Empirical therapy for complicated late-onset CAP in term neonates, and CAP in children younger than 2 months

Although Streptococcus pneumoniae is the most common bacterial cause of CAP in children, Streptococcus pyogenes (group A streptococcus) and Staphylococcus aureus cause a significant number of cases of complicated CAP (eg cavitary or necrotising pneumonia, pneumatoceles on chest X-ray, postinfluenza pneumonia). For complicated late-onset CAP (occurring more than 72 hours after birth) in term neonates (gestational age 37 weeks or older), and complicated CAP in children younger than 2 months, replace the empirical therapy regimen with:

1cefotaxime 50 mg/kg intravenously cefotaxime

neonate 7 days or younger: 8-hourly

child older than 7 days and younger than 2 months not requiring intensive care support: 8-hourly

child older than 7 days and younger than 2 months requiring intensive care support: 6-hourly¹

1ceftriaxone (child 1 month or older) 50 mg/kg intravenously, daily; for children requiring intensive care support, use ceftriaxone 50 mg/kg intravenously, 12-hourly² ³ ceftriaxone

PLUS with either of the above regimens

vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for young infants and children. vancomycin

If the child does not have life-threatening CAP and local epidemiology indicates that methicillin-resistant S. aureus (MRSA) is likely to be susceptible to clindamycin, consider replacing vancomycin with clindamycin in the above regimen. Use⁴:

clindamycin 15 mg/kg up to 600 mg intravenously, 8-hourly. clindamycin

For term neonates and children younger than 2 months who have life-threatening CAP or if a severe toxin-mediated syndrome is suspected (ie staphylococcal or streptococcal toxic shock syndrome), add both clindamycin and vancomycin to cefotaxime or ceftriaxone (at the dosages above) and seek expert advice.

Review antibiotic therapy at 24 to 48 hours. If staphylococcal pneumonia is confirmed by investigations, see Staphylococcal pneumonia. For pneumonia confirmed to be caused by S. pyogenes, manage as for complicated S. pyogenes bacteraemia.

Seek expert advice for management of children younger than 2 months with complications of CAP, such as lung abscess, complicated parapneumonic effusion or empyema complicating CAP.

¹ Pharmacokinetics may be altered in children who are critically ill (eg because of enhanced kidney clearance or changes in volume of distribution). To ensure adequate drug exposure for patients with septic shock or requiring intensive care support, a modified dosage of cefotaxime is recommended. Once the critical illness has resolved, consider switching to the standard dosage.Return

² Ceftriaxone may be a suitable alternative to cefotaxime in term neonates who are not receiving intravenous calcium solutions (eg parenteral nutrition, compound sodium lactate [Hartmann solution], lactated Ringer solution) and do not have jaundice, hypoalbuminaemia, acidosis, unconjugated hyperbilirubinaemia, or impaired bilirubin binding – seek expert advice and see Practical information on using beta lactams: cephalosporins.Return

³ Pharmacokinetics may be altered in children who are critically ill (eg because of enhanced kidney clearance or changes in volume of distribution). To ensure adequate drug exposure for patients with septic shock or requiring intensive care support, a modified dosage of ceftriaxone is recommended. Once the critical illness has resolved, consider switching to the standard dosage.Return

⁴ There are more clinical and microbiological data to support the use of clindamycin than lincomycin. Intravenous lincomycin can be used at the same dosage if clindamycin is unavailable or if a local protocol recommends its use.Return