The following guidelines were prepared by the Alaska Antimicrobial Stewardship Collaborative (A2SC), and are reproduced here as a service to practitioners in the state.
These guidelines have not been reviewed or approved by the Sanford Guide Editorial Board.

Initial Testing/Imaging

  • Vital Signs: VS including BP and Pulse Oximetry
  • Labs:
    • Blood work: CBC with differential, CRP, blood culture
    • Viral Testing: Influenza PCR during influenza season and COVID
    • Sputum gram stain and culture: if intubating, collect at time of initial ET tube placement; consider testing in older children who can produce sputum sample
    • Urinary antigen detection testing is not recommended in children; false-positive tests are common.
  • Radiography:
    • AP and lateral CXR

Inpatient Admission Criteria

  • Pediatric Floor
    • Respiratory distress
    • SpO2 <90% on room air
    • Unable to tolerate PO
    • Suspected or documented CAP caused by pathogen with increased virulence (ex. CA-MRSA)
    • Concerns about observation at home, inability to be comply with therapy, inability to be followed up
  • PICU
    • Respiratory support: Intubated or requiring non-invasive positive pressure ventilation
    • Concern for respiratory failure
    • Concern for sepsis
    • FiO2 needs HFNC >50% to keep saturation ≥92%
    • Altered mental status

Treatment Selection

Suspected Bacterial Pneumonia

  • Most Common Pathogens:
    • Streptococcus pneumoniae
    • Haemophilus influenzae

Previously Healthy AND Fully Immunized

  • Parenteral Treatment
    • Preferred: Ampicillin 50mg/kg IV q6hr (max 12g/day)
    • Alternatives:
      • Non-Type 1 β-Lactam Allergy: Ceftriaxone 50mg/kg IV q24hr (max 2g/day)
      • Type 1 β-Lactam Allergy: Levofloxacin
        • <5 years: 10mg/kg IV BID (max dose 750mg/day)
        • >5 years: 10mg/kg IV q24hr (max dose 750mg/day)

Not Appropriately Immunized with PCV13 + Hib OR Suspicion for H. influenzae OR Severe Disease and/or Complicated Pneumonia

  • Parenteral Treatment
    • Preferred: Ceftriaxone 50mg/kg IV q24hr (max 2g/day)
    • Alternatives:
      • Type 1 β-Lactam Allergy: Levofloxacin
        • <5 years: 10mg/kg IV/PO BID (max dose 750mg/day)
        • >5 years: 10mg/kg IV/PO q24hr (max dose 750mg/day)

Oral Step-Down

Antibiotic Choice

Antibiotic Duration

  • Uncomplicated pneumonia: complete a 10 day course
  • Complicated pneumonia: dependent on clinical response, in general 2-4 week course

Suspicion for S. aureus

  • Parenteral Treatment:
    • In addition to one of the above antibiotics, ADD Clindamycin 10mg/kg IV q6hr (max 900mg/dose)
    • For PICU or Severe Infection: Vancomycin 15mg/kg IV q6hr (max 4g/day)
  • Oral Step-Down:
    • Antibiotic choice: Based on cultures and susceptibilities
    • Antibiotic duration: May require longer treatment

Suspected Atypical Pneumonia

  • Most Common Pathogens:
    • Mycoplasma pneumoniae
    • Chlamydophila pneumoniae
  • Demographics:
    • In ≥5yo empirically add macrolide if atypical CAP cannot be ruled out
  • Preferred Treatment:
    • Azithromycin 10mg/kg IV daily x 1-2 days then transition to oral step down if possible (max 500mg/dose)
  • Oral Step-Down:
    • Azithromycin 10mg/kg PO daily to complete a 3 day course (max 500mg/dose)

Suspected Viral Pneumonia

  • Most Common Pathogens:
    • Influenza A & B
    • Adenovirus
    • Respiratory Syncytial Virus
    • Parainfluenza
  • Demographics:
    • Most common in <5yo
  • Preferred Treatment:
    • No antimicrobial therapy is necessary.
    • If influenza positive, see influenza guidelines for treatment algorithm.


  • Children should show clinical signs of improvement within 48-72 hours allowing de-escalation of therapy based on available culture results and consideration of transition to oral step-down therapy
  • If no improvement or worsening, pursue further diagnostic work up as indicated, consider broadening antibiotics and formal infectious disease consultation


  1. Bradley IDSA CAP Infants & Children 2011; AAP endorsed
  2. Ficnar B, et al. Azithromycin: 3-Day Versus 5-Day Course in the Treatment of Respiratory Tract Infections in Children. J Chemother. 1997;9(1):38-43.
  3. Kogan R, et al. Comparative Randomized Trial of Azithromycin versus Erythromycin and Amoxicillin for Treatment of Community-acquired Pneumonia in Children. Pediatr Pulmonol. 2003; 35(2):91-8.

Approved A2SC Advisory April 2021

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