What is the treatment protocol for pediatric acquired pneumonia?

Pediatric Community-Acquired Pneumonia Treatment Protocol

Initial Assessment and Antibiotic Selection

For children under 5 years with presumed bacterial pneumonia, start oral amoxicillin 90 mg/kg/day divided into 2 doses as first-line therapy. 1 This recommendation is based on the predominance of Streptococcus pneumoniae as the primary bacterial pathogen in this age group, and amoxicillin provides excellent coverage while being well-tolerated and cost-effective. 2

For children 5 years and older, oral amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) remains first-line, but consider adding a macrolide if atypical pathogens (Mycoplasma pneumoniae or Chlamydophila pneumoniae) are suspected. 1 The higher prevalence of atypical organisms in school-aged children justifies empiric macrolide coverage in this population. 2

Age-Specific Antibiotic Protocols

Children <5 years:

• First-line: Amoxicillin 90 mg/kg/day in 2 doses 1
• Alternative for β-lactam allergy: Azithromycin 10 mg/kg on day 1, then 5 mg/kg/day once daily on days 2-5 1, 3
• Alternative oral options: Co-amoxiclav, cefaclor, erythromycin, clarithromycin 2

Children ≥5 years:

• First-line: Amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) 1
• Consider macrolide monotherapy: Azithromycin 10 mg/kg day 1, then 5 mg/kg/day days 2-5 1, 3
• Dual therapy if severe or atypical features: Amoxicillin plus azithromycin 2

Pathogen-Specific Treatment

Streptococcus pneumoniae (Penicillin-Susceptible)

• Oral: Amoxicillin 90 mg/kg/day in 2 doses 1
• IV: Ampicillin 200 mg/kg/day every 6 hours or penicillin G 100,000-250,000 U/kg/day every 4-6 hours 2

Streptococcus pneumoniae (Penicillin-Resistant, MIC ≥4.0 μg/mL)

• IV preferred: Ceftriaxone 100 mg/kg/day every 12-24 hours 2, 4
• IV alternatives: Ampicillin 300-400 mg/kg/day every 6 hours, levofloxacin 16-20 mg/kg/day every 12 hours (ages 6 months-5 years) or 8-10 mg/kg/day once daily (ages 5-16 years, max 750 mg) 2
• Oral step-down: Levofloxacin (same dosing) or linezolid 30 mg/kg/day in 3 doses (<12 years) or 20 mg/kg/day in 2 doses (≥12 years) 2

Mycoplasma pneumoniae / Chlamydophila pneumoniae

• Preferred: Azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 1, 3
• Alternatives: Clarithromycin or erythromycin 2

Haemophilus influenzae

• β-lactamase negative: Amoxicillin 75-100 mg/kg/day in 3 doses 2, 1
• β-lactamase producing: Amoxicillin-clavulanate (amoxicillin component 45 mg/kg/day in 3 doses or 90 mg/kg/day in 2 doses) 2, 1
• IV: Ceftriaxone 50-100 mg/kg/day every 12-24 hours or cefotaxime 150 mg/kg/day every 8 hours 2

Staphylococcus aureus (Methicillin-Susceptible)

• IV: Cefazolin 150 mg/kg/day every 8 hours or oxacillin 150-200 mg/kg/day every 6-8 hours 2, 5
• Oral: Cephalexin 75-100 mg/kg/day in 3-4 doses 2, 1

Staphylococcus aureus (Methicillin-Resistant, Clindamycin-Susceptible)

• IV: Vancomycin 40-60 mg/kg/day every 6-8 hours (target AUC/MIC >400) or clindamycin 40 mg/kg/day every 6-8 hours 2, 5
• Oral: Clindamycin 30-40 mg/kg/day in 3-4 doses 2, 1

Group A Streptococcus

• IV: Penicillin G 100,000-250,000 U/kg/day every 4-6 hours or ampicillin 200 mg/kg/day every 6 hours 2
• Oral: Amoxicillin 50-75 mg/kg/day in 2 doses or penicillin V 50-75 mg/kg/day in 3-4 doses 2

Hospitalization Criteria and IV Therapy

Indications for hospitalization and IV antibiotics:

• Inability to tolerate oral medications (vomiting) 2
• Oxygen saturation <92% on room air 2, 6
• Severe respiratory distress (grunting, significant retractions, tachypnea) 7
• Dehydration, poor feeding, altered consciousness, or seizures 6
• Age <6 months with suspected bacterial pneumonia 2

Preferred IV regimens for severe pneumonia:

• Co-amoxiclav, cefuroxime, or cefotaxime 2
• If S. pneumoniae confirmed: Ampicillin, penicillin, or amoxicillin alone 2
• For suspected MRSA: Add vancomycin or clindamycin 4, 5

Transition to oral therapy when:

• Clear clinical improvement documented 2
• Able to tolerate oral intake 2
• Afebrile for 12-24 hours 2

Treatment Duration

For uncomplicated pneumonia: 5-7 days of antibiotic therapy is adequate. 1 Recent evidence supports shorter courses (5 days) for uncomplicated cases, which reduces antibiotic exposure without compromising outcomes. 7

For complicated pneumonia (empyema, necrotizing pneumonia, lung abscess): 2-4 weeks of therapy depending on clinical response and adequacy of drainage. 2, 1 The duration should be individualized based on fever resolution, clinical improvement, and imaging findings. 2

Assessment of Treatment Response

Reassess within 48-72 hours of initiating therapy. 2, 1 Expect documented clinical improvement including:

• Decreased fever 2
• Improved level of activity and appetite 2
• Reduced respiratory distress 2

If no improvement after 48-72 hours, perform the following:

• Clinical and laboratory assessment of illness severity 2
• Imaging evaluation (chest radiograph or ultrasound) to assess extent and progression 2
• Consider complications: parapneumonic effusion, empyema, necrotizing pneumonia, lung abscess 2, 6
• Obtain cultures if not already done: blood culture, pleural fluid if effusion present 2
• Consider BAL for mechanically ventilated children 2
• Broaden antibiotic coverage or change therapy based on suspected resistant organisms 2

Management of Complications

Parapneumonic Effusion/Empyema

Small effusion (<10mm rim):

• Continue antibiotics alone 2
• Do not attempt drainage 2
• Reassess effusion size if no clinical improvement 2

Moderate effusion (10mm-50% hemithorax) with low respiratory compromise:

• IV antibiotics alone 2
• Obtain chest ultrasound and pleural fluid culture by thoracentesis or chest tube 2

Large effusion (>50% hemithorax) or high respiratory compromise:

• Non-loculated: Chest tube alone or chest tube with fibrinolytics 2
• Loculated: Chest tube with fibrinolytics; if not responding (~15% of patients), proceed to VATS 2

Antibiotic duration for empyema: 2-4 weeks depending on drainage adequacy and clinical response. 2, 1

Necrotizing Pneumonia/Lung Abscess

Initial management: IV antibiotics alone. 2 Most abscesses drain through the bronchial tree and heal without surgical intervention. 2

Consider drainage for:

• Well-defined peripheral abscesses without bronchial connection 2
• Persistent fever despite appropriate antibiotics 2
• Use imaging-guided aspiration or drainage catheter placement 2

Discharge Criteria

Patients are eligible for discharge when ALL of the following are met:

• Overall clinical improvement (activity level, appetite) for 12-24 hours 2
• Decreased or absent fever for 12-24 hours 2
• Oxygen saturation >90% on room air for 12-24 hours 2
• Stable/baseline mental status 2
• No substantially increased work of breathing 2
• No sustained tachypnea or tachycardia 2

Special Considerations and Pitfalls

Common pitfalls to avoid:

• Over-treatment of viral pneumonia: Young children with wheeze or other viral features often do not require antibiotics. 2, 6 Consider withholding antibiotics in children <5 years with clinical features suggesting viral etiology. 6
• Inadequate dosing of amoxicillin: Use high-dose amoxicillin (90 mg/kg/day) to ensure adequate coverage of penicillin-resistant S. pneumoniae. 1 Standard dosing (45 mg/kg/day) is insufficient. 2
• Premature discontinuation of IV therapy: Ensure clinical stability before transitioning to oral antibiotics. 2 Switching too early may result in treatment failure.
• Routine chest radiography: Not indicated for uncomplicated cases responding to therapy. 7 Reserve imaging for diagnostic uncertainty, hypoxemia, respiratory distress, or lack of improvement at 48-72 hours. 7
• Excessive fluid administration: Give IV fluids at 80% of maintenance requirements and monitor electrolytes. 2 Over-hydration can worsen respiratory status.
• Chest physiotherapy: Not beneficial and should not be performed. 2

Penicillin allergy considerations:

• For non-severe allergic reactions: Consider oral cephalosporins under medical supervision 1
• For severe penicillin allergies: Use macrolides, linezolid, or clindamycin 1

Prevention strategies:

• Comprehensive immunization against S. pneumoniae, H. influenzae type b, B. pertussis, and influenza 7
• Maternal immunization during pregnancy 7