Pneumonia, Community-Acquired — Antibiotic Recommendations — Clinical Pathway: All Settings

Community Acquired Pneumonia Clinical Pathway — All Settings

Initial Antibiotic Recommendations for Children with Community-Acquired Pneumonia

General Principles:

  • The tables below outline initial treatment recommendations. If increasing respiratory distress, increasing respiratory support requirement, or worsening fever curve after > 48 hrs of preferred first-line therapy at appropriate dosing, consider treatment failure.
  • Consider diagnostic testing and treatment for atypical pneumonia in children ≥ 5 yrs with insidious onset of symptoms or failed treatment for typical pneumonia.
First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative		 Duration of Treatment/Comments
  • Amoxicillin, oral:
    • 90 mg/kg/day in 2-3 divided doses
      Maximum; 4,000 mg/day
  • 1st Line Recommendation
    • Clindamycin, oral:
      • 14 mg/kg/dose every 8 hours;
        Maximum: 600 mg/dose
    • or
  • 2nd Line Recommendation
    • Levofloxacin, oral:
      • ≥ 6 months and < 5 years:
        10 mg/kg/dose every 12 hours
        Maximum: 375 mg/dose
      • ≥ 5 years: 10 mg/kg/dose every 24 hours
        Maximum: 750 mg/dose
  • Duration:
    • 5 days
  • Target pathogen:
    • Streptococcus pneumoniae
  • High dose amoxicillin:
    • Active against ~ 95% of S. pneumoniae
    • Intervals of every 8-12 hours are used for the treatment of CAP
    • Every 12 hour dosing is likely adequate for most children, considering the relatively low rate of penicillin resistance among pneumococcus locally coupled with compliance challenges with every 8 hour dosing
    • Every 8 hour dosing optimizes amoxicillin exposure in lung and should be considered for hospitalized children transitioning to oral therapy
  • Clindamycin:
    • Active against ~ 90% of S. pneumoniae
  • Levofloxacin:
    • Active against > 95% of S. pneumoniae, Mycoplasma pneumoniae, Legionella;
  • Oral cephalosporins:
    • Inferior to high-dose amoxicillin for S.pneumoniae;
  • Azithromycin:
    • Resistance in up to 40% of S. pneumoniae and therefore is not recommended

Moderate Pneumonia, Uncomplicated (Inpatient/ICU)

Defined as children with retractions, grunting, nasal flaring; pulse oximetry < 90% in room air requiring HFNC or other non-invasive mechanical ventilation not meeting severe criteria. May include children with small, simple effusions.

First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative		 Duration of Treatment/Comments
  • Ampicillin, IV:
    • 75 mg/kg/dose every 6 hours
      Maximum: 2,000 mg/dose
  • or
  • Consider ceftriaxone IV monotherapy for unimmunized children
    • Ceftriaxone, IV:
      • 100 mg/kg/dose every 24 hours
      • Maximum: 2,000 mg/dose
  • Alt if tolerating PO, no concern for enteral absorption
  • Amoxicillin, oral:
  • 90 mg/kg/day in 2-3 divided doses
  • Maximum; 4,000 mg/day
  • 1st Line Recommendation
    • Clindamycin, IV/Oral:
      • 14 mg/kg/dose every 8 hours
      • Maximum: 900 mg/dose IV or 600 mg/dose oral
    • or
  • 2nd Line Recommendation
    • Levofloxacin, IV/Oral:
      • ≥ 6 months and < 5 years:
        10 mg/kg/dose every 12 hours
        Maximum: 375 mg/dose
      • ≥ 5 years: 10 mg/kg/dose every 24 hours
        Maximum: 750 mg/dose
  • Duration:
    • 5 days total (inpatient + discharge antibiotics)
  • See recommendations for treatment failure for children who worsen or fail to improve within ~ 48-72 hours
  • Longer durations are also necessary for children with bacteremia or complicated infections
  • Target pathogen:
    • S. pneumoniae
  • Aspiration pneumonia/pneumonitis:
    • Most aspiration events cause a chemical pneumonitis that does not warrant antibiotic therapy. In such cases, no antimicrobials are suggested for mild or moderately ill children
  • Concurrent/recent influenza infection:
    • Ampicillin is the first-line antibiotic for most children with current/recent influenza infections where there is concern for bacterial superinfection
    • Antistaphylococcal therapy could be considered on a case-by-case basis; in general, staphylococcal pneumonia is associated with high fever, lobar infiltrate, and severe illness
  • High dose ampicillin:
    • Active against > 95% S. pneumoniae
  • Clindamycin:
    • Active against ~ 90% of S. pneumoniae
  • Levofloxacin:
    • Active against > 95% of S. pneumoniae, mycoplasma pneumoniae, Legionella
  • Azithromycin:
    • Resistance in up to 40% of S. pneumoniae and therefore is not recommended

Moderate Pneumonia, Complicated (Inpatient/ICU)

Includes children meeting the definition for moderate pneumonia AND have a pleural empyema or moderate or large effusions. Does NOT include children with small, simple effusions.

First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative		 Duration of Treatment/Comments
  • Clindamycin, IV:
    • 14 mg/kg/dose every 8 hours
      Maximum: 900 mg/dose
  • and
  • Ceftriaxone, IV:
    • 100 mg/kg/dose every24 hours
      Maximum: 2,000 mg/dose
  • Please obtain a nasal MRSA screening culture upon admission in children with severe lobar pneumonia or complicated pneumonia
  • Anti-MRSA therapy therapy can generally be stopped in children who do not grow MRSA. However, prior exposure to anti-MRSA antibiotic therapy may affect culture results, so clinical judgement is required in these cases, particularly if anti-MRSA therapy has been administered ≥ 48 hours at the time of culture collection
  • Susceptibilities can be performed upon request in positive cases
  • Clindamycin, IV:
    • 14 mg/kg/dose every 8 hours
      Maximum: 900 mg/dose
  • and
  • Levofloxacin, IV:
    • ≥ 6 months and < 5 years:
      10 mg/kg/dose every 12 hours
      Maximum: 375 mg/dose
    • ≥ 5 years: 10 mg/kg/dose every 24 hours
      Maximum: 750 mg/dose
  • Duration:
    • 7 days from drainage of effusion or 7 days from afebrile for moderate-large or complex effusions not amenable to drainage
    • Please consult Infectious Diseases Team for pneumonia with mod-large effusion, empyema, necrotizing pneumonia, or lung abscess
  • Target pathogens:
    • Streptococcus pneumoniae, streptococcus pyogenes (Group A Strep), S. aureus
  • Clindamycin:
    • For suspected CA-MRSA ~ 80% of MRSA and ~ 75% of all S. aureus are susceptible to clindamycin
    • CHOP Antibiogram

Severe Pneumonia Complicated or Uncomplicated (ICU)

Includes children with hypoxemic or hypercarbic respiratory failure requiring invasive mechanical ventilation or non-invasive mechanical ventilation with high (e.g., > 40%) or escalating FiO2 requirement attributable to a bacterial pneumonia; or systemic signs of inadequate perfusion (change in mental status, hemodynamic instability) — Review Sepsis Pathway. This includes children with or without effusion/empyema.

First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative		 Duration of Treatment/Comments
  • Vancomycin, IV:
    • < 50 kg:
      15 mg/kg/dose every 6 hours
      Maximum: 750 mg/dose
    • ≥ 50 kg and/or > 18 years:
      15 mg/kg/dose every 8 hours;
      Maximum: 1,000 mg/dose
  • and
  • Ceftriaxone, IV:
    • 100 mg/kg/dose IV every 24 hours
      Maximum: 2,000 mg/dose
  • Please obtain a nasal MRSA screening culture upon admission in children with severe lobar pneumonia or complicated pneumonia
  • Anti-MRSA therapy can generally be stopped in children who do not grow MRSA. However, prior exposure to anti-MRSA antibiotic therapy may affect culture results, so clinical judgement is required in these cases, particularly if anti-MRSA therapy has been administered ≥ 48 hours at the time of culture collection
  • Susceptibilities can be performed upon request in positive cases.
  • Vancomycin, IV:
    • < 50 kg:
      15 mg/kg/dose every 6 hour
      Maximum: 750 mg/dose
    • ≥ 50 kg and/or > 18 years:
      15 mg/kg/dose every 8 hours
      Maximum: 1,000 mg/dose
  • and
  • Levofloxacin, IV:
    • ≥ 6 months and < 5 years:
      10 mg/kg/dose every 12 hours
      Maximum: 375 mg/dose
    • ≥ 5 years:
      10 mg/kg/dose every 24 hours
      Maximum: 750 mg/dose
  • Duration (severe, uncomplicated):
    • For children who respond promptly to therapy and are medically ready for transfer from the ICU within ~ 48 hours: 5 days (same as moderate pneumonia)
    • See recommendations for treatment failure for children who worsen or fail to improve within ~ 48-72 hours
    •  
    • Longer durations are also necessary for children with bacteremia or complicated infections
  • Duration (complicated pneumonia):
    • 7 days from drainage of effusion or 7 days from afebrile for moderate-large or complex effusions not amenable to drainage
    • Please consult Infectious Diseases Team for pneumonia with mod-large effusion, empyema, necrotizing pneumonia, or lung abscess
  • Target pathogens:
  • S. pneumoniae, S. pyogenes and S. aureus

Atypical Pneumonia (All Settings and Severities)

  • Mycoplasma pneumonia is usually characterized by prolonged duration of fever, cough, malaise, headache in children ≥ 5 yrs. Chest X-ray may show non-lobar, patchy, or interstitial pattern. Mycoplasma can colonize the respiratory tract for weeks to months, and approximately 20% of asymptomatic children may test positive for Mycoplasma by PCR.
  • Legionella pneumonia is uncommonly reported in children but should be considered in severe pneumonia with associated GI symptoms, especially in those who fail to respond to treatment for typical pathogens. Most cases are associated with exposure to contaminated water reservoirs (showers, pools, drinking water systems).
First-Line Therapy Duration of Treatment/Comments
  • 1st Line
    • Azithromycin IV/Oral (preferred):
      • Oral: 10 mg/kg/dose on day one
        Maximum: 500 mg/day
        Followed by 5 mg/kg/dose once daily on days 2-5
        Maximum: 250 mg/day
    • or
  • Levofloxacin, IV/Oral
    • ≥ 6 months and < 5 years:
      10 mg/kg/dose every 12 hours;
      Maximum: 375 mg/dose
    • ≥ 5 years:
      10 mg/kg/dose every 24 hours:
      Maximum: 750 mg/dose
  • Target pathogens:
    • Mycoplasma pneumoniae, Legionella pneumophila
  • In general, children < 5 years old should not be treated empirically for Mycoplasma, as antibiotic therapy has not been shown to be beneficial in this age group.
  • If considering treatment for atypical pneumonia, send Mycoplasma nasopharyngeal PCR or Legionella urine antigen test.
  • Duration (for proven infections):
    • Mycoplasma pneumoniae:
      • Azithromycin: 5 days
      • Levofloxacin: 7 days
    • Legionella pneumophila:
      • Azithromycin: 5-10 days
      • Levofloxacin: 14-21 days
    • Azithromycin is preferred to levofloxacin for first line treatment of atypical pathogens, but it often does not treat S. pneumoniae and does not treat S. aureus; please administer in addition to antibiotics above for typical CAP if the clinical syndrome is less compatible with atypical pneumonia.
    • Levofloxacin has activity against S. pneumoniae as well as atypicals so no additional agents targeting atypicals are needed when levofloxacin is otherwise indicated.