What is the recommended treatment for pneumonia in a 7-year-old child?

Treatment of Pneumonia in a 7-Year-Old Child

For a 7-year-old child with community-acquired pneumonia treated as an outpatient, start with high-dose oral amoxicillin 90 mg/kg/day divided into 2 doses (maximum 4 g/day) for presumed bacterial pneumonia. 1

Outpatient Treatment Algorithm

First-Line Therapy for Bacterial Pneumonia

• Amoxicillin 90 mg/kg/day divided into 2 doses is the recommended first-line treatment for children ≥5 years old with presumed bacterial pneumonia 1
• The maximum daily dose is 4 g/day 1
• Alternative option: amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses, maximum 4000 mg/day) 1

Treatment Duration

• 5-day course is as effective as 10-day course for uncomplicated community-acquired pneumonia 2, 3
• Recent high-quality evidence demonstrates non-inferiority of 5-day treatment compared to 10-day treatment with no difference in clinical cure rates 2, 3
• 3-day regimens may be associated with unacceptable failure rates and should be avoided 4

When to Add Atypical Coverage

• Add a macrolide to the β-lactam if clinical, laboratory, or radiographic features do not clearly distinguish bacterial from atypical pneumonia 1
• For presumed atypical pneumonia alone: azithromycin 10 mg/kg on day 1 (maximum 500 mg), followed by 5 mg/kg/day once daily on days 2-5 (maximum 250 mg) 1, 5
• Alternative macrolides: clarithromycin 15 mg/kg/day in 2 doses (maximum 1 g/day) or erythromycin 1
• Doxycycline is an option for children >7 years old with atypical pneumonia 1

Inpatient Treatment (If Hospitalization Required)

Fully Immunized Children with Minimal Local Penicillin Resistance

• Ampicillin or penicillin G intravenously as first-line therapy 1
• Alternatives: ceftriaxone or cefotaxime 1, 6
• Add azithromycin if atypical pneumonia diagnosis is uncertain 1
• Add vancomycin or clindamycin if community-associated MRSA is suspected 1, 6

Not Fully Immunized or Significant Local Penicillin Resistance

• Ceftriaxone or cefotaxime as first-line therapy 1
• Add vancomycin or clindamycin for suspected CA-MRSA 1
• Add azithromycin if diagnosis is uncertain 1

Special Considerations

Penicillin Allergy Management

• For non-serious allergic reactions: trial of amoxicillin under medical observation OR oral cephalosporin (cefpodoxime, cefprozil, or cefuroxime) under medical supervision 1, 6
• Alternative options: levofloxacin, linezolid, or clindamycin (if susceptible) 1, 6
• Exercise particular caution with bacteremic pneumococcal pneumonia due to risk of secondary sites of infection including meningitis 1

Influenza-Associated Pneumonia

• Add oseltamivir or zanamivir (zanamivir for children ≥7 years old) if influenza is suspected 1, 6
• Alternatives under investigation: peramivir, intravenous oseltamivir and zanamivir 1

Monitoring for Treatment Failure

• Assess for clinical improvement within 48-72 hours of starting therapy 1, 7
• If condition deteriorates or shows no improvement within 48-72 hours, perform further investigation 1, 7
• Treatment failure may indicate resistant organisms, inadequate dosing, poor compliance, or other underlying conditions 7

Common Pitfalls to Avoid

• Do not use 3-day amoxicillin regimens as they may have unacceptable failure rates 4
• Avoid relying solely on macrolides for typical bacterial pneumonia, as they should be reserved for atypical pathogens or added to β-lactams when diagnosis is uncertain 1
• Do not underdose amoxicillin—the 90 mg/kg/day dose is critical to overcome resistant Streptococcus pneumoniae strains 1, 6
• Be aware that gastrointestinal symptoms are common with clindamycin and can be associated with Clostridium difficile-associated diarrhea 8