What is the treatment for pediatric pneumonia?

Treatment of Pediatric Pneumonia

Oral amoxicillin is the first-line treatment for pediatric community-acquired pneumonia (CAP), with dosing and duration based on age, severity, and suspected pathogen. 1

Age-Based Treatment Approach for Outpatient Management

Children Under 5 Years

• Oral amoxicillin at 90 mg/kg/day in 2 doses is the first-line treatment for presumed bacterial pneumonia 1, 2
• Alternative: Oral amoxicillin-clavulanate (amoxicillin component: 90 mg/kg/day in 2 doses) 1
• For presumed atypical pneumonia: Azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5) 1
• Alternatives for atypical pneumonia: Oral clarithromycin (15 mg/kg/day in 2 doses for 7-14 days) or oral erythromycin (40 mg/kg/day in 4 doses) 1

Children 5 Years and Older

• Oral amoxicillin at 90 mg/kg/day in 2 doses (maximum 4 g/day) for presumed bacterial pneumonia 1, 2
• For children with presumed bacterial CAP without clear distinction from atypical CAP, a macrolide can be added to a β-lactam antibiotic 1
• For 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, 3
• Alternatives for atypical pneumonia: Oral clarithromycin, erythromycin, or doxycycline for children >7 years old 1

Inpatient Treatment

Fully Immunized Children (Hib and Pneumococcal Vaccines)

• Ampicillin or penicillin G when local penicillin resistance is minimal 1, 2
• Alternatives: Ceftriaxone or cefotaxime 1
• Add vancomycin or clindamycin for suspected community-associated MRSA 1
• Add azithromycin if atypical pneumonia is suspected 1

Not Fully Immunized or Areas with Significant Penicillin Resistance

• Ceftriaxone or cefotaxime as first-line therapy 1
• Add vancomycin or clindamycin for suspected community-associated MRSA 1
• Add azithromycin if atypical pneumonia diagnosis is in doubt 1

Treatment Duration

• 3-5 days of amoxicillin is sufficient for most cases of non-severe pneumonia 1, 4, 5
• Recent evidence shows that 3-day courses are as effective as 5-day courses for non-severe pneumonia 4, 5
• For azithromycin, a 5-day course is recommended (10 mg/kg on day 1, followed by 5 mg/kg/day on days 2-5) 3

Treatment of Viral Pneumonia

• For presumed influenza pneumonia in children <7 years: Oseltamivir 1, 6
• For presumed influenza pneumonia in children ≥7 years: Oseltamivir or zanamivir 1
• Supportive care is the primary treatment for most viral pneumonias 6
• Monitor for secondary bacterial infection which would require appropriate antibacterial therapy 6

Monitoring Response to Treatment

• Children on adequate therapy should show clinical and laboratory improvement within 48-72 hours 1, 2
• If no improvement occurs within 48-72 hours or condition deteriorates, further investigation should be performed 1
• Treatment failure should prompt systematic evaluation of possible explanations including non-adherence and alternative diagnoses 1

Special Considerations

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 therapy if the pathogen is susceptible 1
  • Levofloxacin, linezolid, or clindamycin (if susceptible) 1

HIV-Infected Children

• For children living in areas of high HIV prevalence or with suspected/diagnosed HIV infection who present with non-severe pneumonia, amoxicillin is still recommended regardless of co-trimoxazole prophylaxis status 1, 7
• If first-line therapy fails, refer to hospital for management including HIV testing and broad-spectrum parenteral antibiotics 1

Malaria Co-infection

• In malaria-endemic regions, children with rapid breathing should be assessed for both pneumonia and severe anemia 1
• If malaria cannot be excluded, provide recommended first-line therapies for both malaria and pneumonia 1

Common Pitfalls and Caveats

• Failure to recognize the need for hospitalization in children with severe pneumonia 2
• Overuse of broad-spectrum antibiotics when narrow-spectrum would be effective 1, 8
• Unnecessarily long treatment courses contributing to antimicrobial resistance 4, 5
• Not considering atypical pathogens in children ≥5 years old 7, 2, 9
• Failing to reassess children who do not improve within 48-72 hours of starting treatment 1
• Not considering local antimicrobial resistance patterns when selecting empiric therapy 1