What is the recommended treatment for pediatric pneumonia?

Pediatric Pneumonia Treatment Guidelines

The recommended first-line treatment for pediatric community-acquired pneumonia is oral amoxicillin at 90 mg/kg/day in 2 doses for presumed bacterial pneumonia, and azithromycin for presumed atypical pneumonia. 1, 2

Age-Based Treatment Recommendations

Outpatient Treatment

• For children under 5 years with presumed bacterial pneumonia: oral amoxicillin 90 mg/kg/day in 2 doses 3, 1
• For children 5 years and older with presumed bacterial pneumonia: oral amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) 3, 1
• For children with presumed atypical pneumonia (any age): oral azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 1, 4
• For children with presumed bacterial pneumonia who do not have clinical evidence distinguishing bacterial from atypical pneumonia, a macrolide can be added to a β-lactam antibiotic for empiric therapy 3

Inpatient Treatment

• For fully immunized children: ampicillin or penicillin G; alternatives include ceftriaxone or cefotaxime 3
• For children not fully immunized against H. influenzae type b and S. pneumoniae: ceftriaxone or cefotaxime 3
• For suspected methicillin-resistant Staphylococcus aureus (MRSA): add vancomycin or clindamycin 3
• For suspected atypical pneumonia in hospitalized patients: add azithromycin 3

Pathogen-Specific Treatment

Streptococcus pneumoniae

• Preferred: oral amoxicillin (90 mg/kg/day in 2 doses) 3, 1
• Alternative for penicillin-allergic patients: oral cephalosporins with substantial activity against S. pneumoniae (cefpodoxime, cefprozil, or cefuroxime) 1, 2

Mycoplasma pneumoniae/Chlamydophila pneumoniae

• Preferred: oral azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5) 3, 4
• Alternatives: clarithromycin (15 mg/kg/day in 2 doses) or erythromycin (40 mg/kg/day in 4 doses) 3
• For children >7 years old: doxycycline (2-4 mg/kg/day in 2 doses) can be considered 3

Haemophilus influenzae

• For β-lactamase negative strains: amoxicillin (75-100 mg/kg/day in 3 doses) 3
• For β-lactamase producing strains: amoxicillin-clavulanate (amoxicillin component, 45 mg/kg/day in 3 doses or 90 mg/kg/day in 2 doses) 3, 2

Staphylococcus aureus

• For methicillin-susceptible S. aureus (MSSA): oral cephalexin (75-100 mg/kg/day in 3-4 doses) 3
• For methicillin-resistant S. aureus (MRSA): oral clindamycin (30-40 mg/kg/day in 3-4 doses) if susceptible 3
• For MRSA resistant to clindamycin: oral linezolid (30 mg/kg/day in 3 doses for children <12 years and 20 mg/kg/day in 2 doses for children ≥12 years) 3

Duration of Treatment

• For uncomplicated pneumonia, a 5-day course of antibiotics is recommended 1, 5
• Recent high-quality evidence shows that 5 days of high-dose amoxicillin is as effective as 10 days for uncomplicated community-acquired pneumonia in children not requiring hospitalization 6, 5
• For pneumonia with complications such as parapneumonic effusion, longer treatment (2-4 weeks) may be necessary 1

Assessment of Treatment Response

• Children should demonstrate clinical improvement within 48-72 hours of starting appropriate therapy 1, 2
• If no improvement is seen within this timeframe, reevaluation is necessary, including consideration of alternative diagnoses, resistant pathogens, or complications 1, 2

Common Pitfalls to Avoid

• Underdosing amoxicillin: Using standard doses (40-45 mg/kg/day) rather than the recommended higher doses (90 mg/kg/day) for pneumonia may lead to treatment failure due to resistant pneumococci 1, 7
• Inappropriate use of macrolides as first-line therapy for presumed bacterial pneumonia in young children, as resistance rates may be higher 2
• Failing to reassess children not improving within 48-72 hours 1, 2
• Using unnecessarily prolonged antibiotic courses, which can contribute to antibiotic resistance and adverse effects 6, 8

Special Considerations

• For children with non-serious allergic reactions to amoxicillin, consider oral cephalosporins with substantial activity against S. pneumoniae under medical supervision 3
• For children with severe penicillin allergies, consider macrolides (for atypical pathogens) or linezolid/clindamycin (for suspected S. pneumoniae or S. aureus) 3
• For influenza pneumonia, oseltamivir or zanamivir should be considered based on age appropriateness 3