What is the recommended treatment for a pediatric patient with community-acquired pneumonia (CAP)?

Treatment for Pediatric Community-Acquired Pneumonia

Amoxicillin 90 mg/kg/day divided into 2 doses is the first-line treatment for previously healthy, appropriately immunized children with mild to moderate bacterial community-acquired pneumonia, regardless of age. 1, 2

Outpatient Treatment Algorithm

Preschool Children (<5 years old)

• Most preschool-aged children with CAP do not require antibiotics, as viral pathogens cause the majority of clinical disease 1

• When bacterial CAP is suspected (high fever >38.5°C, focal consolidation on chest X-ray, elevated inflammatory markers), prescribe oral amoxicillin 90 mg/kg/day divided into 2 doses for fully immunized children 1, 2

• For children with incomplete immunization against Haemophilus influenzae type b or Streptococcus pneumoniae, use amoxicillin-clavulanate 90 mg/kg/day of the amoxicillin component divided into 2 doses 2, 3

• Treatment duration is 5-10 days, with reassessment at 48-72 hours 2, 3

School-Aged Children and Adolescents (≥5 years old)

• Start with oral amoxicillin 90 mg/kg/day (maximum 4 g/day) divided into 2 doses for presumed bacterial pneumonia 1, 2

• If atypical pneumonia is suspected (Mycoplasma pneumoniae, Chlamydophila pneumoniae)—characterized by gradual onset, prominent cough, minimal fever, normal WBC—prescribe azithromycin 10 mg/kg on day 1 (maximum 500 mg), followed by 5 mg/kg/day (maximum 250 mg) on days 2-5 1, 2, 4

• If no improvement after 48 hours on amoxicillin and clinical condition remains stable, add a macrolide to cover atypical pathogens 1, 3

• For children >7 years with atypical pneumonia, doxycycline 2-4 mg/kg/day divided into 2 doses is an alternative to azithromycin 2

Penicillin Allergy Considerations

• For non-anaphylactic penicillin allergy, use second- or third-generation cephalosporins (cefpodoxime, cefprozil, or cefuroxime) under medical supervision 2

• For serious Type I hypersensitivity, use azithromycin or clarithromycin 1, 2

Inpatient Treatment Algorithm

Fully Immunized Children with Mild-Moderate Severity

• 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 when local epidemiology documents minimal high-level penicillin resistance in invasive S. pneumoniae 1

• Alternative: Ceftriaxone 50-100 mg/kg/day IV every 12-24 hours OR cefotaxime 150 mg/kg/day IV every 8 hours 1, 5

Children Requiring Broader Coverage

• Ceftriaxone or cefotaxime should be used for:

  • Incompletely immunized children 1, 5
  • Regions with high-level penicillin resistance 1, 5
  • Life-threatening infection including empyema 1, 5

• Add a macrolide (azithromycin or clarithromycin) to β-lactam therapy when M. pneumoniae or C. pneumoniae are significant considerations, particularly in school-aged children 1

Suspected Staphylococcal Pneumonia

• Add vancomycin 40-60 mg/kg/day IV every 6-8 hours OR clindamycin 40 mg/kg/day IV every 6-8 hours (based on local susceptibility) when clinical features suggest Staphylococcus aureus: 1

  • Severe necrotizing pneumonia with rapid progression
  • Pneumatoceles or empyema on imaging
  • Recent influenza infection
  • Failure to improve on standard β-lactam therapy within 48-72 hours

• Do NOT use oxacillin empirically—it lacks coverage for S. pneumoniae and H. influenzae, the most common pediatric pneumonia pathogens 5

• Switch to oxacillin 150-200 mg/kg/day IV every 6-8 hours only after methicillin-susceptible S. aureus (MSSA) is confirmed 5

Influenza Considerations

• Administer influenza antiviral therapy (oseltamivir or zanamivir) as soon as possible for children with moderate to severe CAP consistent with influenza during local circulation, particularly those with clinically worsening disease 1

• Do not delay treatment for test confirmation—negative rapid antigen tests do not exclude influenza 1

• Treatment after 48 hours of symptoms may still benefit those with severe disease 1

Critical Monitoring Parameters

• Children on appropriate therapy must demonstrate clinical improvement within 48-72 hours 2, 5, 6

• If no improvement or deterioration occurs within 48-72 hours: 5

  • Obtain blood cultures and pleural fluid cultures if effusion present
  • Consider imaging for complications (empyema, pneumatoceles)
  • Broaden coverage to include MRSA and atypical pathogens
  • Reassess for non-infectious causes or resistant organisms

• Fever typically resolves within 24-48 hours for pneumococcal pneumonia, though cough may persist longer 6

Common Pitfalls to Avoid

• Do not underdose amoxicillin—using standard doses (40-45 mg/kg/day) rather than high-dose (90 mg/kg/day) may lead to treatment failure with resistant pneumococci 2, 6

• Do not use macrolides as first-line monotherapy for presumed bacterial pneumonia—they should be reserved for atypical pneumonia or as add-on therapy 2, 5

• Do not routinely combine oxacillin with ceftriaxone for empiric therapy—this is overly broad and not guideline-recommended 5

• Do not continue broad-spectrum therapy once a specific pathogen is identified—narrow to targeted therapy based on culture results 5

• Do not forget to add macrolide coverage if atypical pneumonia cannot be excluded, especially in children ≥5 years old 5, 6