What are the current recommendations for treating pneumonia in children?

Current Recommendations for Pneumonia in Children

High-dose oral amoxicillin at 90 mg/kg/day divided into 2 doses is the definitive first-line treatment for outpatient management of community-acquired pneumonia in children over 3 months of age, with a treatment duration of 5-7 days. 1, 2, 3

Outpatient Management Algorithm

Children Under 5 Years

• Amoxicillin 90 mg/kg/day divided into 2 doses (maximum 4 g/day) is the first-line therapy for presumed bacterial pneumonia 1, 2, 3
• The high-dose regimen (90 mg/kg/day) is essential to overcome pneumococcal resistance; underdosing with 40-45 mg/kg/day is a common and dangerous error 2, 3
• Do not use macrolides as first-line therapy in this age group due to inadequate coverage of Streptococcus pneumoniae and low prevalence of atypical pathogens 2, 3
• For suspected Staphylococcus aureus involvement, use amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) 2
• If MRSA is suspected, add clindamycin 30-40 mg/kg/day in 3-4 doses to beta-lactam therapy 2

Children 5 Years and Older

• Amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) remains first-line for presumed bacterial pneumonia 1, 2, 3
• Consider adding azithromycin (10 mg/kg on day 1, then 5 mg/kg/day on days 2-5; maximum 500 mg day 1, then 250 mg days 2-5) if atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae) are suspected based on clinical presentation 2, 3, 4
• Atypical pneumonia is more prevalent in this age group, making macrolide consideration more appropriate than in younger children 1, 2

Inpatient Management Algorithm

Fully Immunized, Low-Risk Children

• Ampicillin 150-200 mg/kg/day IV every 6 hours or penicillin G 200,000-250,000 U/kg/day IV every 4-6 hours in regions with minimal penicillin resistance 1, 2
• Alternative: Ceftriaxone 50-100 mg/kg/day IV every 12-24 hours or cefotaxime 150 mg/kg/day IV every 8 hours 1, 2

Not Fully Immunized or High-Risk Children

• Ceftriaxone 50-100 mg/kg/day IV or cefotaxime 150 mg/kg/day IV every 8 hours to address potential resistant organisms and beta-lactamase-producing Haemophilus influenzae 1, 2
• 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-acquired MRSA is suspected based on severe presentation, necrotizing infiltrates, empyema, or recent influenza infection 1, 2

Suspected Atypical Pneumonia (Hospitalized)

• Add azithromycin 10 mg/kg IV on days 1 and 2, then transition to oral therapy, in addition to beta-lactam therapy 1, 2, 4
• Alternative: Erythromycin lactobionate 20 mg/kg/day IV every 6 hours 2

Supportive Care Measures

• Oxygen therapy to maintain saturation >92% via nasal cannulae, head box, or face mask 1, 5
• Intravenous fluids at 80% basal levels if needed, with serum electrolyte monitoring 1
• Antipyretics and analgesics for comfort and to help with coughing 1, 5
• Avoid chest physiotherapy as it is not beneficial and should not be performed 1
• Minimal handling in severely ill children to reduce metabolic and oxygen requirements 1, 5
• Nasogastric tubes should be avoided in severely ill children, especially infants with small nasal passages 1

Treatment Duration

• 5-7 days for uncomplicated pneumonia 3, 5
• 2-4 weeks for pneumonia with parapneumonic effusion, depending on drainage adequacy and clinical response 1, 3

Reassessment and Treatment Failure

When to Reassess

• Re-evaluate if no improvement or worsening after 48-72 hours of appropriate antibiotic therapy 1, 3, 5
• Children cared for at home should be reviewed if deteriorating or not improving after 48 hours 1

Management of Non-Responders

• Clinical and laboratory assessment to determine severity and need for higher levels of care 1
• Imaging evaluation (chest radiograph or ultrasound) to assess extent and progression of pneumonic or parapneumonic process 1
• Further investigation to identify persistent pathogen, resistance development, or new secondary infection 1
• Obtain blood cultures and consider pleural fluid sampling if effusion is present 2, 5
• Consider complications: parapneumonic effusion, empyema, pulmonary abscess, necrotizing pneumonia 1
• Verify adequate dosing and appropriate drug selection 5

Management of Parapneumonic Effusions

Small Effusions (<10mm rim or <10% thorax opacified)

• Treat with antibiotics alone; do not attempt pleural drainage unless high respiratory compromise 1, 3
• Reassess effusion size during treatment 1

Moderate to Large Effusions (≥10mm rim or ≥10% thorax opacified)

• Obtain chest ultrasound and pleural fluid for culture by thoracentesis or chest tube placement 1, 3
• Drainage options: chest tube alone, chest tube with fibrinolytics, or video-assisted thoracoscopic surgery (VATS) 1
• Preferred approach: chest tube with fibrinolytics; if not responding (approximately 15% of patients), proceed to VATS 1

Discharge Criteria

Patients are eligible for discharge when ALL of the following are met:

• Documented overall clinical improvement including level of activity, appetite, and decreased fever for at least 12-24 hours 1, 3
• Pulse oximetry measurements >90% in room air for at least 12-24 hours 1, 3
• Stable and/or baseline mental status 1
• Tolerating oral intake without vomiting 5

Penicillin Allergy Considerations

Non-Severe Allergic Reactions

• Oral cephalosporins (cefpodoxime, cefuroxime, or cefprozil) can be used under medical supervision 2, 5

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, 2
• Linezolid 30 mg/kg/day in 3 doses (children <12 years) or 20 mg/kg/day in 2 doses (children ≥12 years) 1, 2
• Macrolides (azithromycin or clarithromycin) for atypical coverage 2, 5

Common Pitfalls to Avoid

• Underdosing amoxicillin: Using 40-45 mg/kg/day instead of the recommended 90 mg/kg/day leads to treatment failure with resistant pneumococci 2, 3
• Inappropriate macrolide use: Using macrolides as first-line therapy for presumed bacterial pneumonia in children under 5 years provides inadequate S. pneumoniae coverage 2, 3
• Failure to consider MRSA: Not recognizing risk factors (severe pneumonia, necrotizing infiltrates, empyema, recent influenza, known MRSA colonization) leads to inadequate coverage 2
• Routine use of broad-spectrum antibiotics: Ceftriaxone or amoxicillin-clavulanate should not be used routinely when narrow-spectrum therapy is appropriate 6, 7
• Obtaining unnecessary chest radiographs: Routine chest X-rays are not needed for outpatients well enough to be treated at home 5
• Using acute-phase reactants alone: ESR, CRP, and procalcitonin cannot distinguish viral from bacterial pneumonia as the sole determinant 5

Switching from IV to Oral Therapy

• Switch to oral antibiotics when clear clinical improvement is demonstrated, typically within 48-72 hours 1, 5
• Criteria for switching: afebrile for 24 hours, improved respiratory rate and work of breathing, tolerating oral intake without vomiting 5
• Oral antibiotics are as effective as IV antibiotics for children presenting with CAP who can absorb oral medications 1