What are the first-line antibiotic recommendations for pediatric pneumonia?

First-Line Antibiotic Treatment for Pediatric Community-Acquired Pneumonia

Amoxicillin 90 mg/kg/day divided into 2 doses is the first-line antibiotic for outpatient treatment of pediatric community-acquired pneumonia in children over 3 months of age, with treatment duration of 5 days. 1, 2

Outpatient Management by Age and Clinical Presentation

Children Under 5 Years

• Amoxicillin 90 mg/kg/day in 2 doses is the preferred first-line agent for presumed bacterial pneumonia 1, 2
• This higher dose (90 mg/kg/day rather than 40-45 mg/kg/day) is critical to overcome pneumococcal resistance 1
• Treatment duration should be 5 days for uncomplicated cases 1, 3

Children 5 Years and Older

• Amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) remains first-line 1, 2
• Consider adding azithromycin (10 mg/kg on day 1, then 5 mg/kg/day on days 2-5) if atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae) are suspected based on clinical presentation 4, 2, 5
• If no improvement after 48 hours and clinical condition remains stable, add a macrolide to cover atypical organisms 1, 6

Special Circumstances Requiring Modified Therapy

Incomplete Immunization Status

• For children not fully immunized against Haemophilus influenzae type b or Streptococcus pneumoniae, use amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) instead of amoxicillin alone 1, 6
• This provides coverage for β-lactamase-producing H. influenzae 4, 2

Suspected Staphylococcal Involvement

• If Staphylococcus aureus (MSSA) is suspected, use amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) 1
• If community-associated MRSA is suspected (severe pneumonia, necrotizing features, empyema), add clindamycin 30-40 mg/kg/day in 3-4 doses to beta-lactam therapy 1, 2

Inpatient Management

Fully Immunized, Low-Risk Patients

• Ampicillin 150-200 mg/kg/day IV every 6 hours or penicillin G IV are preferred 1, 2
• Alternative: Ceftriaxone 50-100 mg/kg/day IV every 12-24 hours 4, 2

Not Fully Immunized or High-Risk Patients

• Ceftriaxone or cefotaxime (150 mg/kg/day every 8 hours) plus vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin (40 mg/kg/day every 6-8 hours) 4, 1
• This broader coverage addresses potential resistant organisms and MRSA 1

Atypical Pneumonia (Hospitalized)

• Azithromycin IV 10 mg/kg on days 1 and 2, then transition to oral therapy 4, 2, 5
• Alternative: Erythromycin lactobionate 20 mg/kg/day IV every 6 hours 4

Critical Pitfalls to Avoid

Dosing Errors

• Underdosing amoxicillin (using 40-45 mg/kg/day instead of 90 mg/kg/day) is the most common error and leads to treatment failure against resistant pneumococci 1
• The 90 mg/kg/day dose is essential for adequate tissue penetration and overcoming resistance 1, 6

Inappropriate Macrolide Use

• Do not use macrolides as first-line monotherapy for presumed bacterial pneumonia in children under 5 years due to high pneumococcal resistance rates 1
• Macrolides should be reserved for atypical pathogens or added to beta-lactams when atypical coverage is needed 1, 2

Failure to Consider MRSA

• In severe pneumonia with necrotizing features, empyema, or post-influenza pneumonia, failure to add MRSA coverage can be life-threatening 1
• Risk factors include recent influenza, severe illness, and presence of complications 1

Treatment Duration and Monitoring

• 5-day course is adequate for uncomplicated CAP treated with amoxicillin 1, 3
• Reassess at 48-72 hours: patients should show clinical improvement within this timeframe 1, 2
• If no improvement by 48-72 hours, consider:
  • Adding macrolide for atypical coverage 1, 6
  • Broadening coverage for resistant organisms 1
  • Obtaining imaging and cultures if not already done 1
  • Evaluating for complications (empyema, abscess) 1

Penicillin Allergy Considerations

Non-Severe Allergic Reactions

• Consider oral cephalosporins with substantial pneumococcal activity: cefpodoxime, cefprozil, or cefuroxime under medical supervision 2

Severe Allergic Reactions (Anaphylaxis)

• Use macrolides (azithromycin or clarithromycin), though resistance rates may be higher 2
• For severe cases requiring hospitalization, consider levofloxacin or linezolid based on age and severity 4