See further Community-acquired Pneumonia (CAP) management guidelines from the UCSF Northern California Pediatric Hospital Medicine Consortium, though reference below recommendations for updated antibiotic selection.
At BCH OAK follow site-specific CAP algorithm (link requires password log in to Box); recommendations provided below are compatible with BCH OAK CAP algorithm, but the algorithm provides additional details in pathway form.
| Condition | Major Pathogens | First-choice Therapy | Alternative Therapy | Comments |
|---|---|---|---|---|
Outpatient Therapy |
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|
Community-acquired pneumonia, 3 months-5 years old, outpatient therapy |
Majority: respiratory viruses Streptococcus pneumoniae |
Antimicrobial therapy is not routinely indicated unless suspected bacterial etiology If suspected typical bacterial etiology: Amoxicillin 45 mg/kg/dose (max 1000 mg/dose)* enterally bid Note: Atypical pneumonia is rare in this age group |
Penicillin allergy with lower risk for allergic reaction: Oral cephalosporin (follow link for options) ------------------------- Penicillin allergy with higher risk for allergic reaction: Azithromycin 10 mg/kg/dose enterally x 1 dose on day 1, then 5 mg/kg/dose enterally daily on days 2-5 |
Duration: 5 days *See guidance on Amoxicillin maximum dosing and formulations |
|
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 ------------------------ If atypical bacterial etiology suspected: Azithromycin |
Penicillin allergy with lower risk for allergic reaction: Oral cephalosporin (follow link for options) ------------------------- Penicillin allergy with higher risk for allergic reaction: Replace Amoxicillin with Azithromycin 10 mg/kg/dose (max 500 mg/dose) enterally on day 1, then 5 mg/kg/dose (max 250 mg/dose) enterally daily on days 2-5 |
Duration: 5 days Blood cultures are not usually indicated for outpatients with community- acquired pneumonia *See guidance on Amoxicillin maximum dosing and formulations
|
Inpatient Therapy, Uncomplicated CAP |
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|
Community-acquired pneumonia, < 3 months old |
Streptococcus pneumoniae Respiratory viruses Also consider: Bordetella pertussis Chlamydia trachomatis |
Ampicillin Refer to Neonatal Dosing Guideline for dose Convert to enteral therapy when clinically appropriate (Amoxicillin per Lexi-Comp or clinical pharmacist) |
Initial inpatient therapy is recommended Blood culture is recommended Assess for viral & atypical pathogens, ampicillin is directed towards Streptococcus pneumoniae. Consider evaluation and empiric therapy for Pertussis especially for infants with apnea, significant post-tussive emesis, lymphocytosis or older contacts with prolonged cough Duration: Usually 7 days for uncomplicated CAP suspected to be caused by typical bacteria (S. pneumoniae) |
|
| Community-acquired pneumonia, > 3 months old, suspected bacterial etiology, inpatient therapy but not complicated (empyema, necrotizing pneumonia) | Similar to outpatient etiologies |
Suspected typical bacterial etiology: Ampicillin Convert to enteral therapy (Amoxicillin per dosing in outpatient therapy sections above) when clinically appropriate ------------------------- If Mycoplasma PCR positive on respiratory panel (BCH OAK) or strongly suspected atypical etiology: Azithromycin Note: Atypical pneumonia is rare in children < 5 years old, and observational data has not shown a clear benefit of empiric macrolide therapy for pediatric inpatients with CAP |
Penicillin allergy with lower risk for allergic reaction: Ceftriaxone ------------------------- Penicillin allergy with higher risk for allergic reaction, age >6 months: Levofloxacin
|
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 Duration: 7 days |
Inpatient Therapy, Complicated CAP |
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| Community-acquired pneumonia, complicated (empyema, necrotizing pneumonia) |
Streptococcus pneumoniae Staphylococcus aureus |
Patients without severe respiratory failure or hemodynamic instability: Ampicillin/sulbactam Patients with severe respiratory failure or hemodynamic instability: Addition of MRSA coverage recommended, consult ID for recommendations |
Penicillin allergy with higher risk for allergic reaction: Patients without severe respiratory failure or hemodynamic instability, age > 6 months: Levofloxacin Patients with severe respiratory failure or hemodynamic instability: Addition of MRSA coverage recommended, consult ID for recommendations |
ID consult recommended Surgery consult recommended for management of empyema Blood cultures are recommended for patients with complicated pneumonia Bacterial culture and pleural fluid studies should be sent at the time of empyema drainage but should not be sent from a chest tube after it has been in place Consider therapy for Influenza if patient admitted during active Influenza season If cavitation present consider possibility of Tuberculosis Duration: 14-28 days total with initial IV therapy followed by conversion to enteral therapy. Therapy should be modified to target identified pathogen. Duration individualized based on severity and response to therapy, with follow-up assessment by ID service |
References
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.
Williams DJ, Edwards KM, Self WH, et al. Effectiveness of β-Lactam monotherapy vs macrolide combination therapy for children hospitalized with pneumonia. JAMA Pediatr. 2017;171(12):1184-1191.
Pernica JM, Harman S, Kam AJ, et al. Short-course antimicrobial therapy for pediatric community-acquired pneumonia: the SAFER randomized clinical trial. JAMA Pediatr. 2021;175:475-482.
American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.
Pediatric Empiric Antimicrobial Therapy Guidelines
This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites.
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. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.
For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK.
The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.