Community-acquired pneumonia in children: A look at the IDSA guidelines

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Applied Evidence

Community-acquired pneumonia in children: A look at the IDSA guidelines

J Fam Pract. 2013 January;62(1):9-15

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References

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TABLE 2
Empiric outpatient antibiotic therapy for pediatric CAP^1,19
Duration of treatment is 10 days unless otherwise noted

Patient age	Presumed bacterial pneumonia	Presumed atypical pneumonia
3 mo to <5 y, regardless of immunization status	Preferred: amoxicillin 90 mg/kg/d PO in 2 divided doses Alternative: amoxicillin clavulanate 90 mg/kg/d PO in 2 divided doses	For all children regardless of age and immunization status: Preferred: azithromycin 10 mg/kg PO on Day 1, followed by 5 mg/kg PO once daily on Days 2-5 Alternative: clarithromycin 15 mg/kg/d PO in 2 divided doses OR In children >7 y: erythromycin 40 mg/kg/d PO in 4 divided doses; or doxycycline 2-4 mg/kg/d PO in 2 divided doses
≥5 y and fully immunized against Streptococcus pneumoniae and Haemophilus influenzae	Preferred:* amoxicillin 90 mg/kg/d PO in 2 divided doses to a maximum 4 g/d, with or without a macrolide antibiotic Alternatives: Second- or third-generation cephalosporins such as oral cefpodoxime, cefuroxime, or cefprozil OR levofloxacin (5-16 y) 8-10 mg/kg PO once daily (max 750 mg/d)^†OR linezolid (<12 y) 30 mg/kg/d PO (max 1200 mg/d) in 3 divided doses; or (≥12 y) 20 mg/kg/d (max 1200 mg/d) in 2 divided doses
≥5 y and NOT fully immunized against S pneumoniae and H influenzae	Preferred:* amoxicillin 90 mg/kg/d PO in 2 divided doses to a max of 4 g/d; or amoxicillin clavulanate 90 mg/kg/d PO in 2 divided doses Alternatives: Second- or third-generation cephalosporins such as oral cefpodoxime, cefuroxime, or cefprozil OR levofloxacin (5-16 y) 8-10 mg/kg PO once daily (max 750 mg/d)^†
CAP, community-acquired pneumonia. Preferred treatments of choice change in areas of high S pneumoniae* resistance. Refer to the complete guidelines for specific recommendations. ^†The guidelines do not fully address the controversy concerning the use of quinolones in children. The use of quinolones in infants and children is considered a risk vs benefit decision.

Patients with mild or moderate CAP may be treated first in the outpatient setting with amoxicillin. This antibiotic has been the agent of choice for many years and continues to be the empiric therapy recommended in the guidelines.¹ Appropriate dosing depends on the age of the patient.

TABLE 2 also includes treatment alternatives to amoxicillin for patients with drug allergies, treatment failures, or suspected atypical pathogens. Amoxicillin and the alternative treatments provide coverage for S pneumoniae, the most common invasive bacterial pathogen in older children.^1,20 When atypical pathogens are suspected, macrolide antibiotics become the antibiotic drug class of choice, with azithromycin being the preferred first-line agent.^1,21-23

FAST TRACK

Amoxicillin remains the empiric treatment of choice for patients with a suspected bacterial pathogen.

Bacterial CAP necessitating hospitalization. The guidelines strongly recommend hospitalization for infants and children with respiratory distress or hypoxemia (oxygen saturation <90%); for suspicion of infection caused by community-acquired methicillin-resistant Staphylococcus aureus (MRSA) or any pathogen with high virulence; or for infants 3 to 6 months old.¹

Treat with parenteral antibiotics to provide reliable blood and tissue concentrations (TABLE 3).^1,19 Ampicillin or penicillin G may be given to fully immunized children; however, take into account the local resistance pattern of S pneumoniae to drugs within the penicillin class. For hospitalized children who are not yet fully immunized, who have life-threatening infections, or who are in a facility with a documented high rate of penicillin resistance, administer a third-generation parenteral cephalosporin such as ceftriaxone or cefotaxime empirically.^1,24 In monotherapy treatment of pneumococcal pneumonia, non–beta-lactam agents such as vancomycin have not been shown to be more effective than the third-generation cephalosporins.¹

TABLE 3
Empiric antibiotic therapy for hospitalized patients with CAP^1,19
Duration of treatment is 10 days unless otherwise noted

Patient age	Presumed bacterial pneumonia	Presumed atypical pneumonia
3 mo to <5 y and fully immunized against Streptococcus pneumoniae and Haemophilus influenzae	Preferred:* ampicillin 150-200 mg/kg/d IV divided every 6 h; or penicillin G 200,000-250,000 units/kg/d IV divided every 4-6 h Alternatives: ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h	For all children regardless of age and immunization status: Preferred: azithromycin, 10 mg/kg IV (max of 500 mg) on Days 1 and 2, then transition to oral therapy 10 mg/kg/d for remaining 7-10 days of therapy Alternatives: erythromycin lactobionate 20 mg/kg/d IV divided every 6 h; or levofloxacin 16-20 mg/kg/d IV divided every 12 h to a max of 750 mg/d^†
<5 y and NOT fully immunized against S pneumoniae and H influenzae	Preferred:* ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h Alternative: levofloxacin (6 mo–<5 y) 16-20 mg/kg/d IV divided every 12 h^†
≥5 y and fully immunized against S pneumoniae and H influenzae	Preferred:* ampicillin 150-200 mg/kg/d IV divided every 6 h; or penicillin G 200,000-250,000 units/kg/d IV divided every 4-6 h Alternatives: ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h
≥5 y and NOT fully immunized against S pneumoniae and H influenzae	Preferred:* ceftriaxone 50-100 mg/kg/d IV/IM divided every 12-24 h; or cefotaxime 150 mg/kg/d IV divided every 8 h Alternatives: ampicillin 150-200 mg/kg/d IV divided every 6 h; or levofloxacin 8-10 mg/kg IV once daily (max of 750 mg/d)^†
CAP, community-acquired pneumonia. The addition of clindamycin 40 mg/kg/d IV divided every 6-8 hours or vancomycin 40-60 mg/kg/day IV divided every 6-8 hours is recommended for suspected or confirmed community-acquired methicillin-resistant Staphylococcus aureus*. ^†The guidelines do not fully address the controversy concerning the use of quinolones in children. Use of quinolones in infants and children is considered a risk vs benefit decision.