Management of Pneumonia in Children

Outpatient Management

The American Academy of Pediatrics recommends amoxicillin 90 mg/kg/day divided into two doses as the first-line treatment for children with presumed bacterial community-acquired pneumonia 1, 2
For a 19 kg child, amoxicillin dosing is 855 mg twice daily, with a maximum of 4 g/day 1
High-dose amoxicillin (90 mg/kg/day) is critical to overcome pneumococcal resistance and should not be underdosed to 40-45 mg/kg/day 1, 2
Azithromycin should be added if atypical pathogens are suspected based on clinical presentation, with dosing of 190 mg on day 1 and 95 mg once daily on days 2-5 for a 19 kg child 1, 2

For fully immunized, low-risk children, the Infectious Diseases Society of America recommends ampicillin 150-200 mg/kg/day IV or penicillin G 100,000-250,000 units/kg/day IV 3, 1, 2
Alternative inpatient treatment includes ceftriaxone 50-100 mg/kg/day IV every 12-24 hours 3, 2
For not fully immunized or high-risk children, ceftriaxone 50-100 mg/kg/day IV or cefotaxime 150 mg/kg/day IV is recommended, with addition of vancomycin or clindamycin if MRSA is suspected 3, 1, 2

Reassessment for clinical improvement should occur within 48-72 hours of starting therapy, with signs of treatment failure including persistent or worsening fever, worsening respiratory distress, or development of complications 1, 2, 3
Management of treatment failure includes obtaining blood cultures, considering pleural fluid sampling, and switching to broader-spectrum coverage or adding vancomycin/clindamycin for MRSA coverage 3, 1, 2

For children with penicillin allergy, a trial of oral cephalosporin under medical supervision or use of levofloxacin or linezolid may be considered 3, 2
Oseltamivir or zanamivir should be added if influenza is suspected, and pleural effusion management includes no drainage for small effusions and consideration of chest ultrasound or CT for moderate to large effusions 3, 1