Pediatric Guidelines: Respiratory Infections - Community-Acquired Pneumonia

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Condition Major Pathogens First Choice Therapy Alternative Therapy Comments
Community-acquired pneumonia, 3 months-5 years old, outpatient therapy

Majority: respiratory viruses

Streptococcus pneumoniae

Haemophilus influenzae

Antimicrobial therapy is not routinely indicated unless suspected bacterial etiology

If suspected typical bacterial etiology:

Amoxicillin 45mg/kg/dose PO BID (max 1000mg/dose)*

Note: Atypical pneumonia is rare in this age group

Non-severe penicillin allergy:

Cefdinir 7mg/kg/dose PO BID (max 600mg/day)

 

Duration for beta lactam therapy (not Azithromycin):

7 days

*Click here for guidance on Amoxicillin maximum dosing and formulations

Severe penicillin allergy:

Azithromycin 10mg/kg/dose PO x 1 on day 1 then 5mg/kg/dose PO daily on days 2-5

Community-acquired pneumonia, > 5 years old, outpatient therapy

Typical, lobar:

Streptococcus pneumoniae

Atypical, bilateral interstitial infiltrates:

Respiratory viruses

Mycoplasma pneumoniae

If typical bacterial etiology suspected:

Amoxicillin 45mg/kg/dose PO BID (max 1000mg/dose)*

Non-severe penicillin allergy:

Replace Amoxicillin with Cefdinir 7mg/kg/dose PO BID (max 600mg/day)

Duration for beta lactam therapy (not Azithromycin):

7 days

Blood cultures are not usually indicated for outpatients with community-acquired pneumonia

*Click here for guidance on Amoxicillin maximum dosing and formulations

If atypical bacterial etiology suspected: 

Azithromycin 10mg/kg/dose PO on day 1 (max 500mg/dose) then 5mg/kg/dose PO daily on days 2-5 (max 250mg/dose)

Severe penicillin allergy:

Replace Amoxicillin with Azithromycin 10mg/kg/dose PO on day 1 (max 500mg/dose) then 5mg/kg/dose PO daily on days 2-5 (max 250mg/dose)

Community-acquired pneumonia, < 3 months old

Streptococcus pneumoniae

Haemophilus influenzae

Respiratory viruses

 

Also consider: 

Bordetella pertussis

Chlamydia trachomatis

Ceftriaxone 50mg/kg/dose IV q24h if corrected gestational age > 44 weeks

Corrected gestational age < 44 weeks:

Use Cefotaxime per Neonatal Dosing Guideline in place of Ceftriaxone

Initial inpatient therapy is recommended 

Blood culture is recommended

Consider evaluation and empiric therapy for Pertussis especially for infants with apnea, significant post-tussive emesis, lymphocytosis or older contacts with prolonged cough

Community-acquired pneumonia, > 3 months old and up, inpatient therapy but not complicated (empyema, necrotizing pneumonia) Similar to outpatient etiologies

Suspected typical bacterial etiology:

Ampicillin 50mg/kg/dose IV q6h (max 2g/dose)

Non-severe penicillin allergy:

Replace Ampicillin with Ceftriaxone 50mg/kg/dose IV q24h (max 2g/dose)

Duration for beta lactam therapy (not Azithromycin or Levofloxacin):

Mild: 7 days

Moderate: 10 days

Consider blood culture for patients with moderate to severe illness, young age, incomplete vaccines, or immunocompromised

Consider therapy for Influenza if patient admitted during active Influenza season. 

Strong suspicion for atypical etiology:

Azithromycin 10mg/kg/dose PO on day 1 (max 500mg/dose) then 5mg/kg/dose PO daily on days 2-5 (max 250mg/dose)

Note: Atypical pneumonia is rare in children < 5 years old

Severe beta lactam allergy:

Levofloxacin 10mg/kg/dose IV q24h if >= 5 years old, q12h if < 5 years old (max 750mg/day) (provides both typical and atypical bacterial activity)

OR 

Azithromycin 10mg/kg/dose PO on day 1 (max 500mg/dose) then 5mg/kg/dose PO daily on days 2-5 (max 250mg/dose) if strong suspicion for atypical etiology with low suspicion for typical bacterial etiology

If no distinguishing features for typical vs. atypical bacterial etiology and especially if > 5 years old:

Consider combination of Ampicillin + Azithromycin (doses as above)

Community-acquired pneumonia, complicated (empyema, necrotizing pneumonia)

Streptococcus pneumoniae

Staphylococcus aureus

Ceftriaxone 50mg/kg/dose IV q24h (max 2g/dose)

AND

One of the following agents with MRSA activity:

Clindamycin 10mg/kg/dose IV q8h (max 900mg/dose) for clinically stable patients

OR 

Vancomycin 15mg/kg/dose IV q6-8h (initial max 1g/dose) for critically ill/clinically unstable patients

Severe beta lactam allergy:

Replace Ceftriaxone with Levofloxacin 10mg/kg/dose IV q24h if >= 5 years old, q12h if < 5 years old (max 750mg/day)

ID consult recommended

Blood cultures are recommended for patients with complicated pneumonia

Consider therapy for Influenza if patient admitted during active Influenza season

Reference: Bradley, JS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011;53:e25-e76.

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP).