Management of Community Acquired Pneumonia in Infants and Children Older than 3 Months of Age Daniel Urschel, MD, Charles Pace, MD, Sherman Alter, MD Department.

Management of Community Management of Community Acquired Pneumonia in Acquired Pneumonia in

Infants and Children Older Infants and Children Older than 3 Months of Age than 3 Months of Age

Daniel Urschel, MD, Charles Daniel Urschel, MD, Charles Pace, MD, Sherman Alter, MDPace, MD, Sherman Alter, MDDepartment of Pediatrics, Department of Pediatrics, Boonshoft School of Medicine, Boonshoft School of Medicine, Wright State University, The Wright State University, The Children’s Medical Center of Children’s Medical Center of DaytonDayton

Clin Infect Dis 2011; 53 (7): 617-630

ObjectivesObjectives

1. List common pathogens causing community-acquired pneumonia (CAP) in infants and children.

2. Discuss appropriate use of diagnostic laboratory and imaging tests in a child with CAP in an outpatient or inpatient setting.

3. Review choice of anti-infective therapy and duration of treatment provided to a child with suspected CAP in the outpatient or inpatient setting.

“Teasers are docile male horses, usually old and past prime with undesirable genes, who set up aggressive just off-the-track mares to be bred by the wild testosterone crazed prize stallions whose only job is to deliver the goods, which they do. “

A 3yr old female presents to your office in A 3yr old female presents to your office in November with cough and tachypnea. You hear November with cough and tachypnea. You hear

crackles in left lower lobe and minimal crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good retractions. She is alert, talkative, has had good

fluid intake. Previously healthy and fluid intake. Previously healthy and immunizations up to date. You believe patient immunizations up to date. You believe patient

may be well enough to manage as an outpatient. may be well enough to manage as an outpatient. Which diagnostic tests should be performed on Which diagnostic tests should be performed on

this patient?this patient?

1 2 3 4 5

0%

33% 33%

0%

33%

1.1. Complete blood countComplete blood count

2.2. Chest radiographChest radiograph

3.3. Pulse oximetryPulse oximetry

4.4. Blood cultureBlood culture

5.5. All of the aboveAll of the above

A 3yr old female presents to your office in A 3yr old female presents to your office in November with cough and tachypnea. You hear November with cough and tachypnea. You hear

crackles in left lower lobe and minimal crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good retractions. She is alert, talkative, has had good

fluid intake. Previously healthy and fluid intake. Previously healthy and immunizations up to date. You believe patient immunizations up to date. You believe patient

may be well enough to manage as an outpatient. may be well enough to manage as an outpatient. Which diagnostic tests should be performed on Which diagnostic tests should be performed on

this patient?this patient?

1 2 3 4 5

0%

33% 33%

0%

33%

1.1. Complete blood countComplete blood count

2.2. Chest radiographChest radiograph

3.3. Pulse oximetryPulse oximetry

4.4. Blood cultureBlood culture

5.5. All of the aboveAll of the above

A school aged child hospitalized with A school aged child hospitalized with community-acquired pneumonia can be safely community-acquired pneumonia can be safely discharged if he meets which of the following discharged if he meets which of the following

criteria?criteria?

1 2 3 4 5

33%

67%

0%0%0%

1.1. Able to tolerate Able to tolerate outpatient meds, outpatient meds, greater level of activity, greater level of activity, improving appetite. improving appetite.

2.2. Afebrile for over 24 Afebrile for over 24 hourshours

3.3. Pulse oximetry Pulse oximetry measurements >90% in measurements >90% in room air at least 12 room air at least 12 hourshours

4.4. A and CA and C

5.5. A, B, and CA, B, and C

Previously healthy 2 yr old diagnosed with pneumonia Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. (faint crackles in the right base) in late October.

Respiratory rate is 30 breaths/minute and Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all temperature is 38.5° C. She has received all

recommended immunizations. She attends a day care recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided Which oral anti-infective therapy should be provided

to this child managed as an outpatient?to this child managed as an outpatient?

1 2 3 4 5

33%

0% 0%

33%33%

1.1. A second-or third-generation A second-or third-generation cephalosporin (e.g., cefdinir, cephalosporin (e.g., cefdinir, cefixime) for 10 days.cefixime) for 10 days.

2.2. Amoxicillin 90mg/kg/day Amoxicillin 90mg/kg/day divided 2 times a day for 10 divided 2 times a day for 10 daysdays

3.3. Azithromycin 10 mg/kg on Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5day 1, 5 mg/kg on days 2-5

4.4. Combined treatment with Combined treatment with both amoxicilln and both amoxicilln and azithromycin as noted aboveazithromycin as noted above

5.5. No anti-infective therapy No anti-infective therapy indicatedindicated

A fully-immunized 6 yr old boy is hospitalized at A fully-immunized 6 yr old boy is hospitalized at Dayton Children’s. Radiography demonstrates left Dayton Children’s. Radiography demonstrates left lower lobe consolidation without an effusion. He lower lobe consolidation without an effusion. He

has a 92% SpO2 on 30% FiO2, some retractions and has a 92% SpO2 on 30% FiO2, some retractions and poor oral fluid intake. A blood culture is obtained. poor oral fluid intake. A blood culture is obtained. What first-line antibiotic therapy is recommended?What first-line antibiotic therapy is recommended?

1 2 3 4 5

0%

33%

0%0%

67%

1.1. A third-generation A third-generation parenteral cephalosporin parenteral cephalosporin (e.g., cefotaxime or (e.g., cefotaxime or ceftriaxone)ceftriaxone)

2.2. Intravenous clindamycinIntravenous clindamycin

3.3. A third-generation A third-generation parenteral cephalosporin parenteral cephalosporin plusplus azithromycin azithromycin

4.4. Intravenous ampicillinIntravenous ampicillin

5.5. Intravenous vancomycinIntravenous vancomycin

A 5 yr old is admitted with a right upper lobe A 5 yr old is admitted with a right upper lobe pneumonia. Child is not fully immunized. His pneumonia. Child is not fully immunized. His

blood cultures yield Streptococcus pneumoniae. blood cultures yield Streptococcus pneumoniae. Susceptibility testing on the blood isolate Susceptibility testing on the blood isolate

demonstrates a penicillin MIC of > 4 ug/mL. demonstrates a penicillin MIC of > 4 ug/mL. Appropriate antibiotic therapy directed at this Appropriate antibiotic therapy directed at this

pathogen consists of:pathogen consists of:

1 2 3 4 5

0%

100%

0%0%0%

1.1. Ceftriaxone Ceftriaxone intravenously at intravenously at 100mg/kg/day100mg/kg/day

2.2. Levofloxacin Levofloxacin intravenously at 20 intravenously at 20 mg/kg/daymg/kg/day

3.3. Ampicillin intravenously Ampicillin intravenously at 400 mg/kg/dayat 400 mg/kg/day

4.4. A or CA or C

5.5. A, B, or CA, B, or C

IntroductionIntroduction

The Pediatric Infectious Diseases Society The Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of (PIDS) and the Infectious Diseases Society of America (IDSA) convened multiple America (IDSA) convened multiple subspecialists and expert consultants to subspecialists and expert consultants to create and review guidelinescreate and review guidelines

Guidelines endorsed by AAP, American Guidelines endorsed by AAP, American College of Emergency Physicians, Society of College of Emergency Physicians, Society of Critical Care Medicine….Critical Care Medicine….

The guidelines grade method of The guidelines grade method of recommendation, low or very low evidence recommendation, low or very low evidence situations require clinical judgmentsituations require clinical judgment

Strength of Strength of RecommendationsRecommendations

Strength of Strength of RecommendationsRecommendations

Inpatient CriteriaInpatient Criteria

Age 3-6 months with a suspicion of Age 3-6 months with a suspicion of bacterial pneumoniabacterial pneumonia

Suspicion or documentation of Suspicion or documentation of methicillin-resistant methicillin-resistant Staphylococcus Staphylococcus aureus aureus (MRSA) pneumonia(MRSA) pneumonia

Concern for follow up or Concern for follow up or administration of home therapyadministration of home therapy

Patients Requiring Patients Requiring HospitalizationHospitalization

Diagnostic approach to the child with pneumonia

Outpatient DiagnosticsOutpatient Diagnostics

Chest radiography, blood culture, CBC, Chest radiography, blood culture, CBC, ESR/CRP ESR/CRP not necessarynot necessary

Pulse oximetry should be obtained in all Pulse oximetry should be obtained in all patients patients

If available a rapid test for influenza and for If available a rapid test for influenza and for other viral pathogens should be obtainedother viral pathogens should be obtained

Testing for Testing for Mycoplasma pneumoniae Mycoplasma pneumoniae should should be obtained if suspiciousbe obtained if suspicious

If no improvement on antibiotics for 48-72 hrs, If no improvement on antibiotics for 48-72 hrs, a CXR and blood culture should be obtaineda CXR and blood culture should be obtained

Inpatient WorkupInpatient Workup All pt’s should have CXR All pt’s should have CXR Blood cultureBlood culture CBCCBC ESR/CRPESR/CRP Urinary antigen for Pneumococcal infection is Urinary antigen for Pneumococcal infection is

not recommendednot recommended Sputum samples if able (weak; low evidence)Sputum samples if able (weak; low evidence) Rapid tests for Influenza and viruses should be Rapid tests for Influenza and viruses should be

usedused Mycoplasma pneumoniae Mycoplasma pneumoniae should be tested for should be tested for

if suspiciousif suspicious No reliable test for No reliable test for Chlamydophila pneumoniaeChlamydophila pneumoniae

Inpatient DiagnosticsInpatient Diagnostics

A routine repeat CXR is not necessaryA routine repeat CXR is not necessary Repeat CXR should be obtained if no clinical Repeat CXR should be obtained if no clinical

improvement is demonstrated by 48-72 hrsimprovement is demonstrated by 48-72 hrs If blood culture yields MRSA, a repeat culture If blood culture yields MRSA, a repeat culture

is mandatory todocument sterility of the blood.is mandatory todocument sterility of the blood. If blood culture is positive for another If blood culture is positive for another

organism, repeat culture of blood is not organism, repeat culture of blood is not mandatorymandatory

Tracheal aspirate should be obtained in patient Tracheal aspirate should be obtained in patient with endotracheal intubationwith endotracheal intubation

Criteria for admission to Criteria for admission to an ICUan ICU

Criteria for admission to Criteria for admission to an ICUan ICU

Criteria for admission to Criteria for admission to an ICUan ICU

Intubation, continuous CPAP or Intubation, continuous CPAP or BIPAPBIPAP

Sustained tachycardia or Sustained tachycardia or hypotensionhypotension

<92% SpO2 on >50% FiO2<92% SpO2 on >50% FiO2 Altered mental statusAltered mental status Clinical judgment should be used Clinical judgment should be used

regardless of scoresregardless of scores

Discharge CriteriaDischarge Criteria

Improved Clinical Status >12 hrsImproved Clinical Status >12 hrs RA with Sp02 >90% >12 hrs RA with Sp02 >90% >12 hrs No increased work of breathing , No increased work of breathing ,

tachypnea or tachycardiatachypnea or tachycardia Able to tolerate outpatient therapy Able to tolerate outpatient therapy Chest tube out for >12 hrs Chest tube out for >12 hrs

Antibiotics not routinely required for Antibiotics not routinely required for preschool-aged childrenpreschool-aged children

High-dose amoxicillin should be considered High-dose amoxicillin should be considered first line for presumed bacterial pneumonia first line for presumed bacterial pneumonia in all agesin all ages 90 mg/kg/day divided bid90 mg/kg/day divided bid TID dosing is required for Pen-resistant TID dosing is required for Pen-resistant

pneumococcus (MIC > 2 µg/mL)pneumococcus (MIC > 2 µg/mL) Macrolides (azithromycin) should be Macrolides (azithromycin) should be

considered in school-aged and adolescents considered in school-aged and adolescents with illness consistent with atypical with illness consistent with atypical pneumoniapneumonia

Outpatient Treatment of Outpatient Treatment of PneumoniaPneumonia

Atypical Atypical vs. Bacterialvs. Bacterial

Gradual onsetGradual onset Malaise, headache, Malaise, headache,

sore throat, ear sore throat, ear infectionsinfections

Lower fevers (101-Lower fevers (101-102)102)

Usually Usually nonproductive, nonproductive, persistent coughpersistent cough

May or may not have May or may not have ralesrales

Gradual or acute Gradual or acute onsetonset

Fatigue, dyspnea, Fatigue, dyspnea, chest painchest pain

Fevers often higher Fevers often higher (>103)(>103)

Cough more often Cough more often productiveproductive

Decreased or bronchial Decreased or bronchial breath sounds, rales, breath sounds, rales, dullness to percussion, dullness to percussion, egophonyegophony

Manifestations of Mycoplasma Manifestations of Mycoplasma pneumoniapneumonia

Outpatient Treatment of Outpatient Treatment of PneumoniaPneumonia

For presumed atypical pneumonia, For presumed atypical pneumonia, azithromycin is first-lineazithromycin is first-line 10 mg/kg on day 1; 5 mg/kg on days 2-510 mg/kg on day 1; 5 mg/kg on days 2-5

In season, treat influenza presumptively In season, treat influenza presumptively until a sensitive test is negativeuntil a sensitive test is negative

10-day course of antibiotics is usually 10-day course of antibiotics is usually adequateadequate Azithromycin: 5 day courseAzithromycin: 5 day course MRSA will require a longer course (and MRSA will require a longer course (and

hospitalization!)hospitalization!)

Inpatient Treatment of Inpatient Treatment of PneumoniaPneumonia

For the fully immunized child in regions For the fully immunized child in regions that do not demonstrate high-level that do not demonstrate high-level pneumococcal penicillin resistance:pneumococcal penicillin resistance: Ampicillin or Penicillin G are first-lineAmpicillin or Penicillin G are first-line Azithromycin for suspected atypical Azithromycin for suspected atypical

pneumonia (with a beta-lactam if diagnosis pneumonia (with a beta-lactam if diagnosis is in question)is in question)

Vancomycin or clindamycin should be Vancomycin or clindamycin should be added when added when S. aureus S. aureus is suspected by labs, is suspected by labs, clinical findings or imagingclinical findings or imaging

Ceftriaxone or cefotaxime are alternativesCeftriaxone or cefotaxime are alternatives

Inpatient Treatment of Inpatient Treatment of PneumoniaPneumonia

For a not fully immunized child or in For a not fully immunized child or in regions that demonstrate high-level regions that demonstrate high-level pneumococcal penicillin resistance:pneumococcal penicillin resistance: Ceftriaxone or cefotaxime is preferredCeftriaxone or cefotaxime is preferred Add azithromycin if considering atypical Add azithromycin if considering atypical

pneumoniapneumonia Add vancomycin or clindamycin for Add vancomycin or clindamycin for S. aureusS. aureus

Ceftriaxone or cefotaxime also preferred Ceftriaxone or cefotaxime also preferred for life-threatening infections and for life-threatening infections and empyemaempyema

Empiric Inpatient Empiric Inpatient Treatment of CAPTreatment of CAP

Pneumococcal Penicillin Pneumococcal Penicillin ResistanceResistance

MIC < 0.06 µg/mL: MIC < 0.06 µg/mL: very susceptiblevery susceptible Standard-dose oral amoxicillin effectiveStandard-dose oral amoxicillin effective

MIC 0.12-1 µg/mL: MIC 0.12-1 µg/mL: susceptiblesusceptible High-dose oral amoxicillin effectiveHigh-dose oral amoxicillin effective

MIC 1-2: MIC 1-2: somewhat resistantsomewhat resistant High-dose oral amoxicillin >90% effectiveHigh-dose oral amoxicillin >90% effective

MIC 2-4: MIC 2-4: resistantresistant Oral therapy likely to fail; IV ampicillin or penicillinOral therapy likely to fail; IV ampicillin or penicillin

MIC >4: MIC >4: very resistantvery resistant Standard-dose ampicillin likely to fail; ceftriaxone Standard-dose ampicillin likely to fail; ceftriaxone

effectiveeffective

Specific Treatment for Specific Treatment for CAPCAP

Specific Treatment of Specific Treatment of CAPCAP

Specific Treatment of Specific Treatment of CAPCAP

Specific Treatment of Specific Treatment of CAPCAP

Specific Treatment of Specific Treatment of CAPCAP

Viral Pneumonia in Viral Pneumonia in ChildrenChildren

Guidelines suggest not treating a preschool-Guidelines suggest not treating a preschool-aged child with suspected viral pneumonia aged child with suspected viral pneumonia (except influenza)(except influenza)

Hamano-Hasegawa, Hamano-Hasegawa, J Infect ChemotherJ Infect Chemother (2008) (2008) Younger children more likely to have viral pneumoniaYounger children more likely to have viral pneumonia Evidence of bacterial co-infection in Evidence of bacterial co-infection in 33%33%

Michelow, Michelow, PediatricsPediatrics (2004) (2004) Bacterial co-infections seen in Bacterial co-infections seen in 54%54% of viral of viral

pneumoniaspneumonias 67% of influenza pneumonia67% of influenza pneumonia 55% of RSV pneumonia55% of RSV pneumonia

Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children.” Pediatrics. 2004 Apr;113(4):701-7.

Michelow IC, et al. “Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children.” Pediatrics. 2004 Apr;113(4):701-7.

Viral Pneumonia in Viral Pneumonia in ChildrenChildren

A 2010 retrospective cohort study of 4015 A 2010 retrospective cohort study of 4015 pediatric patients hospitalized with pediatric patients hospitalized with pneumoniapneumonia 27% developed influenza-associated 27% developed influenza-associated

pneumoniapneumonia Of these, 2% had a bacterial co-infectionOf these, 2% had a bacterial co-infection 18 identified by blood cultures; 3 by pleural 18 identified by blood cultures; 3 by pleural

fluidfluid The actual incidence of secondary bacterial The actual incidence of secondary bacterial

pneumonia with influenza is likely much pneumonia with influenza is likely much higherhigherDagwood FS et al. “Influenza-Associated Pneumonia in Children Hospitalized

With Laboratory-Confirmed Influenza, 2003-2008.” Pediatr Infect Dis J. 2010 Jul;29(7):585-90.

Adjunctive TherapyAdjunctive Therapy

CXR should be obtained if suspicious CXR should be obtained if suspicious for effusionfor effusion

US or CT if CXR is inconclusiveUS or CT if CXR is inconclusive Size of effusion and respiratory Size of effusion and respiratory

compromise will determine compromise will determine treatmenttreatment

Pleural Fluid TestsPleural Fluid Tests

Gram stain (+25-50%)Gram stain (+25-50%) Antigen or PCR if available (Antigen or PCR if available (S. S.

pneumoniaepneumoniae, , S.aureusS.aureus)) Pleural fluid analysis rarely changes Pleural fluid analysis rarely changes

management and is not recommendedmanagement and is not recommended WBC count with differntial helps WBC count with differntial helps

differentiate sourcedifferentiate source Majority of cultures will be negativeMajority of cultures will be negative

Effusion/EmpyemaEffusion/Empyema

Total antibiotic therapy 2-4 weeks or 10 days Total antibiotic therapy 2-4 weeks or 10 days after resolution of feverafter resolution of fever

If abscess or necrosis is identified tx should If abscess or necrosis is identified tx should begin with IV antibioticsbegin with IV antibiotics

If abscess is peripheral may attempt to drain, If abscess is peripheral may attempt to drain, most will resolve spontaneously with IV most will resolve spontaneously with IV antibioticsantibiotics

Abscess secondary to congenital malformation Abscess secondary to congenital malformation requires surgery consultationrequires surgery consultation

Necrosis should not routinely be managed Necrosis should not routinely be managed surgically given high rates of broncho-pleural surgically given high rates of broncho-pleural fistulasfistulas

A 3yr old female presents to your office in A 3yr old female presents to your office in November with cough and tachypnea. You hear November with cough and tachypnea. You hear

crackles in left lower lobe and minimal crackles in left lower lobe and minimal retractions. She is alert, talkative, has had good retractions. She is alert, talkative, has had good

fluid intake. Previously healthy and fluid intake. Previously healthy and immunizations up to date. You believe patient immunizations up to date. You believe patient

may be well enough to manage as an outpatient. may be well enough to manage as an outpatient. Which diagnostic tests should be performed on Which diagnostic tests should be performed on

this patient?this patient?

1 2 3 4 5

0%

33% 33%

0%

33%

1.1. Complete blood countComplete blood count

2.2. Chest radiographChest radiograph

3.3. Pulse oximetryPulse oximetry

4.4. Blood cultureBlood culture

5.5. All of the aboveAll of the above

A school aged child hospitalized with A school aged child hospitalized with community-acquired pneumonia can be safely community-acquired pneumonia can be safely discharged if he meets which of the following discharged if he meets which of the following

criteria?criteria?

1 2 3 4 5

0% 0% 0%0%

100%1.1. Able to tolerate Able to tolerate outpatient meds, outpatient meds, greater level of activity, greater level of activity, improving appetite. improving appetite.

2.2. Afebrile for over 24 Afebrile for over 24 hourshours

3.3. Pulse oximetry Pulse oximetry measurements >90% in measurements >90% in room air at least 12 room air at least 12 hourshours

4.4. A and CA and C

5.5. A, B, and CA, B, and C

Previously healthy 2 yr old diagnosed with pneumonia Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. (faint crackles in the right base) in late October.

Respiratory rate is 30 breaths/minute and Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all temperature is 38.5° C. She has received all

recommended immunizations. She attends a day care recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided Which oral anti-infective therapy should be provided

to this child managed as an outpatient?to this child managed as an outpatient?

1 2 3 4 5

0%

67%

33%

0%0%

1.1. A second-or third-generation A second-or third-generation cephalosporin (e.g., cefdinir, cephalosporin (e.g., cefdinir, cefixime) for 10 days.cefixime) for 10 days.

2.2. Amoxicillin 90mg/kg/day Amoxicillin 90mg/kg/day divided 2 times a day for 10 divided 2 times a day for 10 daysdays

3.3. Azithromycin 10 mg/kg on Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5day 1, 5 mg/kg on days 2-5

4.4. Combined treatment with Combined treatment with both amoxicilln and both amoxicilln and azithromycin as noted aboveazithromycin as noted above

5.5. No anti-infective therapy No anti-infective therapy indicatedindicated

Previously healthy 2 yr old diagnosed with pneumonia Previously healthy 2 yr old diagnosed with pneumonia (faint crackles in the right base) in late October. (faint crackles in the right base) in late October.

Respiratory rate is 30 breaths/minute and Respiratory rate is 30 breaths/minute and temperature is 38.5° C. She has received all temperature is 38.5° C. She has received all

recommended immunizations. She attends a day care recommended immunizations. She attends a day care on daily basis. She is interactive and drinking well. on daily basis. She is interactive and drinking well. Which oral anti-infective therapy should be provided Which oral anti-infective therapy should be provided

to this child managed as an outpatient?to this child managed as an outpatient?

1 2 3 4 5

0% 0% 0%

33%

67%

1.1. A second-or third-generation A second-or third-generation cephalosporin (e.g., cefdinir, cephalosporin (e.g., cefdinir, cefixime) for 10 days.cefixime) for 10 days.

2.2. Amoxicillin 90mg/kg/day Amoxicillin 90mg/kg/day divided 2 times a day for 10 divided 2 times a day for 10 daysdays

3.3. Azithromycin 10 mg/kg on Azithromycin 10 mg/kg on day 1, 5 mg/kg on days 2-5day 1, 5 mg/kg on days 2-5

4.4. Combined treatment with Combined treatment with both amoxicilln and both amoxicilln and azithromycin as noted aboveazithromycin as noted above

5.5. No anti-infective therapy No anti-infective therapy indicatedindicated

A 5 yr old is admitted with a right upper lobe A 5 yr old is admitted with a right upper lobe pneumonia. Child is not fully immunized. His pneumonia. Child is not fully immunized. His

blood cultures yield Streptococcus pneumoniae. blood cultures yield Streptococcus pneumoniae. Susceptibility testing on the blood isolate Susceptibility testing on the blood isolate

demonstrates a penicillin MIC of > 4 ug/mL. demonstrates a penicillin MIC of > 4 ug/mL. Appropriate antibiotic therapy directed at this Appropriate antibiotic therapy directed at this

pathogen consists of:pathogen consists of:

1 2 3 4 5

0%

33%

0%

33%33%

1.1. Ceftriaxone Ceftriaxone intravenously at intravenously at 100mg/kg/day100mg/kg/day

2.2. Levofloxacin Levofloxacin intravenously at 20 intravenously at 20 mg/kg/daymg/kg/day

3.3. Ampicillin intravenously Ampicillin intravenously at 400 mg/kg/dayat 400 mg/kg/day

4.4. A or CA or C

5.5. A, B, or CA, B, or C

BMJ 2003; 327:1459-1461