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.

    Criteria for Respiratory Distress

    • Tachypnea, in breaths/min:
      • Age 0-2mo: >60
      • Age 2-12mo: >50
      • Age 1-5yo: >40
      • Age >5yo: >20
    • Dyspnea
    • Retractions
    • Grunting
    • Nasal flaring
    • Apnea
    • Altered mental status
    • Pulse oximetry <90% on room air

    Criteria For Outpatient Management

    • Mild CAP: no signs of respiratory distress
    • Able to tolerate PO
    • No concerns for pathogen with increased virulence (ex. CA-MRSA)
    • Family able to carefully observe child at home, comply with therapy plan, and attend follow up appointments

     **NOTE: If patient does not meet outpatient management criteria refer to inpatient pneumonia guideline for initial workup and testing.

    Testing/Imaging for Outpatient Management

    • Vital Signs: Standard VS and Pulse Oximetry
    • Labs: No routine labs indicated
      • Influenza PCR during influenza season
      • COVID testing
      • Blood cultures if not fully immunized OR fails to improve/worsens after initiation of antibiotics
      • Urinary antigen detection testing is not recommended in children; false-positive tests are common.
    • Radiography: No routine CXR indicated
      • AP and lateral CXR if fails initial antibiotic therapy
      • AP and lateral CXR 4-6 weeks after diagnosis if recurrent pneumonia involving the same lobe

    Treatment Selection

    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.

    Suspected Bacterial Pneumonia

    • Most Common Pathogens:
      • Streptococcus pneumoniae
      • Haemophilus influenzae

    Previously Healthy AND Appropriately Immunized for Age

    • Preferred Treatment:
      • Amoxicillin 45mg/kg PO BID (Max dose 4000mg/day) x 5 days

    Not Appropriately Immunized with PCV13 + Hib OR Suspicion for H. influenzae

    • Preferred Treatment:
      • Amoxicillin/clavulanate
        • <40kg: (ES 600mg/42.5mg/5mL) 45mg/kg PO BID or 15mg/kg PO TID (Max dose 4000mg/day) x 5 days
        • >40kg: 875mg/125mg PO BID PLUS Amoxicillin 1g PO BID x 5 days

    Treatment Alternatives for β-Lactam Allergy

    • Non-anaphylactic β-Lactam Allergy:
      • Cefprozil suspension 15mg/kg PO BID (max 1000mg/day) x 5 days
      • Cefuroxime tablets 15mg/kg PO BID (Max 1000mg/day) x 5 days
    • Anaphylactic β-Lactam Allergy:
      • Levofloxacin
        • <5 years: 10mg/kg PO BID (Max dose 750mg/day) x 5 days
        • >5 years: 10mg/kg PO daily (Max dose 750mg/day) x 5 days

    Duration Considerations

    Exclusion criteria for short course therapy

    • Pneumonia with atypical pathogens
    • Hospital acquired pneumonia (admission for >48 hours in previous 2 months, CAP in previous month, or lung abscess in previous 6 months)
    • Empyema or necrotizing pneumonia
    • Preexisting pulmonary disease
    • Congenital heart disease
    • History of aspiration
    • Malignant neoplasm
    • Immunodeficiency
    • Kidney dysfunction

     **NOTE: Children should show clinical signs of improvement within 48-72 hours

    Suspected Atypical Pneumonia

    • Most Common Pathogens:
      • Mycoplasma pneumoniae
      • Chlamydophila pneumoniae
    • Demographics:
      • Most common in ≥5yo
      • In ≥5yo, macrolide may be empirically added if there is no clinical evidence that distinguishes bacterial from atypical CAP
    • Preferred Treatment:
      • Azithromycin 10mg/kg PO daily (Max dose 500mg/day) x 3 days
    • Alternatives:
      • For children >7yo:
        • Doxycycline 1-2 mg/kg PO BID (Max dose 200mg/day) x 10 days

    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.
    4. Pernica JM et al. Short-Course Antimicrobial Therapy for Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatrics. 2021; Published online March 08, 2021.

    Metadata
    Approved A2SC Advisory April 2021

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