What are the treatment guidelines for pediatric community-acquired pneumonia (CAP)?

Pediatric Community-Acquired Pneumonia Treatment Guidelines

Initial Antibiotic Selection by Age and Setting

For outpatient treatment of pediatric CAP, amoxicillin 90 mg/kg/day divided into 2 doses is the first-line therapy for children under 5 years and for school-aged children/adolescents (maximum 4 g/day), with a treatment duration of 5 days. 1

Preschool-Aged Children (< 5 years)

• Oral amoxicillin 90 mg/kg/day in 2 doses is recommended for suspected bacterial pneumonia 1, 2
• This recommendation applies to fully immunized children (against Haemophilus influenzae type b and Streptococcus pneumoniae) 2
• For unimmunized or incompletely immunized children, use amoxicillin-clavulanate or second/third-generation cephalosporins 2
• Treatment duration should be 5 days with clinical reassessment at 48-72 hours 1, 2

School-Aged Children and Adolescents (≥ 5 years)

• Oral amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) remains first-line 1
• Consider adding macrolides (azithromycin or clarithromycin) if symptoms persist after 48 hours of amoxicillin therapy and clinical condition remains stable, as atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae) become more common in this age group 2, 1
• For children > 7 years with suspected atypical pneumonia, doxycycline 2-4 mg/kg/day in 2 doses is an alternative 1

Hospitalized Patients Requiring Parenteral Therapy

For children admitted to hospital wards, ampicillin or penicillin G is recommended when local epidemiologic data show lack of substantial high-level penicillin resistance for invasive S. pneumoniae. 1

• Ampicillin or penicillin G are first-line intravenous antibiotics for fully immunized children 1
• Ceftriaxone or cefotaxime are alternatives for hospitalized patients 3, 4
• This recommendation assumes local surveillance data confirms low rates of high-level penicillin-resistant pneumococcus 1

Treatment Duration and Monitoring

Standard Duration

• 5 days of therapy is recommended for uncomplicated CAP 1, 2, 5
• This shorter duration (5 days vs 7-10 days) shows equivalent clinical cure rates with similar adverse event profiles 5, 6
• Clinical reassessment should occur at 48-72 hours after antibiotic initiation 1, 2

Expected Clinical Response

• Children should demonstrate clinical improvement within 48-72 hours of appropriate therapy 1, 3
• If no improvement or clinical deterioration occurs within this timeframe, further investigation is warranted 7, 1

Management of Treatment Failure

Children not responding after 48-72 hours require clinical reassessment, imaging evaluation, and consideration of alternative or resistant pathogens. 7

Evaluation Steps for Non-Responders

• Clinical and laboratory assessment to determine severity and need for higher level of care 7
• Imaging evaluation (chest radiograph or ultrasound) to assess extent and progression of pneumonic or parapneumonic process 7
• Further microbiologic investigation to identify persistent pathogens, resistance, or secondary infection 7
• For mechanically ventilated children, obtain bronchoalveolar lavage (BAL) for Gram stain and culture 7

Antibiotic Adjustments

• Consider broadening coverage to include atypical pathogens if not already covered 2
• Evaluate for parapneumonic effusion or empyema requiring drainage 7
• Review antibiotic susceptibility data if cultures are positive 7

Special Considerations

Parapneumonic Effusions

• Small effusions (≤10mm rim): Continue antibiotics alone without drainage 7
• Moderate effusions: Obtain pleural fluid culture by thoracentesis or chest tube if high respiratory compromise 7
• Large effusions (>50% thorax opacified): Chest tube with fibrinolytics, with VATS reserved for non-responders (approximately 15% of patients) 7
• Antibiotic duration for parapneumonic effusions: 2-4 weeks depending on adequacy of drainage and clinical response 7

Influenza-Associated Pneumonia

• Antiviral therapy (oseltamivir) should be administered as soon as possible to children with moderate to severe CAP consistent with influenza during local influenza circulation 1, 3
• Do not delay treatment pending confirmatory testing 3
• Monitor for secondary bacterial infection, which is more common in hospitalized children with influenza 3
• If secondary bacterial infection suspected, initiate amoxicillin 90 mg/kg/day for empiric coverage 3

Dosing Considerations

• 90 mg/kg/day divided into 2 doses improves compliance compared to 3 daily doses, with equivalent efficacy 2
• Higher doses (70-90 mg/kg/day) show no advantage over standard doses (35-50 mg/kg/day) for clinical cure rates or adverse events 5
• The 2-dose regimen is preferred for practical adherence while maintaining therapeutic levels 2

Diagnostic Approach

When to Obtain Chest Radiographs

• Routine chest radiographs are not necessary for outpatient-managed suspected CAP 1
• Obtain chest radiographs in patients with suspected hypoxemia, significant respiratory distress, or failed initial antibiotic therapy 1
• Follow-up radiographs should be obtained only in children who fail to improve or have progressive symptoms within 48-72 hours 1, 3
• Routine follow-up radiographs are not required in children who recover uneventfully 3

Oxygenation Assessment

• Pulse oximetry should be performed in all children with pneumonia to assess for hypoxemia 1
• Supplemental oxygen is indicated if SpO2 ≤92% 3, 4

Common Pitfalls to Avoid

• Avoid routine use of amoxicillin-clavulanate as first-line therapy in fully immunized children, as it increases adverse effects without improving outcomes 2
• Do not extend treatment beyond 5 days for uncomplicated CAP, as longer courses do not improve cure rates and increase antibiotic exposure 5, 6
• Do not add macrolides empirically to all children under 5 years, as atypical pathogens are uncommon in this age group 2
• Avoid obtaining pleural fluid cultures for small parapneumonic effusions, as drainage is not indicated 7
• Do not delay antiviral therapy for suspected influenza pneumonia while awaiting test results 3