The treatment of community-acquired
pneumonia (CAP) in children is empirical, being based on the knowledge of the etiology of CAP at different ages. As a result of currently available methods in everyday clinical practice, a microbe-specific diagnosis is not realistic in the majority of patients. Even the differentiation between viral, 'atypical' bacterial (Mycoplasma pneumoniae or Chlamydia pneumoniae) and 'typical' bacterial (Streptococcus pneumoniae) CAP is often not possible. Moreover, up to one-third of CAP cases seem to be mixed viral-bacterial or dual
bacterial infections. Recent serologic studies have confirmed that S. pneumoniae is an important causative agent of CAP at all ages. M. pneumoniae is common from the age of 5 years onwards, and C. pneumoniae is common from the age of 10 years onwards. In addition to age, the etiology and treatment of CAP are dependent on the severity of the disease.
Pneumococcal infections are predominant in children treated in hospital, and mycoplasmal
infections are predominant in children treated at home.In ambulatory patients with CAP,
amoxicillin (or
penicillin V [
phenoxymethylpenicillin]) is the drug of choice from the age of 4 months to 4 years, and at all ages if S. pneumoniae is the presumptive causative organism.
Macrolides, preferably
clarithromycin or
azithromycin, are the first-line drugs from the age of 5 years onwards. In hospitalized patients who need parenteral
therapy for CAP,
cefuroxime (or
penicillin G [
benzylpenicillin]) is the drug of choice.
Macrolides should be administered concomitantly if M. pneumoniae or C. pneumoniae
infection is suspected. Radiologic findings and
C-reactive protein (CRP) levels offer limited help for the selection of antibacterials; alveolar infiltrations and high CRP levels indicate
pneumococcal pneumonia, but the lack of these findings does not rule out bacterial CAP. Most guidelines recommend antibacterials for 7-10 days (except
azithromycin, which has a recommended
treatment duration of 5 days). If no improvement takes place within 2 days,
therapy must be reviewed.