Treatment for Pediatric Community-Acquired Pneumonia
Amoxicillin 90 mg/kg/day divided into two doses for 5-7 days is the definitive first-line therapy for fully immunized children with community-acquired pneumonia managed as outpatients. 1, 2, 3
Initial Assessment and Site-of-Care Decision
Pulse oximetry must be performed in every child with suspected pneumonia to identify hypoxemia and guide whether the child can be managed at home or requires hospitalization. 4, 2, 3
Outpatient Management Criteria
A child can be safely managed as an outpatient if ALL of the following are met: 3
- Oxygen saturation >90% on room air
- Well-appearing with no moderate-to-severe respiratory distress (no significant retractions, grunting, nasal flaring)
- Able to maintain oral hydration
- Reliable caregivers available for monitoring
- Age ≥3-6 months
Hospitalization Criteria
Hospitalization is required if ANY of the following are present: 2
- Oxygen saturation <90% on room air
- Moderate to severe respiratory distress (increased work of breathing, grunting, nasal flaring)
- Inability to maintain oral hydration
- Failed outpatient antibiotic therapy after 48-72 hours
- Complicated pneumonia (pleural effusion, empyema, necrotizing pneumonia)
- Suspected CA-MRSA infection 4
- Concern about careful observation at home or inability to comply with therapy 4
Antibiotic Selection by Clinical Setting
Outpatient Therapy (First-Line)
For fully immunized children (completed Hib and pneumococcal vaccines): 1, 2, 3, 5
- Amoxicillin 90 mg/kg/day divided into 2 doses (maximum 4g/day) for 5-7 days
- The twice-daily dosing improves compliance compared to three times daily, though both are acceptable 5
For children NOT fully immunized or with incomplete Hib/pneumococcal coverage: 5
- Amoxicillin-clavulanate OR
- Second- or third-generation cephalosporins (cefuroxime, cefdinir, cefpodoxime)
Alternative Outpatient Therapy (Penicillin Allergy)
If true penicillin allergy exists: 2
- Clindamycin OR
- Azithromycin (macrolide)
Special Consideration for Atypical Pathogens
For children ≥5 years with gradual onset, prominent cough, and minimal fever (suspicious for Mycoplasma pneumoniae): 2
- Consider adding a macrolide (azithromycin) to amoxicillin if symptoms persist after 48 hours and clinical condition remains stable 5
- Azithromycin dosing: 10 mg/kg on Day 1, then 5 mg/kg on Days 2-5 6
Inpatient Therapy
For hospitalized, fully immunized children with uncomplicated CAP: 1, 2
- IV ampicillin OR
- IV penicillin G OR
- IV ceftriaxone/cefotaxime (if not fully immunized or high local pneumococcal resistance)
- Transition to oral amoxicillin when clinically stable (afebrile, improved respiratory effort, tolerating oral intake)
- Complete 5-7 days total therapy (IV + oral combined)
For suspected CA-MRSA (necrotizing pneumonia, empyema, severe illness): 2
- Add vancomycin OR clindamycin to beta-lactam coverage
Treatment Duration
For uncomplicated CAP: 5-7 days total therapy is equally effective as traditional 10-day courses and reduces antibiotic exposure and resistance selection. 1, 3, 5
For complicated pneumonia (parapneumonic effusion/empyema): 1, 3
- 2-4 weeks of total antibiotic therapy required
- Duration determined by adequacy of drainage and clinical response
Diagnostic Testing Approach
Chest Radiography
Routine chest X-rays are NOT necessary for well-appearing children managed as outpatients. 4, 2, 3 This reduces unnecessary radiation exposure.
Obtain chest radiographs (posteroanterior and lateral views) if: 4, 2
- Suspected or documented hypoxemia
- Significant respiratory distress
- Failed initial antibiotic therapy after 48-72 hours
- Hospitalization is required
- Need to identify complications (effusion, necrotizing pneumonia, pneumothorax)
Blood Cultures
Blood cultures should NOT be routinely obtained in nontoxic, fully immunized children managed as outpatients. 4, 2
Obtain blood cultures in: 4
- Children requiring hospitalization for moderate to severe CAP
- Children with complicated pneumonia
- Children who fail to improve or deteriorate after 48-72 hours of appropriate therapy
Laboratory Testing
Complete blood count and acute-phase reactants (CRP, ESR, procalcitonin) are NOT routinely necessary for outpatient management and cannot distinguish viral from bacterial CAP as the sole determinant. 4, 2
These tests may provide useful information in hospitalized children or those with more severe disease when interpreted alongside clinical findings. 4
Monitoring and Follow-Up
Children on adequate antibiotic therapy should demonstrate clinical improvement within 48-72 hours, including decreased fever, improved respiratory effort, and increased oral intake. 1, 2, 3
Reassessment is required at 48-72 hours if: 4, 2
- No clinical improvement occurs
- Progressive symptoms develop
- Clinical deterioration is observed
At reassessment, obtain repeat chest radiograph and consider: 4, 2
- Alternative pathogens (atypical bacteria, resistant organisms, CA-MRSA)
- Complications (effusion, empyema, necrotizing pneumonia)
- Non-infectious causes
Routine follow-up chest radiographs are NOT necessary in children who recover uneventfully. 4, 2, 3
Common Pitfalls to Avoid
Do not fail to reassess children who are not improving after 48-72 hours of therapy. 2 This is a critical time point for identifying treatment failure or complications.
Do not obtain unnecessary chest radiographs in children who are clinically improving. 2, 3 This exposes children to unnecessary radiation without changing management.
Do not use broad-spectrum antibiotics (ceftriaxone, azithromycin) as first-line therapy for uncomplicated CAP in fully immunized children. 1, 2, 3 This promotes antibiotic resistance without improving outcomes.
Do not extend antibiotic duration beyond 5-7 days for uncomplicated CAP. 1, 3 Longer courses increase antibiotic exposure and resistance without additional benefit.
Do not use acute-phase reactants or complete blood count as the sole basis for distinguishing viral from bacterial pneumonia. 4 These tests lack sufficient specificity and should not drive antibiotic decisions in isolation.