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

• If culture positive: based on cultures and susceptibilities.
• If culture negative: refer to Ambulatory CAP Treatment Guidelines

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.

Considerations

• 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

References

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.

Metadata
Approved A2SC Advisory April 2021