Treatment of Pneumonia in Children

Outpatient Treatment

The American Academy of Pediatrics recommends amoxicillin 90 mg/kg/day divided into 2 doses (maximum 4 g/day) as the first-line treatment for children ≥5 years old with presumed bacterial pneumonia 1, 2, 3, 4
For presumed atypical pneumonia alone, azithromycin 10 mg/kg on day 1 (maximum 500 mg), followed by 5 mg/kg/day once daily on days 2-5 (maximum 250 mg) is recommended 1, 2, 4
Adding a macrolide to the β-lactam is recommended if clinical, laboratory, or radiographic features do not clearly distinguish bacterial from atypical pneumonia 1, 2, 4

The Infectious Diseases Society of America recommends ampicillin or penicillin G intravenously as first-line therapy for fully immunized children with minimal local penicillin resistance 1, 2, 4
Ceftriaxone or cefotaxime are recommended as first-line therapy for not fully immunized or significant local penicillin resistance 1, 2, 4
Vancomycin or clindamycin should be added for suspected community-associated MRSA 1, 2, 4, 5

Oseltamivir or zanamivir should be added if influenza is suspected 2, 3, 4, 6
Clinical improvement should be assessed within 48-72 hours of starting therapy 1, 3, 7
Treatment failure may indicate resistant organisms, inadequate dosing, poor compliance, or other underlying conditions 7

Macrolides should not be relied upon solely for typical bacterial pneumonia, but rather reserved for atypical pathogens or added to β-lactams when diagnosis is uncertain 1, 2
Amoxicillin should not be underdosed, as the 90 mg/kg/day dose is critical to overcome resistant Streptococcus pneumoniae strains 1, 5

The American Academy of Pediatrics and Infectious Diseases Society of America recommend azithromycin as the first-line treatment for community-acquired pneumonia in children allergic to amoxicillin, at a dose of 10 mg/kg on day 1 (maximum 500 mg) and 5 mg/kg/day on days 2-5 (maximum 250 mg/day) 8
Azithromycin provides excellent coverage for both typical bacterial pathogens (Streptococcus pneumoniae) and atypical organisms (Mycoplasma pneumoniae, Chlamydophila pneumoniae), which are increasingly common in children ≥5 years of age 9, 8

The British Thoracic Society recommends hospitalization for children with community-acquired pneumonia who have oxygen saturation ≤92% on room air, respiratory rate >50 breaths/min, difficulty breathing or grunting, signs of dehydration, or inability of family to provide appropriate observation 9, 10

For penicillin-allergic patients requiring hospitalization, the Infectious Diseases Society of America recommends azithromycin IV 10 mg/kg on days 1 and 2, then transition to oral therapy, and adding vancomycin or clindamycin if MRSA is suspected 8

The Infectious Diseases Society of America recommends reassessing clinical response within 48-72 hours, and considering treatment failure due to resistant organisms, complications, or alternative diagnosis if no improvement occurs 8