Children > 5 years

[Paediatr Child Health 2015;20:441-5, Clin Infect Dis 2011; Aug: e1-52, and Thorax 2011;66:ii1-23]

Diagnosis

- Chest x ray recommended to confirm diagnosis whenever possible and if deterioration to rule out empyema.

Macrolides:

• significant macrolide resistance in S. pneumoniae

• poor Haemophilus coverage

• recent (within previous 3 months) macrolide use may predispose to infection with multidrug resistant S. pneumoniae

• monotherapy with macrolides has uncertain efficacy for pneumococcal bacteremia (clinical history of rigors/positive blood cultures).

Doxycycline:

• excellent activity against most CAP pathogens, including S. pneumoniae (increasing resistance), H. influenzae, M. catarrhalis, S. aureus, including MRSA, M. pneumoniae, C. pneumoniae, and Legionella spp.

• less doxycycline resistance than macrolide resistance in S. pneumoniae

• has not been associated with causing an increase in penicillin resistance among S. pneumoniae (macrolides have)

• excellent pharmacokinetics/dynamics (high serum and lung levels, concentration-dependent killing)

• less expensive than newer macrolides.

- In sickle cell anemia, overwhelming pneumococcal infection can occur and Mycoplasma pneumoniae is common. There may be a small risk of hemolysis from ceftriaxone, so cefotaxime is preferred for inpatients (ceftriaxone for outpatients), plus a macrolide if 5 years of age or older.

Stepdown to oral therapy if:

• afebrile

• clinically improving

• tolerating oral intake

• no complications (e.g.empyema)

Mycoplasma pneumoniae
S. pneumoniae
H. influenzae
S. aureus/MRSA
Group A streptococci
Chlamydia pneumoniae
Viruses

Mild-moderate

Mild-moderate & Penicillin allergy ≤ 8 years old

Mild-moderate & Penicillin allergy > 8 years old

Mild-moderate & Post-influenza

Hospitalized

PICU admission