What is the treatment for a 6-year-old boy with community-acquired pneumonia (pna) who is allergic to amoxicillin?

Treatment for a 6-Year-Old Boy with Pneumonia and Amoxicillin Allergy

For a 6-year-old boy with community-acquired pneumonia who is allergic to amoxicillin, azithromycin is the recommended first-line treatment at a dose of 10 mg/kg on day 1 (maximum 500 mg), followed by 5 mg/kg/day once daily on days 2-5 (maximum 250 mg/day). 1

Treatment Algorithm Based on Allergy Type

For Non-Serious (Type 4) Penicillin Allergy

• Oral cephalosporins with strong pneumococcal activity are preferred alternatives, including cefpodoxime, cefprozil, or cefuroxime, provided under medical supervision 2
• These should be given under observation for the first dose to monitor for cross-reactivity 2
• Cephalosporins are particularly appropriate when typical bacterial pneumonia (especially Streptococcus pneumoniae) is strongly suspected 3

For Serious (Type 1) Hypersensitivity to Penicillin

• Azithromycin is the drug of choice at the dosing described above 1, 4
• This provides excellent coverage for both typical bacterial pathogens (S. pneumoniae) and atypical organisms (Mycoplasma pneumoniae, Chlamydophila pneumoniae), which are increasingly common in children ≥5 years 1
• Alternative options include clarithromycin or erythromycin if azithromycin is not tolerated 2
• Levofloxacin should be reserved only for severe penicillin allergy when other options are unsuitable, as fluoroquinolones are not first-line in children 5

Outpatient vs. Inpatient Decision

Outpatient Management (Mild-Moderate Pneumonia)

• Azithromycin oral suspension is appropriate for outpatient treatment 1, 4
• The 5-day course provides adequate coverage and has demonstrated clinical success rates of 88-98% in pediatric pneumonia trials 4

Hospitalization Criteria

• Hospitalize if the child has: oxygen saturation ≤92% on room air, respiratory rate >50 breaths/min, difficulty breathing or grunting, signs of dehydration, or inability of family to provide appropriate observation 1

Inpatient Treatment (If Hospitalization Required)

• For penicillin-allergic patients requiring hospitalization, use intravenous azithromycin 10 mg/kg on days 1 and 2, then transition to oral therapy 1
• Add vancomycin or clindamycin if community-associated MRSA is suspected based on local epidemiology, severe illness, or presence of empyema 2, 6

Critical Pitfalls to Avoid

Do Not Rely on Macrolides Alone for Severe Pneumococcal Disease

• Exercise particular caution with macrolide monotherapy in bacteremic pneumococcal pneumonia due to potential for secondary sites of infection, including meningitis 2
• If severe pneumococcal infection is suspected and the allergy is non-serious, strongly consider cephalosporins over macrolides 2

Assess Clinical Response Within 48-72 Hours

• Reassess the patient within 48-72 hours of starting therapy 1, 6
• Treatment failure may indicate resistant organisms, inadequate dosing, poor compliance, complications (such as empyema), or alternative diagnosis 1

Duration of Therapy

• Complete the full 5-day course of azithromycin as prescribed 1, 4
• For severe cases or complications, duration may need to be extended to 7-10 days 6

Additional Considerations

• If influenza is suspected based on seasonal patterns or clinical presentation, add oseltamivir regardless of antibacterial choice 2
• The safety profile of azithromycin in pediatric pneumonia trials shows treatment-related adverse events (primarily gastrointestinal) in 10-17% of patients, with diarrhea being most common at 3-6% 4