What are the recommended antibiotics for pediatric pneumonia?

Recommended Antibiotics for Pediatric Pneumonia

Amoxicillin 90 mg/kg/day divided into 2 doses is the definitive first-line antibiotic for outpatient treatment of pediatric community-acquired pneumonia in children over 3 months of age. 1

Outpatient Treatment Algorithm

Children Under 5 Years

• First-line: Amoxicillin 90 mg/kg/day in 2 divided doses (maximum 4 g/day) 1
• Not fully immunized against H. influenzae type b or S. pneumoniae: Amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) to cover β-lactamase-producing organisms 1
• Suspected Staphylococcus aureus: Amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) 1
• Suspected MRSA: Add clindamycin 30-40 mg/kg/day in 3-4 doses to beta-lactam therapy 1

Children 5 Years and Older

• First-line: Amoxicillin 90 mg/kg/day in 2 divided doses (maximum 4 g/day) 1
• If atypical pathogens suspected (based on clinical presentation with persistent symptoms after 48 hours): Add azithromycin 10 mg/kg on day 1, then 5 mg/kg/day on days 2-5 1, 2
• Atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae) are uncommon in children under 5 years, so macrolides should not be used as first-line therapy in this age group 1

Treatment Duration

• 5 days of amoxicillin is as effective as 10 days for uncomplicated CAP, with moderate quality evidence supporting this shorter duration 3, 4, 5
• Reassess at 48-72 hours after starting antibiotics to evaluate symptom resolution 1, 4

Inpatient Treatment Algorithm

Fully Immunized, Low-Risk Children

• First-line: Ampicillin 150-200 mg/kg/day IV every 6 hours OR penicillin G 100,000-250,000 U/kg/day IV every 4-6 hours 1
• Alternative: Ceftriaxone 50-100 mg/kg/day IV every 12-24 hours 1

Not Fully Immunized or High-Risk Children

• Recommended: Ceftriaxone 50-100 mg/kg/day IV every 12-24 hours OR cefotaxime 150 mg/kg/day IV every 8 hours 1
• If MRSA suspected (severe presentation, necrotizing infiltrates, empyema, recent influenza): Add vancomycin 40-60 mg/kg/day IV every 6-8 hours OR clindamycin 10-13 mg/kg/dose IV every 6-8 hours (maximum 40 mg/kg/day) 1, 6

Atypical Pneumonia (Hospitalized)

• Azithromycin 10 mg/kg IV on days 1 and 2, then transition to oral therapy 1
• Alternative: Erythromycin lactobionate 20 mg/kg/day IV every 6 hours 1

Critical Dosing Considerations

Why High-Dose Amoxicillin Matters

• The 90 mg/kg/day dose is essential to overcome pneumococcal resistance 1
• Common pitfall: Underdosing with 40-45 mg/kg/day instead of the recommended 90 mg/kg/day leads to treatment failure 1
• High-dose amoxicillin causes significantly less diarrhea than amoxicillin-clavulanate or macrolides 1

Inappropriate Antibiotic Use to Avoid

• Do not use macrolides as first-line therapy for presumed bacterial pneumonia in children under 5 years 1
• Do not use cefixime for pediatric pneumonia—it is explicitly not recommended 1
• Do not use second or third-generation cephalosporins as first-line outpatient therapy in fully immunized children 1

Penicillin Allergy Management

Non-Severe Allergic Reactions

• Consider oral cephalosporins with substantial activity against S. pneumoniae (cefpodoxime, cefprozil, or cefuroxime) under medical supervision 1

Severe Allergic Reactions (Anaphylaxis)

• Levofloxacin: 16-20 mg/kg/day every 12 hours (children 6 months to 5 years) OR 8-10 mg/kg/day once daily (children 5-16 years; maximum 750 mg/day) 1
• Alternative: Linezolid based on age and severity 1

Special Clinical Situations

MRSA Risk Factors to Consider

• Severe pneumonia with necrotizing infiltrates 1
• Parapneumonic effusion or empyema 1
• Recent influenza infection 1
• Failure to consider MRSA in these scenarios is a critical pitfall 1

Treatment Failure (No Improvement at 48-72 Hours)

• Obtain appropriate cultures (blood, pleural fluid if effusion present) 1
• Consider adding azithromycin for atypical coverage in children ≥5 years 1
• Consider switching to ceftriaxone or cefotaxime 1
• Evaluate for complications (empyema, abscess) requiring drainage 1

Pleural Effusion Management

• Obtain pleural fluid for Gram stain and culture 1
• Consider drainage for significant parapneumonic effusions 1

Evidence Quality Summary

The recommendations are based primarily on American Academy of Pediatrics and Infectious Diseases Society of America guidelines from 2025 1, with supporting evidence from recent randomized controlled trials demonstrating non-inferiority of shorter treatment durations 3, 5 and equivalent efficacy of penicillin/ampicillin versus broader-spectrum agents 7. The GRADE certainty of evidence for 5-day versus 10-day treatment is moderate 3, 5.