What are the guidelines for treating pneumonia in children in the Philippines?

Pneumonia Treatment Guidelines for Children in the Philippines

First-Line Antibiotic Treatment

For children under 5 years with non-severe community-acquired pneumonia in the Philippines, oral amoxicillin at 90 mg/kg/day divided into 2-3 doses is the recommended first-line treatment, as it provides effective coverage against the most common bacterial pathogens causing pneumonia in this setting. 1, 2, 3

Age-Based Treatment Approach

Children Under 5 Years:

• Oral amoxicillin 90 mg/kg/day divided into 2 doses (maximum 4000 mg/day) is the first-choice antibiotic 1, 2, 3
• High-dose amoxicillin is preferable given pneumococcal resistance patterns 1
• Treatment duration: 5 days for uncomplicated cases 2, 3

Children 5 Years and Older:

• Oral amoxicillin 90 mg/kg/day divided into 2 doses remains first-line for presumed bacterial pneumonia 2, 3
• Consider adding azithromycin 10 mg/kg on day 1, then 5 mg/kg/day on days 2-5 if atypical pathogens (Mycoplasma, Chlamydophila) are suspected 2, 3, 4
• Macrolides are particularly important in this age group due to higher prevalence of Mycoplasma pneumoniae 2

Criteria for Hospitalization

All children meeting ANY of the following criteria should be hospitalized: 1

• Age less than 6 months 1
• Oxygen saturation <92% on room air 1
• Respiratory distress signs: tachypnea (>60 breaths/min in 0-2 months, >50 in 2-12 months, >40 in 1-5 years), retractions, grunting, nasal flaring 1
• Severe malnutrition (this is particularly important in the Philippines context where malnutrition was the most common factor associated with death) 5
• Inability to tolerate oral medications, vomiting, or dehydration 1
• Failure to respond to oral antibiotics within 48-72 hours 1, 6

Treatment for Hospitalized Children

For severe pneumonia requiring hospitalization:

• Oral amoxicillin can be used as an alternative to injectable penicillin/ampicillin for children without hypoxia 1, 7
• Injectable antibiotics are indicated when: the child cannot absorb oral medications, has severe signs/symptoms, or oxygen saturation <90% 1

Injectable antibiotic options include: 1

• Ampicillin 150-400 mg/kg/day IV divided every 6 hours
• Ceftriaxone 50-100 mg/kg/day IV divided every 12-24 hours
• Penicillin plus gentamicin (superior to chloramphenicol for very severe cases) 7

Special Considerations for the Philippines Context

Viral Pathogens:

• Viruses are detected in approximately 61% of children with severe pneumonia in the Philippines, with respiratory syncytial virus (27%) and rhinovirus (23%) being most common 8, 5
• Influenza A virus positivity is significantly associated with fatal outcomes (OR 4.3) 8
• Consider antiviral therapy when influenza is suspected during local outbreaks 6

Bacterial Pathogens:

• Blood cultures are positive in only 5.8% of cases, with Salmonella species, Gram-negative organisms, and Streptococcus pneumoniae being most common 9
• Burkholderia cepacia, Staphylococcus aureus, and Haemophilus influenzae have also been isolated 8

Malnutrition:

• 55% of children who died from pneumonia were moderately or severely underweight 5
• Severe malnutrition is the most common factor associated with death and requires aggressive nutritional support alongside antibiotic therapy 5

Treatment Failure Protocol

If no clinical improvement within 48-72 hours: 1, 6

1. Reassess clinically for complications (pleural effusion, empyema) or alternative diagnoses 6
2. Obtain chest radiograph to evaluate for progression, consolidation, or pleural effusion 6, 5
3. Measure oxygen saturation - values <90% predict poor outcomes 1, 5
4. Consider broader-spectrum antibiotics: 1
   • Amoxicillin-clavulanate
   • Ceftriaxone
   • Cefuroxime
5. Add macrolide coverage if atypical pathogens suspected 2, 3

Areas Where Referral is Not Possible

In remote areas where hospital referral is impossible, children failing treatment should receive: 1

• Injectable ceftriaxone, penicillin/gentamicin, or chloramphenicol to provide broader coverage against pathogens causing severe pneumonia 1

HIV Considerations

In areas of high HIV prevalence (relevant for some regions in the Philippines): 1

• Amoxicillin remains the recommended treatment for non-severe pneumonia, regardless of co-trimoxazole prophylaxis status 1
• If first-line therapy fails, refer for HIV testing and broad-spectrum parenteral antibiotics 1

Supportive Care

• Maintain oxygen saturation >92% with supplemental oxygen 2
• Antipyretics and analgesics for comfort and to facilitate coughing 2
• Do NOT perform chest physiotherapy - it is not beneficial 2
• Address severe anemia - children with pneumonia and severe anemia require hospital referral 1

Common Pitfalls to Avoid

• Do not use co-trimoxazole as first-line therapy - it is inferior to amoxicillin 1
• Do not delay antibiotics in children with respiratory distress or hypoxemia 1
• Do not discharge children <6 months with pneumonia for outpatient management 1
• Do not ignore nutritional status - malnutrition dramatically increases mortality risk in the Philippines 5
• Do not assume bacterial etiology alone - viral pathogens are present in the majority of cases and may require supportive care rather than antibiotics alone 8, 5