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.

    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

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