*High dose amoxicillin (80-90mg/kg/day) PO in 2 divided doses (max. 4000mg/day) for 5-7 days

Oral weight bands:

3-5kg: 250mg q12h

6-9kg: 375mg q12h

10-14kg: 500mg q12h

15-19kg: 750mg q12h

> 20kg: 500mg q8h or 1g q12h

For influenza: If suspected, treatment to be initiated as early as possible.

Oseltamivir

<9 months old: 3mg/kg PO q12h for 5 days

9-11 months old: 3.5mg/kg PO q12h for 5 days

1-12 years old:

 ≤15 kg: 30mg PO q12h

>15-23kg: 45mg PO q12h

>23-40kg: 60mg PO q12h

>40 kg: 75mg PO q12h

Treatment for 5 days

Erythromycin ethylsuccinate 30-50mg/kg/day PO in 2 divided doses (max. 2g/day)

Antibiotics are not routinely recommended since viral infection is more common. For infant & children admitted to hospital, treat as presumed bacterial unless viral origin is known. 

Macrolide antibiotics should be used if either mycoplasma or chlamydia pneumonia is suspected. It may be started in school-going children where disease predominates.

Duration: minimum 5 days and until afebrile for 2-3 days in empiric therapy with absence of an identified specific etiology and specific therapy with known pneumonia due to pneumococcus, HI & Moraxella catarrhalis.

* At least 40mg/kg/dose, children who do not respond to oral Amoxicillin should be referred to the center with appropriate second line treatment.

Experts recommend using high dose amoxicillin to overcome resistance conferred by cell wall changes of the bacteria (pneumococcus).

Standard dose: Amoxicillin 45-50mg/kg/day PO in 3 divided doses for 5-7 days, to be considered only for children who cannot tolerate high doses.

Benzylpenicillin 150,000-200,000units/kg IV in 3-4 divided doses (max. 24million unit/day) for 5-7 days

Second line/partially treated

Cefuroxime 100-150mg/kg/day IV in 3 divided doses (max. 6g/day)

OR

Amoxicillin/clavulanate 25mg/kg/dose IV q8h (Amoxicillin max. 1g/dose) *

Macrolide antibiotics should be used if either mycoplasma or Chlamydia pneumonia is suspected.

*Amoxicillin dosage, 5:1 formulation 

Cefotaxime 150-200mg/kg/day in 3 to 4 divided doses (max. 8g/day)

OR

Ceftriaxone 75-100mg/kg/day in 2 divided doses (max. 4g/day)

MAY ADD

*Azithromycin 10mg/kg/dose (max. 500mg) IV q24h on Day 1; then 5mg/kg/dose (max. 250mg) on Day 2-5 if considering atypical organisms 

Cefuroxime 100-150mg/kg/day IV in 3 divided doses (max. 6g/day)

MAY ADD

*Azithromycin 10mg/kg/dose (max. 500mg/day) IV q24h on Day 1; then 5mg/kg/dose (max. 250mg/day) on Day 2-5 if considering atypical organisms 

Duration: 5-7 days. Consider longer treatment and assess for complications e.g empyema, if patient not fully recovered.

For the management of empyema, refer to Empyema thoracis section.

*The role of antimicrobials in treating both M. pneumoniae and C. pneumoniae is unknown because most children resolve infection without macrolides, treatment may be appropriate to hasten recovery in children who are more seriously ill or have a persistent cough.

Macrolide resistance is now very common in M. pneumoniae in Asia and routine use should be avoided.

Cefuroxime 100-200mg/kg/day IV in 3 divided doses (max. 4.5g/day)

OR

Cefotaxime 200-300/kg IV in 4 divided doses (max.8g/day)

PLUS

Cloxacillin 200-300mg/kg/day IV in 4-6 divided doses (max.12g/day)

Duration: 4-6 weeks

Staphylococcus aureus (methicillin-sensitive)

Cloxacillin 200-300mg/kg/day IV in 4-6 divided doses (max.12g/day) for 4-6 weeks

Streptococcus pneumoniae (penicillin-sensitive)

Benzylpenicillin 200,000-300,000 units/kg/day IV in 4-6 divided doses (max. 24 million unit/day)

Streptococcus pneumoniae (penicillin- resistant, use result of C&S)

Cefotaxime 200-300mg/kg/day IV in 4 divided doses (max. 8g/day)

OR

Ceftriaxone 100mg/kg/day IV in 1-2 divided doses (max. 4g/day)

Based on C&S of pleural fluid/tissue or blood culture.

All children with empyema need to receive high dose antibiotic therapy via intravenous route to ensure pleural penetration.

Pneumatocele on chest x-ray indicate S. aureus BUT they can also be seen in pneumococcal disease.

There is NO CONSENSUS on how long antibiotic needs to be given. Most recommend 3-6 weeks of total antibiotics depending on severity.

For moderate to severe or Stage 1-2 parapneumonic effusion, to consider pleural drainage and intrapleural fibrinolytic agent on top of antimicrobial therapy.

Stage 2 failed medical therapy and stage 3 empyema thoracis need surgical intervention. (Refer Empyema Thoracic in Children: Consensus Guideline from Malaysia Pediatric Empyema Thoracic Working Group 2020 Edition)