First-Line Outpatient Treatment for a 7-Year-Old with Uncomplicated Community-Acquired Pneumonia
Amoxicillin 90 mg/kg/day divided into two doses (maximum 4 g/day) is the definitive first-line treatment for a previously healthy 7-year-old child with uncomplicated community-acquired pneumonia. 1, 2, 3
Dosing Specifics
For a typical 7-year-old (approximately 20-25 kg): prescribe 900-1125 mg twice daily, which translates to amoxicillin 90 mg/kg/day in two divided doses. 1, 2
The high-dose regimen (90 mg/kg/day) is critical to overcome pneumococcal resistance and should never be underdosed to 40-45 mg/kg/day, which is a common and dangerous error. 2, 4
Treatment duration should be 5-7 days for uncomplicated cases, as recent high-quality evidence demonstrates that 5-day courses are equally effective as 10-day courses with fewer adverse effects and reduced antibiotic resistance. 5, 6
When to Add Azithromycin
Add azithromycin to amoxicillin if clinical features suggest atypical pathogens (Mycoplasma pneumoniae or Chlamydophila pneumoniae), which become increasingly common in school-aged children ≥5 years. 1, 2, 3
Atypical pneumonia features include: gradual onset, prominent cough with minimal fever, absence of toxic appearance, and interstitial infiltrates on chest radiography rather than lobar consolidation. 1, 2
Azithromycin dosing: 10 mg/kg on day 1 (maximum 500 mg), followed by 5 mg/kg once daily on days 2-5 (maximum 250 mg/day). 1, 7
For a 20-25 kg child: this translates to 200-250 mg on day 1, then 100-125 mg daily on days 2-5. 7
Critical Pitfalls to Avoid
Do not use macrolides (azithromycin, clarithromycin) as monotherapy for presumed bacterial pneumonia in this age group, as Streptococcus pneumoniae remains the most common bacterial pathogen and macrolide resistance is increasing. 2, 3
Do not underdose amoxicillin at 40-45 mg/kg/day instead of the recommended 90 mg/kg/day—this is the most common prescribing error and leads to treatment failure. 2, 4
Avoid cefixime or other second/third-generation oral cephalosporins as first-line therapy, as they are explicitly not recommended for pediatric pneumonia and provide inferior coverage compared to high-dose amoxicillin. 2
Reassessment Timeline
Children should demonstrate clinical improvement within 48-72 hours of starting appropriate antibiotic therapy. 1, 2, 4
Signs of improvement include: decreased fever, improved respiratory rate, reduced work of breathing, and improved oral intake. 1, 8
If no improvement occurs within 48-72 hours, consider treatment failure due to resistant organisms, complications (parapneumonic effusion, empyema), incorrect diagnosis, or inadequate dosing. 1, 2, 4
Further investigation should include: chest radiography if not previously obtained, blood cultures, and consideration of hospitalization for parenteral antibiotics. 1, 2
Alternative for Penicillin Allergy
For non-severe penicillin allergy (rash without anaphylaxis), consider oral cephalosporins such as cefpodoxime or cefprozil under medical supervision, as cross-reactivity risk is low (1-3%). 2, 4
For severe penicillin allergy (anaphylaxis), use azithromycin 10 mg/kg on day 1 (maximum 500 mg), then 5 mg/kg daily on days 2-5 (maximum 250 mg/day) as monotherapy, or levofloxacin 8-10 mg/kg once daily (maximum 750 mg/day) for children who have reached growth maturity. 2, 7
Practical Prescribing Example
For a 7-year-old weighing 23 kg with typical bacterial pneumonia:
Amoxicillin 1035 mg (approximately 1000 mg for practical dosing) twice daily for 5-7 days. 2, 4
Counsel parents that clinical improvement should occur within 48-72 hours, with return visit or call if fever persists beyond 72 hours or respiratory symptoms worsen. 1, 8
Amoxicillin causes significantly less diarrhea than amoxicillin-clavulanate or macrolides, making it better tolerated. 2