Parenteral empiric antibiotics for inpatient treatment of pediatric community-acquired pneumonia^[1,2]

Age group and suspected pathogens	Suggested parenteral empiric agent(s)	Comments
1 to 6 months
Bacterial (not Chlamydia trachomatis or Staphylococcus aureus)	One of the following: Ceftriaxone Cefotaxime	If CA-MRSA is suspected, ADD one of the following: Vancomycin or clindamycin Ceftaroline* (alternative)
C. trachomatis	Azithromycin
≥6 months
Uncomplicated bacterial (not Mycoplasma pneumoniae, Chlamydia pneumoniae, or S. aureus)	One of the following: Ampicillin or penicillin G (preferred) Cefotaxime Ceftriaxone	Cefotaxime and ceftriaxone are reserved for: Children with incomplete Hib or Streptococcus pneumoniae immunizations, or Communities with substantial prevalence of penicillin-resistant S. pneumoniae (eg, ≥25%)
M. pneumoniae or C. pneumoniae	One of the following: Azithromycin Erythromycin Levofloxacin
Clinical syndrome (any age)	Suggested empiric parenteral agent(s)	Comments
Severe pneumonia	Combination therapy with one of the following: Ceftriaxone Cefotaxime PLUS one of the following: Azithromycin Erythromycin Doxycycline	Children with severe infection may benefit from broad-spectrum therapy that addresses both typical and atypical pathogens *If S. aureus* is a consideration, either*: ADD vancomycin or clindamycin, OR Provide therapy with ceftaroline PLUS azithromycin
Severe pneumonia requiring ICU admission	Combination therapy with: Vancomycin PLUS one of the following: Ceftriaxone Cefotaxime PLUS: Azithromycin PLUS: Antiviral treatment for influenza if the child is hospitalized during influenza season	*If S. aureus* is likely*: ADD nafcillin^¶, OR SUBSTITUTE linezolid for vancomycin and nafcillin, OR Use ceftaroline PLUS azithromycin PLUS antiviral treatment for influenza if the child is hospitalized during influenza season
Complicated pneumonia (eg, effusion/empyema, necrotizing process, abscess^Δ)	Combination therapy with one of the following: Ceftriaxone Cefotaxime PLUS: Clindamycin if S. aureus or anaerobic infection is a consideration	Potential pathogens include S. pneumoniae, S. aureus, and Streptococcus pyogenes Vancomycin is an alternative to clindamycin for children with allergy to clindamycin or high prevalence of clindamycin resistance in the community^◊ Monotherapy with ceftaroline is an alternative if S. aureus is a consideration

This table is meant for use with UpToDate content on the treatment of CAP in children. Refer to related UpToDate content for details regarding complete Hib and S. pneumoniae immunization, criteria for severe pneumonia, and pneumonia requiring ICU admission. Consultation with a specialist in infectious diseases for children is suggested for children with severe hypersensitivity to beta-lactam antibiotics (eg, penicillins and cephalosporins).

CA-MRSA: community-associated methicillin-resistant S. aureus; Hib: Haemophilus influenzae type b; ICU: intensive care unit; CAP: community-acquired pneumonia; MSSA: methicillin-susceptible S. aureus; MRSA: methicillin-resistant S. aureus.

* Ceftaroline is a fifth-generation cephalosporin. It is available in the United States for the treatment of pediatric CAP due to S. pneumoniae, MSSA, and H. influenzae in children ≥2 months of age. Although ceftaroline has in vitro activity against MRSA, experience in children with documented MRSA CAP is limited.

¶ Nafcillin is added if S. aureus is likely because MSSA is more rapidly killed by nafcillin than by vancomycin.

Δ Ampicillin-sulbactam alone may be effective if lung abscess is thought to be secondary to aspiration.

◊ The threshold prevalence of clindamycin-resistant MRSA (constitutive plus inducible) for choosing vancomycin varies from center to center, usually ranging from 10 to 25%, in an effort to balance the benefit of definitive therapy for the patient with the risk of increasing vancomycin resistance in the community. Additional considerations in the decision to choose vancomycin include the prevalence of MRSA in the community, the severity of illness, and the turn-around time for susceptibilities.

Data from:

McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
Bradley JS, Byington CL, Shah SS, 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:e25.

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Parenteral empiric antibiotics for inpatient treatment of pediatric community-acquired pneumonia[1,2]

Parenteral empiric antibiotics for inpatient treatment of pediatric community-acquired pneumonia^[1,2]