Pediatric Outpatient CAP - Alaska

last updated Jun 10, 2021 07:55 PM
Alaska Antimicrobial Stewardship Collaborative, ambulatory, infants & children 3 months of age and older, bacterial, atypical pneumonia

The following guidelines were prepared by the Alaska Antimicrobial Stewardship Collaborative (A2SC), and are reproduced here as a service to practitioners in the state.
These guidelines have not been reviewed or approved by the Sanford Guide Editorial Board.

Criteria for Respiratory Distress

  • Tachypnea, in breaths/min:
    • Age 0-2mo: >60
    • Age 2-12mo: >50
    • Age 1-5yo: >40
    • Age >5yo: >20
  • Dyspnea
  • Retractions
  • Grunting
  • Nasal flaring
  • Apnea
  • Altered mental status
  • Pulse oximetry <90% on room air

Criteria For Outpatient Management

  • Mild CAP: no signs of respiratory distress
  • Able to tolerate PO
  • No concerns for pathogen with increased virulence (ex. CA-MRSA)
  • Family able to carefully observe child at home, comply with therapy plan, and attend follow up appointments

 **NOTE: If patient does not meet outpatient management criteria refer to inpatient pneumonia guideline for initial workup and testing.

Testing/Imaging for Outpatient Management

  • Vital Signs: Standard VS and Pulse Oximetry
  • Labs: No routine labs indicated
    • Influenza PCR during influenza season
    • COVID testing
    • Blood cultures if not fully immunized OR fails to improve/worsens after initiation of antibiotics
    • Urinary antigen detection testing is not recommended in children; false-positive tests are common.
  • Radiography: No routine CXR indicated
    • AP and lateral CXR if fails initial antibiotic therapy
    • AP and lateral CXR 4-6 weeks after diagnosis if recurrent pneumonia involving the same lobe

Treatment Selection

Suspected Viral Pneumonia

  • Most Common Pathogens:
    • Influenza A & B
    • Adenovirus
    • Respiratory Syncytial Virus
    • Parainfluenza
  • Demographics:
    • Most common in <5yo
  • Preferred Treatment:
    • No antimicrobial therapy is necessary.
    • If influenza positive, see influenza guidelines for treatment algorithm.

Suspected Bacterial Pneumonia

  • Most Common Pathogens:
    • Streptococcus pneumoniae
    • Haemophilus influenzae

Previously Healthy AND Appropriately Immunized for Age

  • Preferred Treatment:
    • Amoxicillin 45mg/kg PO BID (Max dose 4000mg/day) x 5 days

Not Appropriately Immunized with PCV13 + Hib OR Suspicion for H. influenzae

  • Preferred Treatment:
    • Amoxicillin/clavulanate
      • <40kg: (ES 600mg/42.5mg/5mL) 45mg/kg PO BID or 15mg/kg PO TID (Max dose 4000mg/day) x 5 days
      • >40kg: 875mg/125mg PO BID PLUS Amoxicillin 1g PO BID x 5 days

Treatment Alternatives for β-Lactam Allergy

  • Non-anaphylactic β-Lactam Allergy:
    • Cefprozil suspension 15mg/kg PO BID (max 1000mg/day) x 5 days
    • Cefuroxime tablets 15mg/kg PO BID (Max 1000mg/day) x 5 days
  • Anaphylactic β-Lactam Allergy:
    • Levofloxacin
      • <5 years: 10mg/kg PO BID (Max dose 750mg/day) x 5 days
      • >5 years: 10mg/kg PO daily (Max dose 750mg/day) x 5 days

Duration Considerations

Exclusion criteria for short course therapy

  • Pneumonia with atypical pathogens
  • Hospital acquired pneumonia (admission for >48 hours in previous 2 months, CAP in previous month, or lung abscess in previous 6 months)
  • Empyema or necrotizing pneumonia
  • Preexisting pulmonary disease
  • Congenital heart disease
  • History of aspiration
  • Malignant neoplasm
  • Immunodeficiency
  • Kidney dysfunction

 **NOTE: Children should show clinical signs of improvement within 48-72 hours

Suspected Atypical Pneumonia

  • Most Common Pathogens:
    • Mycoplasma pneumoniae
    • Chlamydophila pneumoniae
  • Demographics:
    • Most common in ≥5yo
    • In ≥5yo, macrolide may be empirically added if there is no clinical evidence that distinguishes bacterial from atypical CAP
  • Preferred Treatment:
    • Azithromycin 10mg/kg PO daily (Max dose 500mg/day) x 3 days
  • Alternatives:
    • For children >7yo:
      • Doxycycline 1-2 mg/kg PO BID (Max dose 200mg/day) x 10 days


  1. Bradley IDSA CAP Infants & Children 2011;AAP endorsed.
  2. Ficnar B, et al. Azithromycin: 3-Day Versus 5-Day Course in the Treatment of Respiratory Tract Infections in Children. J Chemother. 1997;9(1):38-43.
  3. Kogan R, et al. Comparative Randomized Trial of Azithromycin versus Erythromycin and Amoxicillin for Treatment of Community acquired Pneumonia in Children. Pediatr Pulmonol. 2003; 35(2):91-8.
  4. Pernica JM et al. Short-Course Antimicrobial Therapy for Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatrics. 2021; Published online March 08, 2021.

Approved A2SC Advisory April 2021