Low-severity CAP in children 2 months or older

Empirical therapy for community-acquired pneumonia (CAP) in children 2 months or older is stratified according to disease severity – see Assessment of severity and clinical features of CAP in children 2 months or older.

Viruses are the most common cause of CAP in children 2 months or older. Treat symptoms with:

paracetamol or ibuprofen for fever or pain (see Oral drugs for mild, acute nociceptive pain in children for dosing)
fluids to achieve and maintain adequate hydration.

Ask the carer to bring the child back for reassessment if symptoms are not improving after 48 to 72 hours, or earlier if symptoms worsen.

Note: Viruses are the most common cause of CAP in children 2 months or older.

If antibiotic therapy is required for children 2 months or older with low-severity CAP, monotherapy that targets Streptococcus pneumoniae (the most common cause of bacterial CAP) is recommended. UseBielicki, 2021 Harris, 2011 McMullan, 2016:

amoxicillin 25 mg/kg up to 1 g orally, 8-hourly for 3 days. amoxicillin

For children 3 months or older with low-severity CAP who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use:

cefuroxime (child 3 months or older) 15 mg/kg up to 500 mg orally, 12-hourly for 3 days¹. cefuroxime

For children in whom a suitable formulation of cefuroxime is not available, azithromycin may be used as an alternative at the dosages used below.

For children 2 months or older with low-severity CAP who have had a severe (immediate or delayed)² hypersensitivity reaction to a penicillin, use:

1azithromycin 10 mg/kg up to 500 mg orally, daily for 3 days azithromycin

2clarithromycin 7.5 mg/kg up to 500 mg orally, 12-hourly for 3 days clarithromycin

2doxycycline orally, 12-hourly for 3 days³ ⁴ doxycycline

child less than 21 kg: 2.2 mg/kg

child 21 to less than 26 kg: 50 mg

child 26 to 35 kg: 75 mg

child more than 35 kg: 100 mg.

If available, modify treatment based on the results of investigations, including susceptibility testing – see Directed therapy for pneumonia.

If the child is not improving after 48 to 72 hours, reassess the diagnosis. Consider infective and noninfective diagnoses. If CAP remains the likely diagnosis, reassess disease severity and consider whether to admit the child to hospital. See Approach to managing children 2 months or older with CAP who are not improving for further considerations.

¹ Cefuroxime is preferred to cefalexin or cefaclor because of its superior antipneumococcal activity; see Practical information on using beta lactams: cephalosporins for further information.Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse. Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return

³ An oral liquid formulation of doxycycline is not marketed in Australia but is available via the Special Access Scheme. For formulation options for children or people with swallowing difficulties, see Don’t Rush to Crush, which is available for purchase from the Advanced Pharmacy Australia website or through a subscription to eMIMSplus.Return

⁴ When used short term (eg less than 21 days), doxycycline has not been associated with tooth discolouration, enamel hypoplasia or bone deposition so can be used in children of all ages.Return