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:
Treatment Alternatives for β-Lactam Allergy
- Non-anaphylactic β-Lactam Allergy:
- Anaphylactic β-Lactam Allergy:
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
- For children >7yo:
References
- Bradley IDSA CAP Infants & Children 2011;AAP endorsed.
- 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.
- 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.
- 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