Pathway for Evaluation and Treatment of Child with Community-Acquired Pneumonia

ANTIBIOTIC RECOMMENDATIONS FOR PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA

  First-Line Therapy1 β-lactam Allergy2
Duration of Tx/Comments
Mild Pneumonia
(Outpatient)

Amoxicillin
90 mg/kg/day, divided BID-TID; max: 1g/dose

Clindamycin
(PO) 30 mg/kg/day divided TID; max: 1.8 g/day

OR

Levofloxacin
(PO) ≥ 6mo and < 5 yrs: 20 mg/kg/day, div Q12hr
≥ 5yr: 10 mg/kg/day, once daily; max: 500 mg

Duration: 7 days

Target pathogen: S. pneumoniae

High dose amoxicillin active against most
S. pneumoniae

Clindamycin active against ~ 90% of
S. pneumoniae;
Levofloxacin active against > 95% of S. pneumoniae;

Oral cephalosporins inferior to high-dose amoxicillin for S. pneumoniae; Azithromycin resistance in up to 40% of S. pneumoniae

Moderate Pneumonia
(Inpatient)

Ampicillin
300 mg/kg/day divided Q6hrs; max: 2g/dose

Clindamycin
(IV) 40 mg/kg/day, divided Q8 hrs; max: 2.7 g/day
(PO) 30 mg/kg/day divided TID; max: 1.8 g/day

OR

Levofloxacin
(IV/PO) ≥ 6mo and < 5 yrs: 20 mg/kg/day, divided Q12hr
≥ 5yr: 10mg/kg/day, once daily; max: 500 mg

Duration: 7 days, or at least 48 hours from resolution of fever and tachypnea (whichever is longer), including oral/outpatient therapy.

Target pathogen: Streptococcus pneumoniae

High dose Ampicillin active against most
S. pneumoniae

Ceftriaxone for treatment failure4 with outpatient amox

Complicated3 Pneumonia
(Inpatient)

Clindamycin
(IV) 40 mg/kg/day, div Q8hrs; max: 2.7 g/day
(PO) 30 mg/kg/day div TID; max: 1.8 g/day

*AND*

Ceftriaxone
100 mg/kg/day, Q24 hrs; max: 2 g/dose

Clindamycin
(IV) 40 mg/kg/day, divided Q8 hrs; max: 2.7 g/day
(PO) 30 mg/kg/day divided TID; max: 1.8 g/day

*AND*

Levofloxacin
(IV/PO) ≥ 6mo and < 5 yrs: 20 mg/kg/day, div Q12hr
≥ 5yr: 10 mg/kg/day, once daily; max: 500 mg

Duration: 7 days from drainage of effusion. If not amenable to drainage, 7 days from afebrile. Please consult Infectious Diseases team for pneumonia with mod-large effusion or empyema.

Target pathogens: S. pneumoniae, Streptococcus pyogenes (Group A Strep),
S. aureus

Clindamycin for suspected CA-MRSA, active against ~ 85% of MRSA (CA and HA)

Severe Pneumonia
(ICU)

Vancomycin
15 mg/kg/dose (max 500 mg), Q6 hrs.

*AND*

Ceftriaxone
100 mg/kg/day, Q24 hrs.; max: 2 g/dose

Vancomycin
15 mg/kg/dose (max 500 mg), Q6 hrs.

*AND*

Levofloxacin
(IV/PO) ≥ 6mo and < 5 yrs: 20 mg/kg/day, div Q12hr
≥ 5yr: 10 mg/kg/day, once daily; max: 500 mg

Duration: 7 days from afebrile. Please consult Infectious Diseases team for pneumonia with mod-large effusion or empyema.

Target pathogens: S. pneumoniae,
S. pyogenes, S. aureus

Vancomycin for suspected CA-MRSA in severe or life-threatening conditions

References

  1. For typical, presumed bacterial community-acquired pneumonia.
    Atypical pneumonia (often characterized by non-lobar, patchy, or interstitial pattern on CXR; insidious onset; low-grade of fever, malaise, H/A, cough; minimal auscultatory findings relative to CXR) is often caused by respiratory viruses, but may be caused by atypical bacterial pathogens including Mycoplasma pneumoniae. Most atypical pneumonia is mild and self-limited; however, for disease requiring hospitalization, consider PCR testing for respiratory viruses and M. pneumoniae. Drugs for confirmed M. pneumoniae infection, or for presumed infection in the presence of severe disease, include Azithromycin: 10 mg/kg on day 1, single dose (max: 500 mg/day), followed by 5 mg/kg/day, once daily, days 2-5 (max: 250 mg/day) OR Levofloxacin (as above).
  2. Defined by urticaria or anaphylaxis
  3. Includes pneumonia with moderate-large parapneumonic effusion.
  4. After > 48 hours of therapy with high dose amoxicillin in a patient that was tolerating the outpatient PO regimen