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. 2011 Aug-Sep;16(7):417–420. doi: 10.1093/pch/16.7.417

TABLE 2.

Guidelines for empirical antimicrobial therapy for previously healthy children three months to 17 years of age with community-acquired, radiologically proven pneumonia of suspected bacterial etiology

Step 1: Assess severity and features of pneumonia*:

  1. Most cases of nonsevere pneumonia → high-dose amoxicillin PO or ampicillin IV

  2. Nonsevere pneumonia with primary features of atypical pneumonia (subacute onset, prominent cough, minimal leukocytosis and a nonlobar infiltrate, usually in a school-age child) → clarithromycin PO or azithromycin PO

  3. Severe pneumonia → ceftriaxone IM/IV or cefotaxime IV plus clarithromycin PO or azithromycin PO/IV

Step 2: Assess whether child has proven or clinically suspected influenza plus evidence of secondary bacterial infection†, consider adding an antiviral for influenza and use the following instead of the antibiotics from step 1†:

  1. Nonsevere pneumonia → amoxicillin/clavulanate PO or cefuroxime IV

  2. Severe pneumonia → ceftriaxone IM/IV or cefotaxime IV plus clarithromycin PO or azithromycin PO/IV. Some experts advise also adding cloxacillin IV

Step 3: If the child also has a pleural effusion‡:

  1. Small effusion → follow carefully for clinical deterioration and use antibiotics as directed in steps 1 and 2

  2. Moderate to large effusion → consider pleural tap‡. Treat with ceftriaxone or cefotaxime instead of antibiotics in steps 1 and 2. Some experts recommend adding clindamycin

Step 4: If the child has features that indicate pneumonia could be due to methicillin-resistantStaphylococcus aureus(MRSA)§, add vancomycin or linezolid to the antibiotics chosen after steps 1, 2 and 3

For penicillin-allergic children, see text under ‘Management’. Nonsevere pneumonia does not require hospital admission or requires admission and minimal supplemental oxygen (fraction of inspired oxygen lower than 0.30) and is in minimal respiratory distress. Severe pneumonia requires significant supplemental oxygen, patient is in moderate respiratory distress and may require intensive care.

*

The primary goal is to offer good coverage for pneumococcus. Ceftriaxone or cefotaxime may offer better coverage than amoxicillin or ampicillin for penicillin-resistant pneumococcus (although this remains controversial), and offer improved coverage for Haemophilus influenzae and Moraxella catarrhalis, but these are rare causes of pneumonia in healthy, immunized children. Clarithromycin and azithromycin do not always cover pneumococcus, so they should be reserved for children with suspected atypical pneumonia. Additionally, in patients who fail to improve after 48 h of therapy with a beta lactam alone (penicillin such as ampicillin or cephalosporins), one should first rule out an empyema and then consider adding clarithromycin or azithromycin for atypical pneumonia;

†

One would suspect secondary bacterial infection if the initial chest x-ray showed significant airspace consolidation or pleural fluid, or the child experienced clinical improvement followed by clinical and radiographic deterioration. Antibiotics should offer good coverage for pneumococcus, methicillin-susceptible Staphylococcus aureus (MSSA) and group A streptococcus. Some experts recommend adding cloxacillin because it will offer additional optimal coverage for MSSA;

‡

The decision to attempt a diagnostic or therapeutic tap of an effusion must be made after considering possible risks and benefits; size, location, and radiological, surgical and diagnostic resources must be considered. If the fluid is serous, management is clinical follow-up. If the fluid is exudative (pH lower than 7.20, glucose level lower than 2.2 mmol/L, lactose dehydrogenase level greater than 1000 U/L, significant white blood cell count, cloudy appearance or bacteria growth), the child likely has an empyema and ongoing drainage should be arranged, usually initially with a chest tube with or without fibrinolytics. Antibiotics should cover pneumococcus, group A streptococcus and MSSA. The need to routinely add additional anaerobic coverage with clindamycin is controversial. For more details, see the Canadian Paediatric Society practice point on management of complicated pneumonia in the present issue of Paediatrics & Child Health (22);

§

Features that should lead to empirical coverage for MRSA pneumonia pending investigations: Child has severe pneumonia and MRSA accounts for more than 5% of all S aureus in the community; child is colonized with MRSA and has severe pneumonia; or child has rapidly progressive disease or pneumatoceles on the chest x-ray, or child has features of septic shock or purpura fulminans. IM Intramuscularly; IV Intravenously; PO Orally