What is the recommended management for a 13-month-old with a Streptococcus pneumoniae infection?

Management of Streptococcus pneumoniae Infection in a 13-Month-Old

Amoxicillin 45 mg/kg/day divided every 12 hours (or 40 mg/kg/day divided every 8 hours) is the first-line treatment for a 13-month-old with confirmed Streptococcus pneumoniae infection. 1

Initial Assessment and Severity Determination

Determine if the child requires hospitalization or can be managed as an outpatient:

• Outpatient management is appropriate if: oxygen saturation >92% on room air, able to tolerate oral intake, no signs of severe respiratory distress, and reliable caregiver for follow-up 1
• Hospitalization is indicated if: oxygen saturation ≤92% on room air, inability to maintain oral hydration, severe respiratory distress, or age-related vulnerability (infants under 3-6 months are at higher risk) 1

Antibiotic Selection and Dosing

For Outpatient Management (Mild to Moderate Infection)

Amoxicillin is the definitive first-line agent because it provides optimal coverage against S. pneumoniae, is well-tolerated, cost-effective, and has excellent bioavailability 1, 2

Specific dosing for a 13-month-old:

• Standard dose: 45 mg/kg/day divided every 12 hours OR 40 mg/kg/day divided every 8 hours 1, 2
• Duration: Minimum 10 days for any streptococcal infection to prevent complications 1, 2
• Administration: Give at the start of meals to minimize gastrointestinal intolerance 2

For Hospitalized Patients (Severe Infection)

If the child is fully immunized with pneumococcal conjugate vaccine AND local penicillin resistance is minimal:

• Ampicillin: 150-200 mg/kg/day IV divided every 6 hours 1
• OR Penicillin G: 200,000-250,000 units/kg/day IV divided every 4-6 hours 1

If the child is NOT fully immunized OR there is high-level penicillin resistance in your region OR life-threatening infection:

• Ceftriaxone: 50-100 mg/kg/day IV every 12-24 hours (preferred for once-daily dosing) 1
• OR Cefotaxime: 150 mg/kg/day IV divided every 8 hours 1

Important caveat: Third-generation cephalosporins remain effective even against penicillin-resistant pneumococcal strains with MICs up to 2.0 μg/mL, and no evidence supports adding vancomycin for pneumonia in North America given current resistance patterns 1

Alternative Agents for Penicillin Allergy

For non-severe, non-anaphylactic penicillin allergy:

• Second-generation cephalosporins: Cefpodoxime, cefuroxime, or cefprozil at standard pediatric doses 1

For severe penicillin allergy (anaphylaxis history):

• Clindamycin: 40 mg/kg/day divided every 6-8 hours (IV or oral depending on severity) 1, 3
• Note: Only use clindamycin if local pneumococcal clindamycin resistance is <10% 3
• Levofloxacin: 16-20 mg/kg/day divided every 12 hours (maximum 750 mg/day) for severe cases, though use in infants requires careful consideration 1

Supportive Care Measures

Oxygen therapy:

• Administer supplemental oxygen via nasal cannula, head box, or face mask if oxygen saturation ≤92% on room air 1
• Target oxygen saturation >92% 1
• Monitor oxygen saturation at least every 4 hours in hospitalized patients 1

Fluid management:

• If IV fluids are needed, administer at 80% of basal maintenance requirements to prevent hyponatremia 1
• Monitor serum electrolytes in hospitalized patients 1
• Avoid nasogastric tubes in severely ill infants as they may compromise breathing through small nasal passages 1

Avoid chest physiotherapy as it provides no benefit and should not be performed 1

Antipyretics and analgesics can be used for comfort and to facilitate coughing 1

Monitoring and Follow-Up

For hospitalized patients:

• Re-evaluate if fever persists or child remains unwell 48 hours after admission 1
• Consider complications such as empyema, lung abscess, or metastatic infection if no improvement 1
• Obtain follow-up chest radiograph only if clinical deterioration, persistent fever beyond 48-72 hours, or concern for complications 1

Transition from IV to oral therapy:

• Switch to oral amoxicillin when clear clinical improvement is evident (typically after 24-48 hours of IV therapy) 1
• Complete the full 10-day course with combined IV and oral therapy 1

For outpatient management:

• Schedule follow-up within 48-72 hours to assess response 1
• Instruct caregivers to return immediately if respiratory distress worsens, child becomes lethargic, or refuses oral intake 1

Common Pitfalls to Avoid

Do not use macrolides (azithromycin, clarithromycin) as monotherapy for confirmed S. pneumoniae in this age group, as macrolide resistance averages 28% in the United States and is geographically variable 4, 5

Do not prescribe amoxicillin-clavulanate as first-line therapy unless β-lactamase-producing organisms (H. influenzae, M. catarrhalis) are suspected, as the clavulanate component increases cost and gastrointestinal side effects without added benefit against pneumococcus 1

Do not stop antibiotics early even if the child appears clinically improved after 3-5 days; complete the full 10-day course to prevent relapse and complications 1, 2

Do not add vancomycin empirically for pneumococcal pneumonia in North America, as third-generation cephalosporins remain highly effective even against resistant strains 1