated CAP, a 5-7 day course of antibiotics appears to be as effective as longer courses (8-14 days) 4
• Children on adequate therapy should demonstrate clinical improvement within 48-72 hours 5, 2
• If a child fails to improve or deteriorates within 48-72 hours after initiation of antibiotics, further investigation should be performed 1

Special Considerations

Influenza-Associated Pneumonia

• Antiviral therapy should be administered as soon as possible to children with moderate to severe CAP consistent with influenza virus infection during widespread local circulation of influenza viruses 1, 5
• Early treatment provides maximal benefit; treatment should not be delayed until confirmation of positive influenza test results 1

Follow-up Recommendations

• Repeated chest radiographs are not routinely required in children who recover uneventfully 1, 5
• Follow-up chest radiographs should be obtained in children who:
  • Fail to demonstrate clinical improvement or have progressive symptoms within 48-72 hours after starting antibiotics 1, 5
  • Have recurrent pneumonia involving the same lobe 1
  • Have lobar collapse at initial radiography with suspicion of anatomic anomaly, chest mass, or foreign body aspiration 1

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) may lead to treatment failure due to resistant pneumococci 2
• Inappropriate use of macrolides as first-line therapy for presumed bacterial pneumonia in young children 2
• Unnecessary use of antibiotics in preschool-aged children with likely viral pneumonia 1
• Failure to reassess children not improving within 48-72 hours of antibiotic initiation 1, 2
• Routine daily chest radiography in children with pneumonia complicated by parapneumonic effusion after chest tube placement or VATS if they remain clinically stable 1