What are the first-line treatment recommendations for community-acquired pneumonia (CAP) in pediatric patients?

Community-Acquired Pneumonia in Pediatric Patients: Treatment Recommendations

First-Line Antibiotic Selection

For outpatient treatment of presumed bacterial CAP, high-dose oral amoxicillin at 90 mg/kg/day divided into 2 doses is the first-line therapy for all pediatric patients. 1

Age-Specific Considerations

Children Under 5 Years Old:

• Amoxicillin 90 mg/kg/day in 2 divided doses is the preferred empiric therapy for presumed bacterial pneumonia 1
• Alternative: Amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) 1
• Maximum daily dose: 4 g/day 1

Children 5 Years and Older:

• Amoxicillin 90 mg/kg/day in 2 divided doses (maximum 4 g/day) remains first-line 1
• Add a macrolide to the β-lactam if clinical features do not clearly distinguish bacterial from atypical CAP 1
• For presumed atypical pneumonia: Azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 (maximum 500 mg day 1, then 250 mg days 2-5) 1, 2

Treatment Duration

A 5-day course of amoxicillin is recommended for uncomplicated CAP 3, 4, 5. Recent evidence demonstrates that 5-day regimens are equally effective as 10-day courses with no difference in clinical cure rates (RR 1.01; 95% CI 0.98-1.05) 4.

Inpatient Management

For hospitalized children requiring parenteral therapy:

Fully Immunized Children (H. influenzae type b and S. pneumoniae) in Areas with Minimal Penicillin Resistance:

• Ampicillin (150-200 mg/kg/day every 6 hours) or Penicillin G as first-line 1, 6
• Alternatives: Ceftriaxone (50-100 mg/kg/day every 12-24 hours) or cefotaxime (150 mg/kg/day every 8 hours) 1
• Add vancomycin (40-60 mg/kg/day every 6-8 hours) or clindamycin (40 mg/kg/day every 6-8 hours) if community-acquired MRSA is suspected 1

Incompletely Immunized Children or Areas with Significant Penicillin Resistance:

• Ceftriaxone or cefotaxime as first-line 1
• Add vancomycin or clindamycin for suspected CA-MRSA 1

For suspected atypical pneumonia in hospitalized patients:

• Azithromycin IV (10 mg/kg on days 1 and 2) in addition to β-lactam therapy 1
• Alternatives: Clarithromycin or erythromycin; doxycycline for children >7 years old 1

Step-Down to Oral Therapy

Switch from IV to oral antibiotics when:

• Child is afebrile for 24 hours 6
• Improved respiratory rate and work of breathing 6
• Tolerating oral intake without vomiting 6
• Typically occurs within 48-72 hours of admission 6

Clinical Monitoring and Response to Therapy

Children on adequate therapy should demonstrate clinical improvement within 48-72 hours 1, 3, 6. Expected improvements include:

• Decreased fever 3, 6
• Improved respiratory rate 6
• Reduced work of breathing 6

If no improvement or clinical deterioration occurs within 48-72 hours, further investigation is mandatory 1, 6. Consider:

• Inadequate antibiotic dosing or inappropriate drug selection 6
• Complications (parapneumonic effusion, empyema) 1
• Resistant organisms 6
• Alternative diagnoses 6

Special Considerations and Common Pitfalls

Dosing Considerations:

• The 90 mg/kg/day amoxicillin dose is critical for adequate coverage against penicillin-resistant S. pneumoniae 1
• Twice-daily dosing may be effective for penicillin-susceptible pneumococci and improves compliance 1, 5
• Three-times-daily dosing provides more consistent drug levels but compliance may be lower 5

Macrolide Use:

• Do not use macrolides as monotherapy for children under 5 years due to inadequate coverage of S. pneumoniae 1
• Macrolides are appropriate as monotherapy for children ≥5 years with presumed atypical pneumonia 1
• For children >7 years, doxycycline is an alternative for atypical pathogens 1

Influenza-Associated Pneumonia:

• Oseltamivir should be administered as soon as possible to children with moderate to severe pneumonia consistent with influenza, without waiting for test confirmation 7
• Dosing: Children <24 months receive 4 mg/kg/day in 2 doses for 5 days; weight-based dosing for older children 7

Immunization Status:

• Antibiotic selection depends heavily on immunization status for H. influenzae type b and S. pneumoniae 1, 5
• Broader spectrum coverage (ceftriaxone/cefotaxime) is needed for incompletely immunized children 1

Return to Normal Activities:

• Children can return to school when fever-free for 24 hours without antipyretics and symptoms have significantly improved 7
• Routine follow-up chest radiographs are not necessary for children who recover uneventfully 7