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Ambulatory Management

What empiric antibiotics are recommended to treat uncomplicated pneumonia?

-We strongly recommend based on low quality evidence treatment for 5-7 days with high dose amoxicillin (80-100 mg/kg/day divided twice a day) for patients with uncomplicated pneumonia. We strongly recommend based on low quality evidence treatment for 5-7 days with high dose amoxicillin (80-100 mg/kg/day divided twice a day) for patients with uncomplicated pneumonia.

Children's Mercy's original CAP CPG recommended treatment duration of 5-7 days for patients with uncomplicated CAP. In reviewing the implementation of CMH’s CAP CPG, providers at CMH were consistent with prescribing a 10 day course of antibiotics for suspected bacterial uncomplicated CAP in hospitalized patients despite the recommendation (Newman, Hedican et al. 2012). On review of the literature, length of therapy for CAP in pediatrics is not outlined in any clinical studies. Two published studies from the developing world, specifically India and Pakistan, found equal effectiveness in treatment of amoxicillin using 3 and 5 days course treatments (2002; Agarwal, Awasthi et al. 2004). The British Thoracic Society guideline comments that it’s unlikely the results of these studies can be applied to the developed world with concerns over the diagnostic methods used without the assistance of modern medical equipment or viral testing (Harris, Clark et al. 2011). 

The PIDS/IDSA guideline discusses that a shorter course of therapy may be effective as longer courses, especially in patients with milder disease. The authors comment that 10 day courses of antibiotics for CAP are best studied, but no cited studies are identified in their evidence review with the exception to a reference to antibiotic registration trials. The guideline also recommends treating for the shortest effective duration to minimize resistance to antimicrobials (Bradley, Byington et al. 2011).

The PIVOT trial out of England had a primary objective to determine whether equivalence exists for the treatment of CAP in pediatrics with oral amoxicillin (low dose) and IV penicillin therapy. Interestingly, oral therapy was found to be as effective as IV in patients without severe disease. Both groups of patients were treated for a total of 7 days. Negative outcomes including treatment failure were minimal with only 8 of 203 total patients requiring further antibiotics. Although the goal of this study was not to research length of therapy, it is the only report we are aware of identifying limited treatment failure with a 7 day course of antibiotics (Atkinson, Lakhanpaul et al. 2007).

Based on the pharmacotherapy of amoxicillin and adult recommendations for short course therapy in CAP (Mandell, Wunderink et al. 2007), ventilator associated pneumonia and hospital acquired pneumonia (Chastre, Wolff et al. 2003; Pugh, Cooke et al. 2010), we advocate for short course therapy, a total of 5-7 days, for patients suspected of uncomplicated community acquired bacterial pneumonia. 

What empiric antibiotic alternatives to penicillin are recommended to treat CAP for patients with a history of type I hypersensitivity reactions?

-We strongly recommend based on very low quality evidence alternatives to penicillin for patients with a history of type I hypersensitivity reactions.

Antimicrobial recommendations for patients that have had a NON-type I hypersensitivity to penicillin (a reaction without hives or anaphylaxis) include oral clindamycin or an anti-pneumococcal cephalosporin.  Anti-pneumococcal cephalosporins are cefuroxime, cefpodoxime, and cefprozil; however, they are more difficult to find in- stock in community pharmacies than clindamycin.  Therefore if prescribing, please call the pharmacy 1 day prior to discharge and send the prescription.  According to the pediatric CAP guidelines, cefdinir is not recommended for oral therapy.

Patients with a history of anaphylaxis should be treated with clindamycin (Bradley, Byington et al. 2011). Recommendations in the PIDS/IDSA guideline for patients with a history of anaphylaxis, where a medically observed trial of an oral cephalosporin is not appropriate, include the use of levofloxacin, or linezolid (both which require ID approval for use if prescribing inpatient.)

What empiric antibiotics are recommended to treat atypical CAP?

-We recommend based on low quality evidence consideration of treatment with a macrolide in patients suspected of atypical pneumonia.

Pediatric patients suspected of lower respiratory tract infections caused by Mycoplasma pneumonia are typically school aged children (age 5-18 years). Treatment recommendations for this patient population include the use of macrolides based on retrospective and adult studies as well as the effectiveness of this antibiotic class against this pathogen (Bradley, Byington et al. 2011).

Significant macrolide resistance exists for Streptococcus pneumoniae isolates making antibiotics such as azithromycin a poor choice for patients suspected of typical bacterial CAP. The 2011 CMH antibiogram demonstrated that 65% of S. pneumoniae were resistant to macrolides.

The British Thoracic Society guideline promotes the use of macrolide antibiotics at any age if no response is seen to first line empirical therapy or if Mycoplasma or Chlamydia is suspected (Harris, Clark et al. 2011). 
Review of primary literature suggests that there is insufficient evidence to conclude that treatment with a macrolide antibiotic either decreases the severity of symptoms or shortens the course of CAP caused by atypical pathogens (Harris, Kolokathis et al. 1998; Bradley, Arguedas et al. 2007)


These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.