Pediatric Community-Acquired Pneumonia Treatment Protocol

Initial Assessment and Antibiotic Selection

For children under 5 years with presumed bacterial pneumonia, the American Academy of Pediatrics recommends starting oral amoxicillin 90 mg/kg/day divided into 2 doses as first-line therapy, due to the predominance of Streptococcus pneumoniae as the primary bacterial pathogen in this age group 1, 2, 3
For children 5 years and older, the American Academy of Pediatrics recommends oral amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) as first-line therapy, but considers adding a macrolide if atypical pathogens (Mycoplasma pneumoniae or Chlamydophila pneumoniae) are suspected 1, 3

For Streptococcus pneumoniae (penicillin-susceptible), the Infectious Diseases Society of America recommends oral amoxicillin 90 mg/kg/day in 2 doses or IV ampicillin 200 mg/kg/day every 6 hours or penicillin G 100,000-250,000 U/kg/day every 4-6 hours 1, 2
For Streptococcus pneumoniae (penicillin-resistant, MIC ≥4.0 μg/mL), the Infectious Diseases Society of America recommends IV ceftriaxone 100 mg/kg/day every 12-24 hours or IV ampicillin 300-400 mg/kg/day every 6 hours 2, 4
For Mycoplasma pneumoniae or Chlamydophila pneumoniae, the American Academy of Pediatrics recommends azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 1, 3
For Haemophilus influenzae, the Infectious Diseases Society of America recommends amoxicillin 75-100 mg/kg/day in 3 doses for β-lactamase negative strains, and amoxicillin-clavulanate for β-lactamase producing strains 1, 2

The American Academy of Pediatrics recommends hospitalization for children with inability to tolerate oral medications, oxygen saturation <92% on room air, severe respiratory distress, dehydration, poor feeding, altered consciousness, or seizures 2, 3
The Infectious Diseases Society of America recommends IV co-amoxiclav, cefuroxime, or cefotaxime for severe pneumonia, and considers adding vancomycin or clindamycin for suspected MRSA 3, 4, 5

The American Academy of Pediatrics recommends 5-7 days of antibiotic therapy for uncomplicated pneumonia 1
The Infectious Diseases Society of America recommends 2-4 weeks of therapy for complicated pneumonia (empyema, necrotizing pneumonia, lung abscess) depending on clinical response and adequacy of drainage 6, 1

The Infectious Diseases Society of America recommends reassessing patients within 48-72 hours of initiating therapy, and expects documented clinical improvement including decreased fever, improved level of activity and appetite, and reduced respiratory distress 6, 3
The American Academy of Pediatrics recommends considering complications such as parapneumonic effusion, empyema, necrotizing pneumonia, or lung abscess if no improvement after 48-72 hours 6, 7

The Infectious Diseases Society of America recommends managing parapneumonic effusion/empyema with IV antibiotics alone for small effusions, and considers drainage for moderate to large effusions or those with high respiratory compromise 7
The American Academy of Pediatrics recommends managing necrotizing pneumonia/lung abscess with IV antibiotics alone, and considers drainage for well-defined peripheral abscesses or persistent fever despite appropriate antibiotics 6, 7

The American Academy of Pediatrics recommends discharging patients when they have overall clinical improvement, decreased or absent fever, oxygen saturation >90% on room air, stable mental status, and no substantially increased work of breathing 6

The American Academy of Pediatrics recommends avoiding over-treatment of viral pneumonia, inadequate dosing of amoxicillin, and premature discontinuation of IV therapy 1, 2, 3
The Infectious Diseases Society of America recommends considering penicillin allergy, and using alternative antibiotics such as macrolides, linezolid, or clindamycin for severe penicillin allergies 1