Treatment of Pneumonia in Children
First-Line Antibiotic Selection
Amoxicillin is the first-line treatment for community-acquired pneumonia in children, given orally at 90 mg/kg/day divided into 2-3 doses for 5 days. 1, 2
Age-Based Treatment Algorithm
Children under 5 years: Oral amoxicillin is the preferred first-line agent because it effectively targets Streptococcus pneumoniae and Haemophilus influenzae, the most common bacterial pathogens causing severe disease in this age group 1, 2
Children 5 years and older: Macrolide antibiotics (erythromycin, clarithromycin, or azithromycin) should be used as first-line empirical treatment due to higher prevalence of Mycoplasma pneumoniae in this age group 2
Alternative approach for children 5+ years: If symptoms persist after 48 hours of amoxicillin therapy and the clinical condition remains stable, add a macrolide rather than switching entirely 3
Dosing Specifications
Standard amoxicillin dose: 90 mg/kg/day divided into three doses, though twice-daily dosing may be considered to improve compliance 2, 3
High-dose amoxicillin: 90 mg/kg/day is preferable given pneumococcal resistance patterns 2
Treatment duration: 5 days for most cases of pediatric CAP, with clinical reassessment at 48-72 hours 1, 2, 4
Minimum treatment for Streptococcus pyogenes: At least 10 days to prevent acute rheumatic fever 5
Severity-Based Treatment Approach
Non-Severe (Outpatient) Pneumonia
Mild symptoms in young children: May not require antibiotics at all 2
Standard non-severe pneumonia: Oral amoxicillin twice daily for 3-5 days 1
Co-trimoxazole alternative: May be used in some settings, though it is not first-line treatment 1
Severe Pneumonia Requiring Hospitalization
Indications for IV antibiotics: Child unable to absorb oral medications, severe signs/symptoms, oxygen saturation <90-92%, age <6 months, respiratory distress, severe malnutrition, inability to tolerate oral medications, vomiting, dehydration, or failure to respond to oral antibiotics within 48-72 hours 2
IV antibiotic options for severe pneumonia:
Alternative for severe pneumonia: Oral amoxicillin can be used as an alternative to injectable penicillin/ampicillin for hospitalized children without hypoxia 2, 6
Treatment Failure Protocol
Treatment failure is defined as a child who develops signs warranting immediate referral OR who does not have a decrease in respiratory rate after 48-72 hours of therapy. 1
Systematic Approach to Treatment Failure
First, exclude non-adherence and alternative diagnoses before assuming antibiotic failure 1
If first-line agent failure confirmed and no indication for immediate referral: Switch to high-dose amoxicillin-clavulanate with or without an affordable macrolide for children over 3 years of age 1
For severe treatment failure: Consider broader-spectrum antibiotics such as amoxicillin-clavulanate, ceftriaxone, or cefuroxime, and add macrolide coverage if atypical pathogens are suspected 2
Re-evaluation timing: Patients should be reassessed if they remain febrile or unwell 48 hours after starting treatment 2
Special Clinical Situations
HIV-Prevalent Areas or HIV-Infected Children
First-line treatment remains amoxicillin for non-severe pneumonia, regardless of co-trimoxazole prophylaxis status 1, 2
If first-line therapy fails: Refer to hospital for management including HIV testing and broad-spectrum parenteral antibiotics 1, 2
Malaria-Endemic Regions
If pneumonia diagnosed but malaria cannot be excluded: Prescribe both first-line therapies for malaria and pneumonia 1
Assess for severe anemia: Children with rapid breathing should be evaluated for severe anemia by examining palms, nail beds, and conjunctivae if laboratory assessment unavailable 1
Any child with pneumonia plus severe anemia: Refer to hospital for assessment 1
Drug interaction caution: Avoid erythromycin as second-line agent if mefloquine or halofantrine prescribed for malaria due to increased arrhythmia risk 1
Areas Where Referral Is Not Possible
Use injectable antimicrobials providing broader coverage and high activity against severe pneumonia pathogens 1
Injectable options: Ceftriaxone, penicillin/gentamicin, or chloramphenicol 1, 2
Pediatric Patients Under 3 Months (12 Weeks)
Maximum recommended dose: 30 mg/kg/day divided every 12 hours due to incompletely developed renal function 5
Minimum treatment duration: 48-72 hours beyond symptom resolution or evidence of bacterial eradication 5
For Streptococcus pyogenes: At least 10 days of treatment to prevent acute rheumatic fever 5
Renal Impairment
GFR 10-30 mL/min: 500 mg or 250 mg every 12 hours depending on infection severity 5
GFR <10 mL/min: 500 mg or 250 mg every 24 hours depending on infection severity 5
Hemodialysis patients: 500 mg or 250 mg every 24 hours, with additional dose during and at end of dialysis 5
Important caveat: Patients with GFR <30 mL/min should NOT receive the 875 mg dose 5
Supportive Care Measures
Oxygen therapy: Maintain oxygen saturation >92% with supplemental oxygen as needed 2
Positioning: Elevate head of bed 30-45 degrees 7
Symptom management: Antipyretics and analgesics help keep child comfortable and assist with coughing 2
Nasal suctioning: Gentle suctioning as needed 7
Avoid chest physiotherapy: Not beneficial and should not be performed in children with pneumonia 2, 7
Common Pitfalls to Avoid
Do not use cefixime in children under 5 years as an alternative regimen 7
Do not prescribe broader-spectrum antibiotics empirically without first trying amoxicillin, as this contributes to antimicrobial resistance 1
Do not assume treatment failure before 48-72 hours unless child develops signs warranting immediate referral 1
Do not forget to take amoxicillin at the start of a meal to minimize gastrointestinal intolerance 5
Do not extend treatment duration beyond 5 days for uncomplicated CAP unless specific indications exist, as 5-day courses are as effective as 10-day courses 4, 3