How should I manage a healthy 5-year-old with community-acquired pneumonia, including severity assessment and appropriate antibiotic regimen?

Management of Community-Acquired Pneumonia in a 5-Year-Old

For a healthy 5-year-old with community-acquired pneumonia, start oral amoxicillin 80-100 mg/kg/day divided into three doses daily for 10 days, and reassess at 48-72 hours for clinical improvement. 1, 2

Severity Assessment and Site-of-Care Decision

Perform pulse oximetry immediately on all children with suspected pneumonia. 3 Hospitalize if any of the following are present:

• Oxygen saturation ≤92% on room air 3, 1, 4
• Respiratory rate >50 breaths/min 1, 4
• Signs of respiratory distress: grunting, intercostal retractions, nasal flaring, cyanosis 3, 1
• Inability to maintain oral intake or signs of dehydration 1, 4
• Altered mental status 3, 2
• Apnea or severe respiratory distress 3, 2

If the child meets none of these criteria and can tolerate oral medications, outpatient management is appropriate. 1

Diagnostic Testing

Chest radiography is NOT routinely required for outpatient management of uncomplicated pneumonia. 3 Order chest X-rays only if:

• Hypoxemia is present (oxygen saturation <92%) 3
• Significant respiratory distress exists 3
• The child fails initial antibiotic therapy after 48-72 hours 3

Acute-phase reactants (CRP, ESR, procalcitonin) are not needed for outpatient management and cannot reliably distinguish bacterial from viral pneumonia. 3

First-Line Antibiotic Therapy

Outpatient Treatment

Amoxicillin 80-100 mg/kg/day divided into three doses (maximum 3 g/day) for 10 days is the first-line treatment. 1, 2 For a typical 20 kg 5-year-old, this translates to approximately 530-670 mg per dose given three times daily. 2

Critical dosing point: Three-times-daily dosing is mandatory—twice-daily dosing fails to maintain adequate drug concentrations against Streptococcus pneumoniae. 2

Alternative Regimens

Use amoxicillin-clavulanate (same amoxicillin dosing: 80-100 mg/kg/day divided TID) if any of these risk factors are present: 1, 2

• Incomplete immunization against H. influenzae type b or S. pneumoniae
• Concurrent purulent acute otitis media
• Antibiotic use within the past 3 months
• Treatment failure after 48-72 hours of amoxicillin

For β-lactam allergy, use azithromycin 10 mg/kg on day 1, then 5 mg/kg daily on days 2-5. 1, 2

Consideration of Atypical Pathogens

At age 5, atypical organisms (Mycoplasma pneumoniae, Chlamydophila pneumoniae) become more prevalent. 1, 2 However, if the child presents with purulent green sputum and typical bacterial pneumonia features, start with amoxicillin rather than a macrolide. 2 Reserve macrolides for treatment failure or when atypical features predominate (dry cough, gradual onset, lack of toxicity). 1

Inpatient Treatment

For hospitalized children without severe disease and able to tolerate oral medications, continue oral amoxicillin at the same dosing. 1

For severe pneumonia or inability to absorb oral medications, use intravenous antibiotics: 1, 2

• Ampicillin 150-400 mg/kg/day IV divided every 6 hours, OR
• Ceftriaxone 50-100 mg/kg/day IV divided every 12-24 hours

Add azithromycin if atypical pathogens are suspected in hospitalized patients. 1

Supportive Care

• Maintain oxygen saturation >92% using supplemental oxygen (nasal cannula, face mask, or head box) 1, 4
• Antipyretics: Paracetamol (acetaminophen) 15 mg/kg per dose every 4-6 hours as needed (maximum 75 mg/kg/day) 2
• Never give aspirin to children under 16 years due to Reye syndrome risk 2
• Avoid chest physiotherapy—it provides no benefit in pediatric pneumonia 1, 4, 2
• If IV fluids are needed, administer at approximately 80% of maintenance volume with electrolyte monitoring 4, 2

Reassessment Protocol

Mandatory reassessment at 48-72 hours is required for all children. 1, 2 Expected clinical course:

• Fever should resolve within 24-48 hours of starting effective antibiotics 2
• Overall clinical improvement (reduced respiratory distress, better feeding) should be evident within 48-72 hours 2
• Cough may persist beyond fever resolution but should gradually diminish 2

Immediate Re-evaluation Triggers

Re-evaluate immediately if any of the following occur: 4, 2

• Persistent or worsening fever beyond 48-72 hours
• Deterioration of respiratory symptoms or increased work of breathing
• Oxygen saturation drops to ≤92%
• Inability to maintain oral intake or new signs of dehydration
• Altered mental status

Management of Treatment Failure

If no improvement after 48-72 hours of appropriate amoxicillin therapy: 1, 2

1. Add or switch to azithromycin (10 mg/kg day 1, then 5 mg/kg daily days 2-5) to cover atypical bacteria 1, 2
2. Obtain chest radiography to exclude complications such as parapneumonic effusion, empyema, or necrotizing pneumonia 3, 2
3. Consider broader-spectrum antibiotics such as amoxicillin-clavulanate, ceftriaxone, or cefuroxime 1
4. Consider hospitalization if outpatient therapy fails after 5 days or if the general condition worsens 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics for mild lower respiratory symptoms without clear evidence of bacterial pneumonia—most cases in young children are viral 2
• Do not use twice-daily amoxicillin dosing—three-times-daily is required for adequate coverage 2
• Do not use first-generation cephalosporins (e.g., cephalexin)—they have inadequate activity against respiratory pathogens 2
• Do not order routine chest X-rays for uncomplicated outpatient pneumonia 3
• Do not perform chest physiotherapy—it is ineffective and not recommended 1, 4, 2
• Do not routinely measure acute-phase reactants (CRP, ESR) in outpatient management 3

Follow-Up Imaging

Routine follow-up chest radiographs are NOT required in children who recover uneventfully. 3 Obtain repeat imaging only if: 3

• The child fails to demonstrate clinical improvement within 48-72 hours
• Progressive symptoms or clinical deterioration occurs
• Complications are suspected (effusion, empyema, necrotizing pneumonia)