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:

  • Most community acquired pneumonia, particularly in young children, is caused by viral infections and does not require antibiotic treatment.
  • Chemical/aspiration pneumonitis is common after aspiration events and does not warrant antibiotic therapy. Observation without antimicrobials is suggested for mild or moderately ill children. Aspiration pneumonitis generally occurs during the first 24 hours after an aspiration event. When it occurs, aspiration pneumonia usually develops at least 24-48 hours after aspiration.
  • The treatment tables below outline initial treatment recommendations. If increasing respiratory distress, increasing respiratory support requirement, or worsening fever curve after > 72 hrs of preferred first-line therapy at appropriate dosing, consider alternative diagnoses (e.g., viral infection) or antibiotic 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.
  • Review spectrum of activity of recommended CAP antibiotics.

Common Pathogens

Uncomplicated Pneumonia Complicated Pneumonia
Viruses (e.g., RSV, adenovirus, influenza) Streptococcus pneumoniae
Streptococcus pneumoniae Staphylococcus aureus (MSSA, MRSA)
Haemophilus influenzae Streptococcus pyogenes (Group A Streptococcus)
Moraxella catarrhalis  
Staphylococcus aureus (MSSA, MRSA)  
Streptococcus pyogenes (Group A Streptococcus)  
Mycoplasma pneumoniae  
Legionella pneumophilia (rare in children)  

Mild Pneumonia, Uncomplicated (Outpatient)

Defined as children without retractions, grunting, nasal flaring, or apnea; pulse oximetry > 90% in
room air; and non-toxic appearance. May include children with small, simple effusions.

First-Line Therapy Allergy to First-Line β-Lactam
Assess Need for Alternative		 Duration of Treatment/Comments
  • Amoxicillin, oral:
    • ≤ 3 months:
      30 mg/kg/day in 2 divided doses
    • > 3 months:
      90 mg/kg/day in 2 divided doses
      Max: 2,000 mg/dose
    • Clindamycin, oral:
      • 14 mg/kg/dose every 8 hours;
        Max: 600 mg/dose
 5 days

Moderate Pneumonia, Uncomplicated (Inpatient/ICU)

Defined as children with retractions, grunting, nasal flaring; pulse oximetry < 90% in room air or 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:
    • 50 mg/kg/dose every 6 hours
      Max: 2,000 mg/dose
  • or
  • Consider ceftriaxone IV monotherapy for unimmunized children
    • Ceftriaxone, IV:
      • 100 mg/kg/dose every 24 hours
      • Max: 2,000 mg/dose
  • If tolerating PO, no concern for
    enteral absorption
    • Amoxicillin, oral:
      • ≤ 3 months:
        30 mg/kg/day in 2 divided doses
      • > 3 months:
        90 mg/kg/day in 2 divided doses
        Max: 2,000 mg/dose
  • Clindamycin, IV/Oral:
    • 14 mg/kg/dose every 8 hours
    • Max: 900 mg/dose IV or 600 mg/dose oral
  • 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
  • Concurrent/recent influenza or other
    viral infection:
    • Ampicillin is the first-line antibiotic for most children with current/recent influenza infections where there is concern for bacterial superinfection
    • Anti-staphylococcal therapy could be considered on a case-by-case basis; staphylococcal pneumonia is associated with high fever, lobar infiltrate, and severe illness

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
      Max: 900 mg/dose
  • and
  • Ceftriaxone, IV:
    • 100 mg/kg/dose every 24 hours
      Max: 2,000 mg/dose
    • 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, 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
      Max: 900 mg/dose
  • and
  • Levofloxacin, IV:
    • ≥ 6 months and < 5 years:
      10 mg/kg/dose every 12 hours
      Max: 375 mg/dose
    • ≥ 5 years:
      10 mg/kg/dose every 24 hours
      Max: 750 mg/dose
  • 7 days from source control of effusion (e.g., chest tube removal or cessation of drainage if chest tube removal is delayed) or 7 days from afebrile for effusions not amenable to drainage
  • Consult Infectious Diseases for pneumonia with mod-large effusion, empyema, necrotizing pneumonia, or lung abscess

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
      Max: 750 mg/dose
    • ≥ 50 kg and/or > 18 years:
      15 mg/kg/dose every 8 hours
      Max: 1,000 mg/dose
  • and
  • Ceftriaxone, IV:
    • 100 mg/kg/dose IV every 24 hours
      Max: 2,000 mg/dose
    • 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, 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 hours
      Max: 750 mg/dose
    • ≥ 50 kg and/or > 18 years:
      15 mg/kg/dose every 8 hours
      Max: 1,000 mg/dose
  • and
  • Levofloxacin, IV:
    • ≥ 6 months and < 5 years:
      10 mg/kg/dose every 12 hours
      Max: 375 mg/dose
    • ≥ 5 years:
      10 mg/kg/dose every 24 hours
      Max: 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 source control of effusion (e.g., Chest tube removal or cessation of drainage if chest tube removal is delayed) or 7 days from afebrile for effusions not amenable to drainage
    • Consult Infectious Diseases for pneumonia with mod-large effusion, empyema, necrotizing pneumonia, or lung abscess

Atypical Pneumonia (All Settings and Severities)

  • Mycoplasma pneumonia is usually characterized by prolonged duration of fever, cough, malaise, headache in children ≥ 5 years. 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.
    • 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.
  • 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):
      • 10 mg/kg/dose on day one
        Max; 500 mg/day
        Followed by 5 mg/kg/dose once daily on days 2-5
        Max: 250 mg/day
    • or
  • 2nd Line
    • Levofloxacin, IV/Oral
      • ≥ 6 months and < 5 years:
        10 mg/kg/dose every 12 hours
        Max: 375 mg/dose
      • ≥ 5 years:
        10 mg/kg/dose every 24 hours
        Max: 750 mg/dose
  • 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; administer in addition to antibiotics above for typical CAP if the clinical syndrome is less compatible with atypical pneumonia.

Spectrum of Activity of Recommended CAP Antibiotics

  • The following table summarizes the anticipated activity of antibiotics against common CAP pathogens
  • CAP is often culture-negative, clinical response to antibiotics should guide treatment decisions
  • See also the CHOP Antibiogram
  S. pneumoniae Strep pyogenes
(Group A Streptococcus)		 H. influenzae MSSA MRSA Mycoplasma pneumoniae
Ampicillin ~ 95% susceptible          
Ampicillin-Sulbactam/
Amox-Clav		 ~ 95% susceptible          
Ceftriaxone            
Cefdinir*            
Clindamycin            
Vancomycin            
Levofloxacin            
Azithromycin            

*Oral cephalosporins are inferior to high-dose amoxicillin for S. pneumoniae due to poor oral absorption and higher levels of resistance among S. pneumoniae isolates.

  Active   Sometimes Active   Often Inactive   Intrinsic Resistance