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

Latest Guidelines for Pediatric Community-Acquired Pneumonia

For outpatient treatment of mild-to-moderate CAP, oral amoxicillin 90 mg/kg/day divided into 2 doses is the first-line antibiotic for all ages, with a 5-day treatment duration recommended based on the most recent high-quality evidence. 1

Diagnostic Approach

• Chest radiographs are not routinely necessary for children well enough to be treated as outpatients with suspected CAP 1
• Obtain chest radiographs in children with suspected hypoxemia, significant respiratory distress, or failed initial antibiotic therapy 1
• Pulse oximetry should be performed in all children with pneumonia to assess for hypoxemia and guide site of care decisions 1
• For mechanically ventilated children, obtain tracheal aspirates for Gram stain, culture, and viral pathogen testing (including influenza) at the time of endotracheal tube placement 2, 1

Treatment Algorithm by Age and Severity

Outpatient Treatment (Mild-to-Moderate CAP)

Preschool-aged children (< 5 years):

• Antimicrobial therapy is not routinely required for preschool-aged children with CAP, as viral pathogens cause the majority of clinical disease 2
• When bacterial CAP is suspected, amoxicillin 90 mg/kg/day divided into 2 doses is first-line therapy 2, 1, 3
• Alternative agents for penicillin allergy include co-amoxiclav, cefaclor, erythromycin, clarithromycin, or azithromycin 2

School-aged children and adolescents (≥ 5 years):

• Amoxicillin 90 mg/kg/day (maximum 4 g/day) divided into 2 doses remains first-line for S. pneumoniae coverage 2, 1
• Consider macrolide antibiotics as first-line empirical treatment in children ≥ 5 years due to higher prevalence of Mycoplasma pneumoniae 2, 3
• Add macrolide coverage if symptoms persist after 48 hours of amoxicillin therapy and clinical condition remains stable 4
• For children > 7 years with atypical pneumonia, doxycycline 2-4 mg/kg/day in 2 doses is an alternative 1

Inpatient Treatment (Severe CAP)

For hospitalized children with severe pneumonia:

• Ampicillin 150-400 mg/kg/day IV divided every 6 hours or penicillin G when local epidemiologic data show lack of substantial high-level penicillin resistance 2, 1, 3
• Alternative IV antibiotics include co-amoxiclav, cefuroxime, or cefotaxime 50-100 mg/kg/day 2, 1, 3
• Switch to oral therapy when there is clear evidence of clinical improvement 2

For very severe CAP or ICU admission:

• Penicillin/ampicillin plus gentamicin is superior to chloramphenicol based on lower mortality rates 5
• Consider ICU admission for children with invasive mechanical ventilation needs, fluid-refractory shock, acute need for noninvasive positive pressure ventilation, or hypoxemia requiring FiO2 > 0.50 2

Treatment Duration

• 5-day course is recommended for most cases of pediatric CAP based on moderate-quality evidence 1, 3, 6
• Clinical monitoring and reassessment at 48-72 hours after starting antibiotics to evaluate symptom resolution 1, 4
• For parapneumonic effusions, antibiotic duration should be 2-4 weeks depending on adequacy of drainage and clinical response 1

Pathogen-Specific Considerations

When S. pneumoniae is suspected:

• Amoxicillin should be used at any age as first-line treatment 2, 3

When Mycoplasma or Chlamydia pneumoniae is suspected:

• Macrolide antibiotics should be used (azithromycin, clarithromycin, or erythromycin) 2, 3
• Azithromycin dosing for children ≥ 6 months: 10 mg/kg as single dose on Day 1, followed by 5 mg/kg on Days 2-5 7

When Staphylococcus aureus is suspected:

• Use a macrolide or combination of flucloxacillin with amoxicillin 2, 3

For influenza-associated CAP:

• Administer antiviral therapy (oseltamivir) as soon as possible to children with moderate-to-severe CAP during widespread local influenza circulation 1, 8
• Do not delay treatment while awaiting influenza test confirmation 8

Treatment Failure Protocol

If no clinical improvement within 48-72 hours:

• Re-evaluate with consideration of complications including parapneumonic effusion, empyema, or resistant pathogens 2, 1
• Obtain repeat chest radiograph to assess for complications 2, 1
• Consider broader-spectrum antibiotics such as amoxicillin-clavulanate, ceftriaxone, or cefuroxime 3
• Add macrolide coverage if atypical pathogens are suspected 3, 4
• For mechanically ventilated children, obtain bronchoalveolar lavage for Gram stain and culture 1

Special Populations

Unimmunized or incompletely immunized children:

• Use amoxicillin-clavulanate or second/third-generation cephalosporins instead of amoxicillin alone for those without complete H. influenzae type b and S. pneumoniae immunization 4

HIV-exposed or high HIV prevalence areas:

• Amoxicillin remains the recommended treatment for non-severe pneumonia regardless of co-trimoxazole prophylaxis status 3
• If first-line therapy fails, refer for HIV testing and broad-spectrum parenteral antibiotics 3

Common Pitfalls to Avoid

• Do not routinely prescribe antibiotics to young children with mild lower respiratory tract symptoms, as most cases are viral 2
• Avoid routine daily chest radiographs in children with parapneumonic effusion after chest tube placement if clinically stable 2
• Do not use chest physiotherapy, as it is not beneficial in children with pneumonia 3
• Avoid 10-day courses when 5-day courses are equally effective, to reduce antibiotic exposure and improve compliance 6
• Do not delay switching to oral antibiotics in hospitalized children showing clear clinical improvement 2