TABLE 69-5.

Guide to Empirical Choice of Antimicrobial Agent for Treating Children with Community-Acquired Pneumonia

PATIENT CHARACTERISTICS	PREFERRED TREATMENT OPTIONS
Outpatient
<5 Years of Age
Presumed bacterial	Oral amoxicillin (90 mg/kg/day) in 2 doses or oral amoxicillin-clavulanate (90 mg/kg/day amoxicillin component) in 2 doses
Presumed atypical	Oral azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/day on days 2-5) or oral clarithromycin (15 mg/kg/day in 2 doses or oral erythromycin (40 mg/kg/day in 4 doses
≥5 Years of Age
Presumed bacterial	Oral amoxicillin (90 mg/kg/day in 2 doses to a maximum of 4 g/day) or oral amoxicillin-clavulanate (amoxicillin component, 90 mg/kg/day in 2 doses to a maximum dose of 4000 mg/day); add macrolide if cannot distinguish bacterial or atypical
Presumed atypical	Oral azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 to a maximum of 500 mg on day 1, followed by 250 mg on days 2-5) or oral clarithromycin (15 mg/kg/day in 2 doses to a maximum of 1 g/day) or erythromycin or doxycycline for children >7 yr old
Inpatient (All Ages)
Fully Immunized against S. pneumoniae and H. influenzae, and Low Local Level of Antibiotic Resistance in S. pneumoniae
Presumed bacterial	Ampicillin or penicillin G or ceftriaxone or cefotaxime; add vancomycin or clindamycin for suspected community-associated MRSA
Presumed atypical	Azithromycin (add β-lactam, if diagnosis of atypical pneumonia is in doubt); or clarithromycin or erythromycin; or doxycycline for children >7 yr old; or levofloxacin for children who have reached growth maturity or who cannot tolerate macrolides
Not Fully Immunized against S. pneumoniae and H. influenzae, or High Local Level of Antibiotic Resistance in S. pneumoniae
Presumed bacterial	Ceftriaxone or cefotaxime; addition of vancomycin or clindamycin for suspected community-associated MRSA; alternative: levofloxacin; addition of vancomycin or clindamycin for suspected community-associated MRSA
Presumed atypical	Azithromycin (add β-lactam if diagnosis in doubt); or clarithromycin or erythromycin; or doxycycline for children >7 yr old; or levofloxacin for children who have reached growth maturity or who cannot tolerate macrolides

MRSA, methicillin-resistant S. aureus.

Adapted from Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:e25-e76.