What are the IDSA (Infectious Diseases Society of America) recommendations for treating pediatric pneumonia?

IDSA Recommendations for Treating Pediatric Community-Acquired Pneumonia

The IDSA, in collaboration with the Pediatric Infectious Diseases Society, recommends oral amoxicillin (90 mg/kg/day in 2 doses) as first-line therapy for outpatient bacterial pneumonia in children, with macrolides (azithromycin) reserved for atypical pathogens, and hospitalized children requiring intravenous ampicillin or ceftriaxone. 1

Outpatient Management

Children Under 5 Years Old

• For presumed bacterial pneumonia: Oral amoxicillin 90 mg/kg/day in 2 doses is the preferred first-line agent 1, 2
• For presumed atypical pneumonia: Oral azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5) 1, 2
• Alternative for bacterial pneumonia: Oral amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) 1

Children 5 Years and Older

• For presumed bacterial pneumonia: Oral amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) 1, 2
• For atypical pneumonia or when bacterial vs. atypical cannot be distinguished: Add a macrolide to the β-lactam antibiotic 1, 2
• Macrolide options: Azithromycin (10 mg/kg day 1, then 5 mg/kg/day days 2-5, max 500 mg/250 mg), clarithromycin (15 mg/kg/day in 2 doses), or erythromycin (40 mg/kg/day in 4 doses) 1
• For children >7 years: Doxycycline (2-4 mg/kg/day in 2 doses) is an alternative for atypical pathogens 1

Inpatient Management

Fully Immunized Children (Hib and Pneumococcal Vaccines)

• Preferred agents: Intravenous ampicillin (150-200 mg/kg/day) or penicillin G 1, 2
• Alternatives: Ceftriaxone (50-100 mg/kg/day) or cefotaxime 1, 2
• For suspected CA-MRSA: Add vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin (30-40 mg/kg/day in 3-4 doses) 1, 2
• For atypical pneumonia: Add intravenous azithromycin (10 mg/kg on days 1 and 2) 1, 2

Not Fully Immunized Children

• Broader coverage required: Ceftriaxone or cefotaxime to cover potential Haemophilus influenzae type b 1

Hospitalization Criteria

Children meeting any of the following should be hospitalized: 1

• Moderate to severe respiratory distress with sustained SpO2 <90% at sea level 1
• Infants <3-6 months of age with suspected bacterial pneumonia 1
• Suspected or documented CA-MRSA infection 1
• Concerns about home observation, compliance with therapy, or follow-up 1

ICU Admission Criteria

Transfer to ICU is indicated for: 1

• Need for invasive mechanical ventilation 1
• Requirement for noninvasive positive pressure ventilation 1
• Impending respiratory failure 1
• Pulse oximetry <92% on FiO2 ≥0.50 1
• Sustained tachycardia, inadequate blood pressure, or need for vasopressor support 1
• Altered mental status due to hypercarbia or hypoxemia 1

Treatment Duration

Standard treatment courses of 10 days have been best studied, though shorter courses may be equally effective for mild disease managed outpatient. 1

• The IDSA acknowledges that 10-day courses are traditional but notes shorter courses (particularly 5 days) may be just as effective for mild outpatient disease 1
• Recent research supports 5-day courses as non-inferior to 10-day courses for uncomplicated pneumonia 3, 4, 5
• CA-MRSA infections may require longer treatment than S. pneumoniae infections 1

Monitoring and Follow-Up

Children on adequate therapy should demonstrate clinical and laboratory improvement within 48-72 hours. 1

• If no improvement or clinical deterioration occurs within 48-72 hours, further investigation is required 1, 2
• Blood cultures should be obtained in hospitalized children with moderate to severe pneumonia 1
• Blood cultures are NOT routinely recommended for nontoxic, fully immunized outpatient children 1

Antimicrobial Stewardship Principles

The IDSA emphasizes four key stewardship principles: 1

• Minimize antibiotic exposure to prevent resistance development 1, 2
• Use narrow-spectrum agents specific to the identified or presumed pathogen 1, 2
• Dose appropriately to achieve minimal effective concentration at infection site 1, 2
• Treat for the shortest effective duration to minimize selection pressure for resistance 1, 2

Special Considerations for β-Lactam Allergies

• For non-serious allergic reactions: Consider oral cephalosporins with substantial anti-pneumococcal activity (cefpodoxime, cefprozil, or cefuroxime) under medical supervision 2, 6
• For severe reactions: Macrolides may be used, though resistance rates may be higher 2
• For hospitalized β-lactam allergic children: Levofloxacin (16-20 mg/kg/day in 2 doses for ages 6 months-5 years; 8-10 mg/kg/day once daily for ages 5-16 years; max 750 mg/day) 1

Common Pitfalls to Avoid

• Underdosing amoxicillin: The IDSA specifically recommends HIGH-DOSE amoxicillin (90 mg/kg/day), not standard doses (40-45 mg/kg/day), to overcome pneumococcal resistance 1, 2, 6
• Inappropriate macrolide monotherapy: Macrolides should not be used as first-line for presumed bacterial pneumonia due to increasing pneumococcal resistance 1, 2, 6
• Clindamycin resistance: Be aware that clindamycin resistance is increasing in certain geographic areas for both S. pneumoniae and S. aureus 1
• Failure to reassess: Children not improving within 48-72 hours require reevaluation and possible change in therapy 1, 2