Treatment of Lower Left Lobe Pneumonia in a 5-Year-Old Child
Oral amoxicillin 90 mg/kg/day divided into 2 doses for 5 days is the recommended first-line treatment for a 5-year-old with lower left lobe pneumonia who can be managed as an outpatient. 1, 2
Initial Assessment and Site of Care Decision
Determine if hospitalization is needed by assessing the following criteria 1, 2:
- Oxygen saturation ≤92% on room air
- Respiratory rate >50 breaths/min
- Difficulty breathing or grunting
- Signs of dehydration
- Family unable to provide appropriate observation
If none of these criteria are present and the child appears well enough for outpatient management, proceed with oral antibiotic therapy. 1
Outpatient Antibiotic Treatment
First-line therapy: Oral amoxicillin 90 mg/kg/day divided into 2 doses (maximum 4 g/day) for 5 days. 1, 2 This dosing provides optimal coverage against Streptococcus pneumoniae, the most common bacterial pathogen in this age group. 1
Alternative oral options if amoxicillin cannot be used 1, 2:
- Amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses)
- Second- or third-generation cephalosporins (cefpodoxime, cefuroxime, cefprozil)
Consider adding a macrolide (azithromycin 10 mg/kg on day 1, then 5 mg/kg/day on days 2-5) if 1, 2:
- The child is ≥5 years old AND
- Atypical pathogens (Mycoplasma pneumoniae, Chlamydia pneumoniae) are suspected based on clinical presentation
- However, for typical bacterial pneumonia with lobar consolidation, amoxicillin alone is appropriate 1, 3
Treatment Duration
A 5-day course is recommended and has been shown to be as effective as 10-day courses for uncomplicated community-acquired pneumonia in children. 2, 4, 5 The evidence demonstrates no difference in clinical cure rates between 5-day and 10-day regimens (RR 1.01; 95% CI 0.98-1.05). 4
Inpatient Treatment (If Hospitalization Required)
For hospitalized children, initiate intravenous therapy 1, 2:
- Preferred: Ampicillin (150-200 mg/kg/day divided every 6 hours) OR penicillin G (200,000-250,000 U/kg/day every 4-6 hours) if the child is fully immunized and local penicillin resistance is minimal 1
- Alternative: Ceftriaxone (50-100 mg/kg/day every 12-24 hours) OR cefotaxime (150 mg/kg/day every 8 hours) if not fully immunized or if local penicillin resistance is significant 1
Add vancomycin (40-60 mg/kg/day every 6-8 hours) OR clindamycin (40 mg/kg/day every 6-8 hours) if community-associated MRSA is suspected based on 1, 2:
- Severe illness with empyema
- Local epidemiology suggesting high MRSA prevalence
- Recent hospitalization or antibiotic exposure
Supportive Care
Provide supplemental oxygen if oxygen saturation ≤92% to maintain saturation >92% using nasal cannulae, head box, or face mask. 1, 2
Ensure adequate hydration and monitor for signs of dehydration. 1, 2
Antipyretics and analgesics can be used to keep the child comfortable. 1, 2
Chest physiotherapy is NOT recommended as it provides no benefit in pneumonia. 1, 2
Monitoring and Follow-Up
Reassess within 48-72 hours of starting treatment to evaluate clinical response. 2, 6, 3 The child should show improvement in fever, respiratory rate, and work of breathing.
If no improvement or deterioration occurs at 48-72 hours 1, 2:
- Consider treatment failure
- Evaluate for complications (parapneumonic effusion, empyema)
- Consider resistant organisms or alternative diagnoses
- Obtain chest radiograph if not already done or if clinical deterioration
Families should be instructed to return immediately if 1, 2:
- Increased work of breathing
- Inability to maintain oral intake
- Worsening fever after initial improvement
- Lethargy or altered mental status
Common Pitfalls to Avoid
Do not use broad-spectrum antibiotics unnecessarily. Amoxicillin remains highly effective for typical bacterial pneumonia, and overuse of broader agents contributes to antimicrobial resistance. 2, 7
Do not prescribe 10-day courses routinely. Evidence supports 5-day treatment for uncomplicated pneumonia, and longer courses do not improve outcomes. 2, 4, 5
Do not miss indications for hospitalization. Oxygen saturation ≤92% is an absolute indication for admission and supplemental oxygen therapy. 1, 2
Do not add macrolides empirically in young children with typical lobar pneumonia. At age 5, bacterial pathogens (particularly S. pneumoniae) remain the primary concern, and amoxicillin monotherapy is appropriate unless atypical features are present. 1, 3