Treatment
Supplemental oxygen should be initiated for any patient with a blood oxygen saturation <90% or a patient in respiratory distress with a blood oxygen saturation <95%. For critically ill children, a non-rebreather mask should be used. For children with cyanotic heart disease, inquire about baseline oxygen saturation on room air and use the patient’s normal range as the goal of oxygen therapy. Although not the sole determinant of final disposition, the IDSA and BTS guidelines recommend admission for oxygen saturation <92% in children with pneumonia.3,4
Antipyretics Oxygen
Early administration (preferably in triage) of weight-based dosing of acetaminophen or ibuprofen usually improves general appearance, along with decreasing heart rate and respiratory rate. A young child who has improved clinical status and vital signs after defervescence is reassuring to both parents and the Urgent Care clinician. While the clinician should not base assessment of the patient solely on these grounds, in the fully immunized patient, clinical assessment after antipyretic dosing is a useful adjunct in determining which children should have additional testing performed to assess for serious etiologies of fever. If a child still appears ill, or tachycardia and tachypnea persist after resolution of a fever, more serious causes should be considered.
Intravenous Fluids
Hydration status should be assessed in all patients. Oral hydration is preferred for those who can tolerate it. Aspiration events secondary to respiratory effort are rare. When intravenous fluids are given, care should be taken to avoid overhydration.121
Albuterol and Corticosteroids
In the febrile child with respiratory distress, the decision to give a trial of bronchodilators should be based on past medical and family history, in addition to physical examination findings. The absence of the classic end-expiratory wheeze should not deter clinicians from the use of bronchodilators in patients for whom there is a strong suspicion of asthma. The American Academy of Pediatrics guidelines recommend against the use of albuterol and ipratropium in patients with bronchiolitis,37 but this does not apply to patients with recurrent wheezing and suspected CAP, in whom a reactive component or asthma may be present. If there is no improvement, discontinuation of bronchodilators is appropriate. Systemic corticosteroids should be considered in children with wheezing that is responsive to bronchodilator therapy, even in patients with suspected CAP.122
Antibiotics
The IDSA states that “antimicrobial therapy is not routinely required for preschool-aged children with CAP, because viral pathogens are responsible for the great majority of clinical disease.”4 Antibiotic therapy can have numerous side effects including diarrhea and allergic reactions (anaphylaxis, serum sickness, and, rarely, Stevens–Johnson syndrome). Development of antibiotic resistance is also a concern.
A limitation of the guidelines is that specific guidance is not provided for when there should be concern for bacterial etiologies and when antibiotic therapy should be initiated. Based on the available literature and experience, we recommend using a combination of historical factors, physical examination findings, and radiographic findings (when indicated) to determine the need for antibiotics in preschool-aged children with CAP.
Empiric antibiotic therapy for children with suspected CAP is initially guided by the site of care, (ie, inpatient vs outpatient). Children who are well enough to be treated as outpatients are then further classified according to suspected pathogen and age. Table 2 summarizes the recommended outpatient empiric, antibiotic regimens for children with suspected CAP. For those with uncomplicated CAP of suspected bacterial etiology, high-dose amoxicillin is the first-line antibiotic due to its narrow spectrum and excellent activity against S pneumoniae. A multicenter, randomized, blinded, placebo-controlled, noninferiority trial compared low-dose amoxicillin (35-50 mg/kg/day) to high-dose amoxicillin and 3-day-versus-7-day duration of therapy for the treatment of uncomplicated outpatient CAP. The authors of this study concluded that low-dose amoxicillin was noninferior to high-dose amoxicillin for uncomplicated outpatient CAP. The shorter course of amoxicillin was associated with longer cough duration, but no other significant differences were found between the 3-day and 7-day durations for the treatment of uncomplicated outpatient CAP.123 Cephalosporins are not as effective as amoxicillin for some strains of pneumococcus.4
Although rates of resistance vary regionally, most S pneumoniae isolates in the United States are resistant to azithromycin, making this a poor choice for first-line therapy in suspected bacterial pneumonia. Azithromycin should only be used as dual therapy when atypical (mycoplasma) pneumonia is suspected. Though azithromycin is the mainstay of treatment for atypical pneumonia, evidence is lacking for its efficacy in treating this infection. High rates of resistance to azithromycin occur among mycoplasma isolates in other parts of the world, especially in Asia.
For children who require hospitalization for management of CAP, local resistance patterns and the immunization history must be considered. Table 3 summarizes the recommended empiric antibiotics that may be started, if available, in the Urgent Care setting prior to transfer for children with suspected CAP. For fully immunized patients with suspected bacterial CAP, ampicillin or penicillin G is recommended unless the patient is in an area with high rates of pneumococcus resistance to penicillin. Ceftriaxone is recommended empirically for unimmunized or under-immunized children, patients in areas with high rates of penicillin resistance, or life-threatening infection, such as empyema or shock.
Table 2. Empiric Outpatient Therapy for Children with Community-Acquired Pneumonia1
Empiric Therapy for Presumed Bacterial Pneumonia | Empiric Therapy for Presumed Atypical Pneumonia |
First-line: ● Amoxicillin PO 90 mg/kg/day, divided BID or TID, max 4 g/daya Alternatives: ● Amoxicillin/clavulanate PO (amoxicillin component, 90 mg/kg/day divided BID or TID, max 4 g/day) For patients with a penicillin allergy: ● Cefdinir PO 14 mg/kg, divided BID, max 600 mg/day ● Cefpodoxime PO 10 mg/kg, divided BID, max 400 mg/day For patients with a mild penicillin allergy: ● Clindamycin PO 40 mg/kg/day divided TIDb ● Levofloxacin PO 16-20 mg/kg/day, divided BID for children aged 6 months-5 years, max 750 mg/dose; 8-10 mg/kg/day once daily for children aged 5-16 years, max 750 mg/dose | First-line: ● Azithromycin PO 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5, max 500 mg on day 1, followed by 250 mg on days 2-5 Alternatives: ● Clarithromycin PO 15 mg/kg/day, divided BID, max 1 g/day for 7-14 days ● Erythromycin PO 40 mg/kg/day, divided 4 times a day, max 2000 mg/day ● For children aged >7 years, doxycycline PO 1 mg/kg BID, max 200 mg/day |
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Antibiotics are not routinely required for children aged <5 years with pneumonia if there is no suspicion of bacterial co-infection.
aFor children aged ≥5 years with clinical, laboratory, and radiographic evidence consistent with either pneumococcal or atypical community-acquired pneumonia, a macrolide can be added to a beta-lactam antibiotic for empiric therapy.
bSome areas have high rates of clindamycin-resistant S pneumoniae. Local antibiograms may be useful to determine the best antibiotic agent.
Abbreviations: BID, 2 times per day; PO, by mouth; TID, 3 times per day.
Table 3. Empiric Antibiotic Therapy for Children Hospitalized with Community-Acquired Pneumonia1
| Empiric Therapy for Presumed Bacterial Pneumonia | Empiric Therapy for Presumed Atypical Pneumonia |
● Fully immunized with conjugate vaccines for H influenzae type B and S pneumoniae ● Local penicillin resistance in invasive strains of pneumococcus is minimal (<25%) | First-line: ● Ampicillin IV 150-200 mg/kg/day, divided every 6 hours, max 2 g/dose; ● Penicillin G IV 200,000-250,000 units/kg/day, divided every 4-6 hours, max 24 million units/day
Alternatives: ● Ceftriaxone IV 50-100 mg/kg/day every 12-24 hours, max 2 g/day ● Cefotaxime 150 mg/kg/day, divided every 8 hours, max 2 g/dose ● For suspected CA-MRSA, consider addition of: ● Vancomycin IV 40-60 mg/kg/day, divided every 6-8 hours or dosing to achieve an AUC/MIC ratio of 400 ● Clindamycin PO or IV 40 mg/kg/day, divided every 6-8 hours, max PO 300 mg/dose, max IV 600 mg/dose | First-line: ● Azithromycin PO or IV 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5, max day 1 500 mg, max days 2-5 250 mg; in addition to beta-lactam if diagnosis is in doubt
Alternatives: ● Clarithromycin PO 15 mg/kg/day in 2 doses, max 1 g/day ● Erythromycin PO 40 mg/kg/day in 4 doses, max 2 g/day ● Doxycycline PO 2-4 mg/kg/day in 2 doses, max 100 mg/ dose for children aged > 7 years; ● Levofloxacin PO or IV 10 mg/kg/dose, divided every 12-24 hours, max 500 mg/dose, for children who have reached growth maturity or patients who cannot tolerate macrolides |
● Not fully immunized for H influenzae type B and S pneumoniae ● Local penicillin resistance in invasive strains of pneumococcus is significant (>25%) ● Life-threatening infection, including empyema | First-line: ● Ceftriaxone IV 50-100 mg/kg/day every 12-24 hours, max 2 g/day ● Cefotaxime 150 mg/kg/day, divided every 8 hours, max 2 g/dose Alternatives: ● Levofloxacin PO or IV 10 mg/kg/dose, divided every 12-24 hours, max 500 mg/dose, for children who have reached growth maturity ● For suspected CA-MRSA, consider addition of: ● Vancomycin IV 40-60 mg/kg/day, divided every 6-8 hours or dosing to achieve an AUC/MIC ratio of 400 ● Clindamycin PO or IV 40 mg/kg/day, divided every 6-8 hours, max PO 300 mg/dose, max IV 600 mg/dose | First-line: ● Azithromycin PO or IV 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5, max day 1 500 mg, max days 2-5 250 mg; in addition to beta-lactam if diagnosis is in doubt
Alternatives: ● Clarithromycin PO 15 mg/kg/day in 2 doses, max 1 g/day ● Erythromycin PO 40 mg/kg/day in 4 doses, max 2 g/day
Doxycycline PO 2-4 mg/kg/day in 2 doses, max 100 mg/dose for children aged > 7 years Levofloxacin PO or IV 10 mg/kg/dose, divided every 12-24 hours, max 500 mg/dose, for children who have reached growth maturity or patients who cannot tolerate macrolides |
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Antibiotics are not routinely required for children aged <5 years with clinical characteristics consistent with viral infection if there is no suspicion of bacterial co-infection.
Treatment should be started in the Urgent Care clinic or emergency department and continued once the patient is admitted.
Abbreviations: AUC/MIC, area under the curve to minimum inhibitory concentration; CA-MRSA, community-acquired methicillin-resistant S aureus; IV, intravenous; PO, by mouth.
Management of Parapneumonic Effusion and Empyema
Although small parapneumonic effusions or empyemas (<10 mm or <1/4 thorax opacified) often respond well to antibiotic therapy without additional interventions, most children with these complications will not be managed in the Urgent Care setting. Both the size and degree of respiratory compromise are important factors in determining management. Patients with moderate (>1/4 but <1/2 thorax opacified) or large (>1/2 thorax opacified) effusions are more likely to lead to respiratory impairment and should be transferred to a higher level of care for further evaluation as they are more likely to require drainage.
References
Excerpted from: Nedved A. Pediatric Community-acquired pneumonia: diagnosis and management in the Urgent Care setting. Evidence-Based Urgent Care. 2024 January;3(1):1-27. Reprinted with permission of EB Medicine.
