What is the treatment protocol for pediatric pneumonia in children with varying severity and potential underlying medical conditions, such as asthma or congenital heart disease?

Treatment of Paediatric Pneumonia

Amoxicillin 90 mg/kg/day divided into 2 doses is the definitive first-line treatment for community-acquired pneumonia in children, with treatment selection based on age, severity, and immunization status. 1

Outpatient Treatment Algorithm

Children Under 5 Years

• Amoxicillin 90 mg/kg/day in 2 divided doses is the first-line oral antibiotic for mild-to-moderate pneumonia, providing excellent coverage against Streptococcus pneumoniae, the most common bacterial pathogen 2, 1
• The higher dose (90 mg/kg/day rather than 40-45 mg/kg/day) is essential to overcome pneumococcal resistance—underdosing is a common and dangerous error 1
• Amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) should be used if the child is not fully immunized against Haemophilus influenzae type b or if Staphylococcus aureus is suspected 1, 3
• Young children with only mild lower respiratory tract symptoms need not be treated with antibiotics at all 2

Children 5 Years and Older

• Amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) remains first-line 1
• Add azithromycin (10 mg/kg on day 1, then 5 mg/kg/day on days 2-5) if atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae) are suspected based on clinical presentation, as these become more prevalent with increasing age 2, 1, 4
• Macrolide monotherapy should not be used as first-line for presumed bacterial pneumonia—this is a critical pitfall 1

Treatment Duration

• 3-5 days of amoxicillin is adequate for uncomplicated non-severe pneumonia 1, 5
• A 3-day course is equally effective as 5-7 days for non-severe cases, reducing cost and antimicrobial resistance 5, 6

Inpatient Treatment Algorithm

Fully Immunized, Low-Risk Children

• 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 are preferred first-line agents 2, 1
• Ceftriaxone 50-100 mg/kg/day IV every 12-24 hours or cefotaxime 150 mg/kg/day IV every 8 hours are acceptable alternatives 2, 1

Not Fully Immunized or High-Risk Children

• Ceftriaxone 50-100 mg/kg/day or cefotaxime 150 mg/kg/day to cover β-lactamase-producing H. influenzae and resistant pneumococci 2, 1
• Add vancomycin 40-60 mg/kg/day IV every 6-8 hours or clindamycin 40 mg/kg/day IV every 6-8 hours if community-associated MRSA is suspected based on severe presentation, necrotizing infiltrates, empyema, or recent influenza infection 2, 1, 7

Severe Pneumonia with Complications

• For severe pneumonia with respiratory compromise, use co-amoxiclav, cefuroxime, or cefotaxime IV 2
• If S. pneumoniae is confirmed microbiologically, narrow to amoxicillin, ampicillin, or penicillin alone 2
• For suspected Staphylococcus aureus (MSSA), use cefazolin 150 mg/kg/day divided into three doses or flucloxacillin with amoxicillin 2, 1, 3

Switching to Oral Therapy

• Transition from IV to oral antibiotics when there is clear evidence of clinical improvement, typically after 48-72 hours 2
• Oral antibiotics are safe and effective for children presenting with CAP, avoiding the trauma and cost of IV administration 2

Special Considerations

Children with Underlying Conditions (Asthma, Congenital Heart Disease)

• These children are at higher risk for severe disease and should be managed more aggressively with early hospitalization and IV antibiotics if they show signs of respiratory distress 2
• Consider broader coverage with ceftriaxone or cefotaxime plus vancomycin/clindamycin given their compromised ability to respond to illness 1, 7

Penicillin Allergy

• For non-severe allergic reactions, consider oral cephalosporins (cefpodoxime, cefprozil, cefuroxime) under medical supervision 1
• For severe allergic reactions (anaphylaxis), use levofloxacin (16-20 mg/kg/day every 12 hours for children 6 months to 5 years; 8-10 mg/kg/day once daily for children 5-16 years, maximum 750 mg/day) or linezolid 1

Failure to Improve After 48-72 Hours

• Re-evaluate clinically and radiologically to assess for complications such as parapneumonic effusion, empyema, or abscess formation 2
• Obtain blood cultures and consider pleural fluid sampling if effusion is present 2, 1
• Consider adding azithromycin if atypical pathogens were not initially covered 1, 7
• Switch to broader-spectrum antibiotics (ceftriaxone/cefotaxime plus vancomycin/clindamycin) if MRSA or resistant organisms are suspected 1, 7

Supportive Care

Oxygen and Monitoring

• Administer supplemental oxygen to maintain oxygen saturation >92% 2
• Children on oxygen therapy require at least 4-hourly observations including oxygen saturation monitoring 2

Fluid Management

• If IV fluids are needed, administer at 80% basal levels and monitor serum electrolytes to prevent hyponatremia 2
• Nasogastric tubes should be avoided in severely ill children, especially infants with small nasal passages, as they may compromise breathing 2

Interventions to Avoid

• Chest physiotherapy is not beneficial and should not be performed in children with pneumonia 2
• Antipyretics and analgesics can be used for comfort and to help with coughing 2
• Minimal handling may reduce metabolic and oxygen requirements in ill children 2

Common Pitfalls

• Underdosing amoxicillin (using 40-45 mg/kg/day instead of 90 mg/kg/day) fails to overcome pneumococcal resistance 1
• Inappropriate use of macrolides as first-line therapy for presumed bacterial pneumonia, particularly in children under 5 years where atypical pathogens are uncommon 1
• Failure to consider MRSA in children with severe pneumonia, necrotizing infiltrates, empyema, or recent influenza infection 1
• Ignoring local antibiotic resistance patterns when selecting empiric therapy 3
• Not reassessing children who fail to improve within 48-72 hours for complications or alternative diagnoses 2, 1