Because viruses cause most community-acquired pneumonias in young children, not all children require empirical antibiotic treatment for pneumonia. Recommended therapies in those without recent antibiotic exposure are listed in Table 110-1. Exceptional situations include lack of response to empirical therapy, unusually severe presentations, nosocomial pneumonia, and immunocompromised children susceptible to infections with opportunistic pathogens (Table 110-3). In contrast to pneumococcal meningitis, presumed pneumococcal pneumonia can be treated with high-dose cephalosporin therapy even with high-level penicillin resistance. Vancomycin can be used if the isolate shows high-level resistance and the patient is severely ill. For infants 4 to 18 weeks old with afebrile pneumonia most likely caused by C. trachomatis, a macrolide is the recommended treatment. Oseltamivir or zanamivir should be used if influenza is identified or suspected, ideally within 48 hours of symptom onset.
Table 110-3 Antimicrobial Therapy for Pneumonia Caused by Specific Pathogens* PATHOGEN RECOMMENDED TREATMENT ALTERNATIVE TREATMENT Streptococcus pneumoniae with MIC for penicillin ≤2.0 μg/mL Ampicillin or penicillin IV; amoxicillin PO Ceftriaxone, cefotaxime, clindamycin or vancomycin IV; Cefuroxime, cefpodoxime, levofloxacin†, or linezolid PO
Streptococcus pneumoniae with MIC for Ceftriaxone IV; levofloxacin† or linezolid PO Ampicillin, levofloxacin†, clindamycin or penicillin ≥4.0 μg/mL
Group A streptococcus Penicillin or ampicillin IV; amoxicillin or Ceftriaxone, cefotaxime, clindamycin or penicillin PO vancomycin IV; clindamycin PO
Group B streptococcus Penicillin or ampicillin IV; amoxicillin or Ceftriaxone, cefotaxime, clindamycin or penicillin PO vancomycin IV; clindamycin PO
Staphylococcus aureus, methicillin Cefazolin, oxacillin, or nafcillin IV; cephalexin Clindamycin or vancomycin IV; clindamycin susceptible (MSSA) PO PO
Staphylococcus aureus, methicillin resistant Clindamycin or vancomycin IV; clindamycin Linezolid IV or PO (MRSA) PO
IV, Intravenous; MIC, minimum inhibitory concentration; PO, per os (orally); TMP-SMX, trimethoprim-sulfamethoxazole. *Oral outpatient therapy may be used for mild illness. Intravenous inpatient therapy should be used for moderate to severe illness.
†Appropriate fluoroquinolones include moxifloxacin, gatifloxacin, levofloxacin, and gemifloxacin. Fluoroquinolones are contraindicated for children younger than 18 years of age and pregnant or lactating women. Tetracyclines are not recommended for children younger than 9 years.
‡Aminoglycoside dosing should be guided by serum antibiotic concentrations after a steady state has been reached.