This is the final post in the PEMBlog community acquired pneumonia series. It focuses on treatment and disposition.

Who should be admitted?

Generally, the sickest kids should be admitted. Babies under 3 to 6 months should also be admitted unless they look absolutely PERFECT. Babies with Chlamydia trachomatis can look very well, and may be cared for at home with close follow up.

Here are some general criteria and select thoughts abut each.

If the patient is hypoxic

This is a sat <90% on room air. Obviously this correlates with a sicker child and precludes care at home.

The patient is dehydrated

Think moderate or worse. You can use ondansetron to help facilitate oral intake, though I wouldn’t use it in a baby under six months of age. If the kid is dehydrated and needs IV fluids this is one approach.

The patient has moderate to severe respiratory distress

Signs to look for are signs of increased work of breathing like retractions, grunting, nasal flaring and at worst apnea. Based on respiratory rate this could include those with rate >70 breaths/minute for infants under a year of age, and >50 breaths/minute for older children. Again, some children with bronchiolitis have these respiratory rates intermittently – make sure you are correctly differentiating between bronchiolitis and bacterial pneumonia. If the child has fever know that an extra 8 or so breaths/minute can be seen for each degree above 38 Celsius.

The patient has a complicated pneumonia

Somewhat ill appearing children with multifocal pneumonia, those with effusions and especially those with abscess/empyema should be admitted.

The patent just looks toxic

You know, in shock. Again, treat fever, and if the kid looks great after the fever is gone then you can be reassured.

The patient has a concerning past medical history

Children with genetic syndromes, cerebral palsy, cardiac disease and more can have a more significant course overall. Have a much lower threshold to admit these children.

The patient has failed outpatient treatment

Generally this means that they’ve worsened or had little to no response by 48 to 72 hours. Make sure you assess whether or not the child is actually getting the medicine. I know from personal experience that it is hard to give medicine to a two year old.

Antibiotics

So you’ve made the diagnosis of community acquired pneumonia – perhaps clinically. Now it is time to start treatment. I’ll start with the uncomplicated patient that is going to be discharged home.

Outpatient Treatment

First Line Therapy

Amoxicillin 90 mg/kg/day divided bid or tid (maximum dose is 4 g/day)

Consider if the patient has had Amoxicillin in the past 30 days

Amoxicillin-clavulanate 90 mg/kg/day of the amoxicillin component divided bid or tid (maximum dose also 4 g/day amoxicillin component)

For the patient with a penicillin allergy – non-type 1 hypersensitivity (not anaphylaxis)

Cefdinir 14 mg/kg/per day divided bid (maximum 600 mg/day)

Cefpodoxime 10 mg/kg/day divided bid (maximum 400 mg/day) only in children >5 years

For the patient with a penicillin allergy – AND type 1 hypersensitivity (anaphylaxis)

Levofloxacin 16 to 20 mg/kg/day divided bid (maximum 750 mg/day)

Clindamycin 30 to 40 mg/kg/day divided tid or qid (maximum 1.8 g/day)

Erythromycin 30 to 50 mg/kg/day divided qid (maximum 2 g/day as base, 3.2 g/day as ethylsuccinate)

Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (maximum 500 mg on day 1 and 250 mg thereafter)

Clarithromycin 15 mg/kg/day divided bid (maximum 1 g/day)

If you work in a community where pneumococcus has very high resistance to penicillins

Levofloxacin 16 to 20 mg/kg/day divided bid  (maximum 750 mg/day)

Linezolid 30 mg/kg/day divided tid (maximum 1800 mg/day)

Inpatient Treatment

1 to 6 months

If you don’t think it is Staph aureus or Chlamydia trachomatis

Ceftriaxone 50-100 mg/kg once per day (or perhaps divided bid for more severe disease)

Cefotaxime 150 mg/kg/day divided did or qid

If it is Chlamydia trachomatis

Azithromycin 10 mg/kg on Day #1 and #2, then 5 mg/kg on days 3-5. Try to go to oral ASAP

>6 months

If you are dealing with common causes (S.pneumo, Moraxella, H. flu)

Ampicillin 150-200 mg/kg per day in 4 divided doses (maximum 12 g/day), OR

Penicillin G 200,000-250,000 units/kg/day divided 4 to 6! times per day

Cefotaxime 150 mg/kg/day divided tid (maximum 8-10 g/day)

Ceftriaxone 50-100 mg/kg/day once or twice daily (maximum 2-4 g/day)

If you think Mycoplasma or Chlamydia may be the culprit

Consider one of the following agents alone or in conjunction with one of the above.

Azithromycin 10 mg/kg on Day #1 and #2, then 5 mg/kg thereafter for 5 days

Erythromycin 20 mg/kg/day divided qid (maximum 4 g/day)

Levofloxacin 16-20 mg/kg/day divided bid in ages 6 months to 5 years and 8-10 mg/kg/day divided bid in kids 8-15 years

If the patient has severe pneumonia

Ceftriaxone or cefotaxime AND Azithromycin, Erythromycin or Doxycycline (4 mg/kg/day divided bid – maximum 200 mg/day)

Defined as:

from the 2011 IDSA Guidelines for community acquired pneumonia

If the patient has severe pneumonia and is in the ICU (Think Staphylococcus aureus)

Vancomycin 60 mg/kg/day divided qid (maximum 4 g/day)

AND

Ceftriaxone or Cefotaxime

AND

Azithromycin

AND… maybe even

Nafcillin 150 mg/kg/day 4 to 6 times per day

AND yes…

an Antiviral for influenza

If the patient has an abscess/empyema

Ceftriaxone or Cefotaxime PLUS Clindamycin 30-40 mg/kg/day divided did or qid (maximum 3.6 g/day) or Vancomycin

If it is an aspiration pneumonia – not MRSA

Ampicillin-sulbactam 150-200 mg/kg/day qid (maximum 8 g/day of ampicillin component)

If it is an aspiration pneumonia – maybe MRSA

Clindamycin or Vancomycin

If the pneumonia is hospital acquired (nosocomial)

Gentamicin
<5 years: 7.5 mg/kg day divided tid
>5 years: 6-7.5 mg/kg/day divided tid

OR

Amikacin 15-22.5 mg/kg/day divided tid

PLUS one of the following

Piperacillin-tazobactam 300 mg/kg per divided qid (maximum 16 g/day)

Meropenem 60 mg/kg/day divided tid (maximum 3 g/day)

Ceftazidime 125 to 150 mg/kg /day divided tid (maximum 6 g/day), OR

Cefepime 150 mg/kg/day divided tid (maximum 4 g/day)

Clindamycin 30-40 mg/kg/day divided tid or qid (maximum 3.6 g/d)Indications for hospitalization

References

Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25-76.