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Initial oral empiric antibiotics for outpatient treatment of pediatric community-acquired pneumonia

Initial oral empiric antibiotics for outpatient treatment of pediatric community-acquired pneumonia
Age group Empiric regimen
1 to 6 months
Bacterial (not Chlamydia trachomatis) Infants <3 to 6 months of age with suspected bacterial pneumonia should be hospitalized
C. trachomatis Refer to UpToDate topic on C. trachomatis infections in the newborn
6 months to 5 years
Typical bacterial* Amoxicillin 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day), or
Amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin component in 2 or 3 divided doses (MAX 4 g/day amoxicillin component)
For children with mild reactions to a penicillin and no features of an IgE-mediated reactionΔ:
  • Amoxicillin 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day), or
  • Amoxicillin-clavulanate 90 mg/kg per day of the amoxicillin component in 2 or 3 divided doses (MAX 4 g/day amoxicillin component), or
  • An extended-spectrum cephalosporin, such as cefuroxime axetil 20 to 30 mg/kg per day in 2 divided doses (MAX 1 g/day) or cefpodoxime 10 mg/kg per day in 2 divided doses (MAX 400 mg/day) in communities with a low rate of pneumococcal resistance to penicillin
For children with IgE-mediated or serious delayed reaction to a penicillin:
  • Levofloxacin◊ 16 to 20 mg/kg per day in 2 divided doses (MAX 750 mg/day), or
  • Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 1.8 g/day), or
  • Linezolid 30 mg/kg per day in 3 divided doses (MAX 1.8 g/day)
In communities with a high rate of pneumococcal resistance to penicillin:
  • Levofloxacin◊ 16 to 20 mg/kg per day in 2 divided doses (MAX 750 mg/day), or
  • Linezolid 30 mg/kg per day in 3 divided doses (MAX 1.8 g/day)
≥5 years
Mycoplasma pneumoniae or Chlamydia pneumoniae Azithromycin 10 mg/kg on day 1 followed by 5 mg/kg daily for 4 more days (MAX 500 mg on day 1 and 250 mg thereafter), or
Clarithromycin 15 mg/kg per day in 2 divided doses (MAX 1 g/day), or
Erythromycin 40 to 50 mg/kg per day in 4 divided doses (MAX 2 g/day as base, 3.2 g/day as ethylsuccinate), or
Doxycycline 4 mg/kg per day in 2 divided doses (MAX 200 mg/day), or
Levofloxacin◊ 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 500 mg/day); 500 mg once daily for children ≥16 years, or
Moxifloxacin◊§ 400 mg once daily (≥18 years)
Typical bacterial* Amoxicillin 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day)
For children with mild reactions to a penicillin and no features of an IgE-mediated reactionΔ:
  • Amoxicillin 90 mg/kg per day in 2 or 3 divided doses (MAX 4 g/day), or
  • An extended-spectrum cephalosporin, such as cefuroxime axetil 20 to 30 mg/kg per day in 2 divided doses (MAX 1 g/day) or cefpodoxime 10 mg/kg per day in 2 divided doses (MAX 400 mg/day) in communities with a low rate of pneumococcal resistance to penicillin
For children with IgE-mediated or serious delayed reaction to a penicillin:
  • Levofloxacin◊ 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 750 mg/day); 750 mg once daily for children ≥16 years, or
  • Clindamycin 30 to 40 mg/kg per day in 3 or 4 divided doses (MAX 1.8 g/day), or
  • Linezolid 30 mg/kg per day in 3 divided doses (MAX 1.8 g/day) for children <12 years; 20 mg/kg per day divided in 2 doses (MAX 1.2 g/day) for children ≥12 years
In communities with a high rate of pneumococcal resistance to penicillin:
  • Levofloxacin◊ 8 to 10 mg/kg once daily for children 5 to 16 years (MAX 750 mg/day); 750 mg once daily for children ≥16 years, or
  • Linezolid 30 mg/kg per day divided in 3 doses (MAX 1.8 g/day) for children <12 years; 20 mg/kg per day divided in 2 doses (MAX 1.2 g/day) for children ≥12 years
Aspiration pneumonia
Community-acquired Amoxicillin-clavulanate 40 to 50 mg/kg per day in 2 or 3 divided doses (MAX 1.75 g/day amoxicillin component)
For children with mild reactions to a penicillin and no features of an IgE-mediated reactionΔ:
  • Amoxicillin-clavulanate 40 to 50 mg/kg per day in 2 or 3 divided doses (MAX 1.75 g/day amoxicillin component)
For children with IgE-mediated or serious delayed reaction to amoxicillin:
  • Clindamycin 30 to 40 mg/kg per day divided in 3 or 4 doses (MAX 1.8 g/day)
  • Moxifloxacin◊ 400 mg once daily (for ≥18 years)

IgE: immunoglobulin E; MAX: maximum.

* For the infant or child who is suspected to have bacterial community-acquired pneumonia and is unable to tolerate liquids at the time of presentation, a single initial dose of ceftriaxone (50 to 75 mg/kg) may be administered intramuscularly or intravenously before starting oral antibiotics.

¶ Preferred agent.

Δ The choice is individualized according to the drug allergy history and the ability to safely conduct an oral challenge if necessary. Refer to UpToDate content on penicillin allergy.

◊ In the United States, fluoroquinolones (eg, levofloxacin and moxifloxacin) are approved by the US Food and Drug Administration for community-acquired pneumonia for patients ≥18 years of age. However, they may be used in younger children if other antibiotics are inappropriate (eg, due to hypersensitivity or local antimicrobial resistance patterns).

§ Also covers typical bacterial pathogens.

Prepared with data from:
  1. McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
  2. 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.
  3. Kimberlin DW, Banerjee R, Barnett ED, et al. Tables of antibacterial drug dosages. In: Red Book: 2024-2027 Report of the Committee on Infectious Diseases, 33rd ed, American Academy of Pediatrics 2024.
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