What is the initial treatment for community-acquired pneumonia (CAP) in pediatric patients?

Community-Acquired Pneumonia in Pediatric Patients: Treatment Algorithm

First-Line Treatment by Age and Setting

For previously healthy, appropriately immunized children with mild to moderate community-acquired pneumonia, amoxicillin at 90 mg/kg/day divided into 2 doses is the definitive first-line therapy across all age groups. 1, 2

Outpatient Management

Preschool Children (Under 5 Years)

• Antimicrobial therapy is NOT routinely required for preschool-aged children with CAP, as viral pathogens cause the vast majority of disease 1
• When bacterial pneumonia is suspected, amoxicillin 90 mg/kg/day divided into 2 doses is first-line therapy, providing optimal coverage against Streptococcus pneumoniae, the most important invasive bacterial pathogen 1, 2
• Treatment duration: 5-7 days 3
• Maximum daily dose: 4 g/day 3

School-Aged Children and Adolescents (5 Years and Older)

• Amoxicillin 90 mg/kg/day divided into 2 doses remains first-line for typical bacterial pneumonia 1, 2
• Add macrolide antibiotics (azithromycin or clarithromycin) when atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae) are suspected based on clinical presentation 1, 4
• Azithromycin dosing: 10 mg/kg on day 1 (maximum 500 mg), then 5 mg/kg once daily on days 2-5 (maximum 250 mg daily) 4, 5
• Do NOT use macrolides as monotherapy in children under 5 years due to inadequate S. pneumoniae coverage 3

Inpatient Management

Fully Immunized Children in Low-Resistance Areas

• 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 for children admitted to hospital wards when local epidemiology shows minimal high-level penicillin resistance 1, 2, 3

Incompletely Immunized Children or High-Resistance Areas

• Ceftriaxone 50-100 mg/kg/day IV every 12-24 hours OR cefotaxime 150 mg/kg/day IV every 8 hours for hospitalized children who are not fully immunized or in regions with high-level penicillin resistance 1, 2, 3
• These third-generation cephalosporins are also indicated for life-threatening infections including empyema 1

Suspected Atypical Pathogens in Hospitalized Children

• Add macrolide therapy (oral or parenteral) to β-lactam antibiotics when M. pneumoniae or C. pneumoniae are significant considerations 1
• Azithromycin IV: 10 mg/kg on days 1 and 2 3

Suspected Community-Acquired MRSA

• 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, laboratory, or imaging characteristics suggest Staphylococcus aureus infection 1, 3

Penicillin Allergy Alternatives

Non-Anaphylactic (Type IV) Reactions

• Oral cephalosporins: cefpodoxime, cefuroxime, or cefprozil under medical supervision 3

Type I Hypersensitivity (Anaphylaxis)

• Macrolides: azithromycin or clarithromycin 3, 6
• Clindamycin 3
• Alternative options: levofloxacin or linezolid (reserve for severe cases) 3

Influenza Considerations

Administer influenza antiviral therapy immediately to 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 tests do not exclude influenza 1
• Treatment after 48 hours may still benefit those with severe disease 1

Transition to Oral Therapy

Switch from IV to oral antibiotics when:

• Child is afebrile for 24 hours 3
• Improved respiratory rate and work of breathing 3
• Tolerating oral intake without vomiting 3
• Typically occurs within 48-72 hours of admission 3

Clinical Monitoring and Treatment Failure

Re-evaluate if no improvement or deterioration within 48-72 hours: 1, 3, 4

• Assess for inadequate antibiotic dosing or inappropriate drug selection 3
• Investigate complications (parapneumonic effusion, empyema) 3, 4
• Consider resistant organisms 3, 4
• Reassess diagnosis 4
• Obtain blood cultures if not already done 3

Critical Pitfalls to Avoid

1. Do NOT routinely prescribe antibiotics for preschool-aged children without clear evidence of bacterial infection—most cases are viral 1
2. Do NOT use macrolides as monotherapy in children under 5 years—inadequate pneumococcal coverage 3
3. Do NOT delay influenza antivirals waiting for test confirmation during flu season 1
4. Do NOT use vancomycin empirically for routine pneumococcal pneumonia—third-generation cephalosporins are equally effective for current North American resistance patterns 1
5. Avoid fluoroquinolones in growing children unless absolutely necessary due to cartilage development concerns 4
6. Avoid doxycycline in children under 7 years due to tooth discoloration risk 4

Evidence Quality Note

These recommendations are based on strong evidence from the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America guidelines 1, which remain the definitive clinical practice guidelines for pediatric CAP management. The American Academy of Pediatrics endorses these recommendations 2, 3. Recent research continues to support amoxicillin as first-line therapy with excellent outcomes and low treatment failure rates (1-1.5%) 7, 8, 6, 9.