Pneumonia, Community Acquired

Similar to pathogens in community-acquired pneumonia and hospital-acquired pneumonia, depending on setting 

Anaerobic organisms may be involved though usually the oral anaerobic flora are frequently susceptible to usual therapy for pneumonia (e.g. ampicillin)  

If symptoms resolve within 24-48 hours of  initial aspiration event: 

This presentation is consistent with aspiration pneumonitis. Antibiotic therapy is not recommended. Antibiotic therapy is also not recommended at this time based on an aspiration event alone (i.e. for prevention of pneumonia).  

For symptoms consistent with aspiration pneumonia developing or lasting >48 hours after initial aspiration event, with community onset (not hospital): 

Ampicillin-sulbactam (Unasyn)
50 mg ampicillin/kg/dose IV q6h (max 2000 mg ampicillin/dose) 

Enteral/transition therapy: 
Amoxicillin-clavulanate (Augmentin)
45 mg amoxicillin/kg/ dose enterally bid (max 1000 mg amoxicillin/dose) 

Penicillin or cephalosporin allergy with higher risk for allergic reaction: 

Clindamycin
10 mg/kg/dose (max 900mg/dose) IV q8h

OR

Clindamycin 10mg/kg/dose (max 600 mg/dose) enterally tid  

Oral hygeine and regular dentistry care are important to reduce risk for aspiration pneumonia in neurologically impaired patients

Follow guidelines for Healthcare-acquired Pneumonia if infection developed in the hospital

Review intravenous antibiotics by 48 hours and consider switching to enteral route if possible

Outpatient Therapy

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) 

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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
45 mg/kg/dose (max 1000mg/dose)* enterally  bid  

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If atypical bacterial etiology suspected:  

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  

Penicillin allergy with lower risk for allergic reaction: 

Oral cephalosporin (follow link for options) 

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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 

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)  

Suspected typical bacterial etiology: 

Ampicillin
50 mg/kg/dose (max 2000 mg/dose) IV q6h 

Convert to enteral therapy (Amoxicillin per dosing in outpatient therapy sections above) when clinically appropriate  

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If Mycoplasma PCR positive on respiratory panel (BCH OAK) or strongly suspected atypical etiology: 

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

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
50 mg/kg/dose (max 2000 mg/dose) IV q24h  

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Penicillin allergy with higher risk for allergic reaction, age >6 months: 

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

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 

Streptococcus pneumoniae 

Staphylococcus aureus 

Patients without severe respiratory failure or hemodynamic instability: 

Ampicillin/sulbactam
50 mg ampicillin/kg/dose IV q6 hours (max 2000mg ampicillin/dose) 

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

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