Pneumonia, Community-Acquired — Treatment Failure— Clinical Pathway: All Settings

Community Acquired Pneumonia Clinical Pathway – All Settings

CAP Treatment Failure

Treatment failure is defined as increasing respiratory distress, increasing respiratory support requirement, or worsening fever curve in a patient who received at least > 72 hrs of adequately dosed preferred first-line therapy.

  • Consider imaging (chest X-ray, chest ultrasound) to evaluate for complicated pneumonia (moderate-large effusion, empyema, or abscess). Consider testing and treatment for atypical organisms (e.g., mycoplasma, legionella) per recommendations for initial treatment.
    • For children with a clinical history most consistent with atypical pneumonia (prolonged duration of fever, cough, malaise, headache in children ≥ 5 yrs) who have failed first line treatment for pneumonia, it is reasonable to start treatment for atypical organisms without broadening antibiotics for typical bacteria.

Antibiotic Recommendations

For children with treatment failure not thought to be caused by atypical pneumonia, complicated pneumonia, or a viral illness.

Initial Empirical
Antibiotic Treatment		 Mild/Moderate Pneumonia
Transition to:		 Severe Pneumonia
Transition to:
High-Dose Amoxicillin
or
Ampicillin
  • Ampicillin-Sulbactam, IV:
    • 50 mg/kg/dose every 6 hours of ampicillin component
    • Max: 2,000 mg/dose rationale: ampicillin-sulbactam adds coverage for MSSA (now more common than MRSA at CHOP – see CHOP antibiogram) and respiratory gram-negatives (including beta-lactamase producing non-typeable H. influenzae)
  • or
  • Amoxicillin-Clavulanate, Oral:
    • Infants < 3 months:
      30 mg/kg/day of amoxicillin component in 2 divided doses
    • Infants ≥ 3 months, children, and adolescents:
      90 mg/kg/day of amoxicillin component in 2 divided doses
      Max: 2,000 mg/dose; 4,000 mg/day
  • or
  • Clindamycin, IV/Oral:
    • 14 mg/kg/dose every 8 hours
    • Max: 900 mg/dose IV or 600 mg/dose oral
      • If History of MRSA or high concern for MRSA pneumonia (e.g., severe lobar pneumonia, ill appearance); severe penicillin allergy
        • Rationale: clindamycin adds coverage for ~ 80% of CA-MRSA at CHOP (see CHOP antibiogram) and no coverage for respiratory gram-negatives. Review prior susceptibilities and consider alternatives for patients with a history of clindamycin resistant MRSA.
  • 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
    • 100 mg/kg/dose every 24 hours
      Max: 2,000 mg/dose
Clindamycin
  • Consider testing and treatment for atypical organisms (e.g., mycoplasma, legionella) per recommendations for initial treatment
  • Ampicillin-Sulbactam, IV:
    • 50 mg/kg/dose every 6 hours of ampicillin component
    • Max: 2,000 mg/dose rationale: ampicillin-sulbactam adds coverage for MSSA (now more common than MRSA at CHOP – see CHOP antibiogram) and respiratory gram-negatives (including beta-lactamase producing non-typeable H. influenzae)
  • or
  • Amoxicillin-Clavulanate, Oral:
    • Infants < 3 months:
      30 mg/kg/day of amoxicillin component in 2 divided doses
    • Infants ≥ 3 months, children, and adolescents:
      90 mg/kg/day of amoxicillin component in 2 divided doses
      Max: 2,000 mg/dose; 4,000 mg/day
  • or
  • Ceftriaxone, IV:
    • 100 mg/kg/dose every 24 hours
    • Max: 2,000 mg/dose
Clindamycin + Ceftriaxone
or
Vancomycin + Ceftriaxone
or
Ceftriaxone		 Consult Infectious Diseases Consult Infectious Diseases