Pneumonia, Community-Acquired — Uncomplicated Cap and Step-Down Therapy — Clinical Pathway: All Settings

Community Acquired Pneumonia Clinical Pathway — All Settings

CAP Step-Down Therapy with Clinical Improvement within 48-72 Hours

These recommendations can generally be applied to patients receiving first-line therapy; for treatment failures, consider preceding antibiotic exposures and likely pathogens when selecting step-down therapy. In all cases, if a bacterial organism is identified from the blood or respiratory system, therapy should target that organism.

If initial empirical
antibiotic treatment was:		 Then transition child to the following oral antibiotics:
Ampicillin
  • High dose amoxicillin:
    • 90 mg/kg/day PO in 2-3 divided doses
    • Maximum: 4,000 mg/day
  • Intervals of q8-12 hours are used for the treatment of CAP. Q12 dosing is likely adequate for most children, considering the relatively low rate of penicillin resistance among pneumococcus locally coupled with compliance challenges with q8 dosing. Q8 dosing optimizes amoxicillin exposure in lung and should be considered for hospitalized patients transitioning to oral therapy.
Ampicillin-sulbactam
  • Amoxicillin-clavulanate:
    • Infants < 3 months:
      30 mg/kg/day of amoxicillin component PO in 2 divided doses
    • Infants ≥ 3 months, children, and adolescents:1
      90 mg/kg/day of amoxicillin component PO in 2 divided doses
      Maximum: 2000 mg/dose; 4000 mg/day
Ceftriaxone
  • Amoxicillin-clavulanate:
    • Infants < 3 months:
      30 mg/kg/day of amoxicillin component PO in 2 divided doses
    • Infants ≥ 3 months, children, and adolescents:1
      90 mg/kg/day of amoxicillin component PO in 2 divided doses
      Maximum: 2000 mg/dose; 4000 mg/day
Levofloxacin
  • Levofloxacin:
    • ≥ 6 months and < 5 years:
      10 mg/kg/dose PO every 12 hours
      Maximum: 375 mg/dose
    • ≥ 5 years:
      10 mg/kg/dose PO every 24 hours
      Maximum: 750 mg/dose
Clindamycin + Ceftriaxone
  • MRSA screen negative
    • Amoxicillin-clavulanate:
      • Infants < 3 months:
        30 mg/kg/day of amoxicillin component PO in 2 divided doses
      • Infants ≥ 3 months, children, and adolescents:1
        90 mg/kg/day of amoxicillin component PO in 2 divided doses
        Maximum: 2000 mg/dose; 4000 mg/day
  • MRSA screen positive and clinical/radiographic features consistent with staphylococcal pneumonia:2
    • Clindamycin:
      • If susceptible, clinically improving on this agent:
        14 mg/kg/dose PO every 8 hours
        Maximum: 600 mg/dose
      • If non-susceptible:
        Tailor regimen to reported susceptibilities
  • No MRSA screen obtained
    • Clindamycin:
      • 14 mg/kg/dose PO every 8 hours
        Maximum: 600 mg/dose
Vancomycin + Ceftriaxone
  • MRSA screen negative
    • Amoxicillin-clavulanate:
      • Infants < 3 months:
        30 mg/kg/day of amoxicillin component PO in 2 divided doses
      • Infants ≥ 3 months, children, and adolescents:1
        90 mg/kg/day of amoxicillin component PO in 2 divided doses
        Maximum: 2000 mg/dose; 4000 mg/day
  • MRSA screen positive and clinical/radiographic features consistent with staphylococcal pneumonia:2
    • Levofloxacin:
      • ≥ 6 months and < 5 years:
        10 mg/kg/dose PO every 12 hours
        Maximum: 375 mg/dose
      • ≥ 5 years:
        10 mg/kg/dose PO every 24 hours
        Maximum: 750 mg/dose
  • AND Clindamycin:
    • If susceptible, clinically improving on this agent:
      14 mg/kg/dose PO every 8 hours
      Maximum: 600 mg/doses
    • If non-susceptible:
      Tailor regimen to reported susceptibilities
  • No MRSA screen obtained
    • Levofloxacin:
      • ≥ 6 months and < 5 years:
        10 mg/kg/dose PO every 12 hours
        Maximum: 375 mg/dose
      • ≥ 5 years:
        10 mg/kg/dose PO every 24 hours
        Maximum: 750 mg/dose
  • AND if high suspicion for MRSA
    • Clindamycin:
      • 14 mg/kg/dose PO every 8 hours
        Maximum: 600 mg/dose
  1. ES (suspension) or ER (tablet) formulation
  2. Clinical/radiographic features include: high fever, lobar infiltrate, severe illness