The Center For Disease Dynamics, Economics & Policy

Acute Lower Respiratory Tract Infection: Severe/Inpatient (Community-acquired)

Clinical definition:

Acute lower respiratory tract infection includes acute viral bronchiolitis, and acute viral and bacterial pneumonia. Antibiotics are indicated in the empiric treatment of pneumonia and are not usually indicated for the treatment of bronchiolitis. However, the decision to prescribe or withhold antibiotics is influenced by several factors: the ability to clinically distinguish acute viral bronchiolitis from pneumonia, laboratory and radiological findings may not provide confident differentiation of viral bronchiolitis from bacterial pneumonia, the knowledge that bacterial co-infection may be present in a variable proportion of children with features of bronchiolitis, the ability of the caregiver to monitor the child and re-access health care urgently in the event of clinical deterioration. WHO recommends that antibiotics should be prescribed for young children with acute onset of cough associated with wheeze, fast breathing and chest indrawing. Antibiotic selection is based on assessment of severity and likely aetiology. Common bacterial causes of pneumonia include: neonates – Group B Streptococci, Klebsiella species, E. coliC. trachomatisS. aureus; older infants and children – S. pneumoniaeH. influenzaeS. aureusM. catarrhalisM. pneumoniae.

 

For mild to moderate disease in ambulatory patients, see these treatment recommendations. For severe disease in inpatients, see below.

 

Neonate

Preferred antibiotic choice
Drug Formulation Dosage Duration
Combination therapy with:

Cefotaxime (IV)A

PLUS

Ampicillin (IV)

Cefotaxime- Powder for injection: 250 mg per vial (as sodium salt) o   First week of life (7 days or less): 50 mg/kg/dose 12 hourly

o   8-20 days: 50 mg/kg/dose 8 hourly

o   21 days & older: 50 mg/kg/dose 6 hourly

5 – 7 days
Ampicillin- Powder for injection: 500 mg, 1 g (as sodium salt) in vial

 

o   First week of life (7 days or less): 100 mg/kg/dose 8 hourly

o   8 days of age & older: 100 mg/kg/dose 6 hourly

Infant, Child & Adolescent

Preferred antibiotic choice
Drug Formulation Dosage Duration
Ampicillin (IV) Powder for injection: 500 mg; 1 g (as sodium salt) in vial. 50 mg/kg/dose 6 hourly, maximum dose 2 g 6 hourly 5 – 7 days
If poor response to treatment or Staphylococcal pneumonia is suspected (empyema, pulmonary cavitation, pneumatocoele formation or the presence of extrapulmonary pyogenic infections), escalate to:
Amoxicillin + clavulanic acid (IV)

OR

Ceftriaxone (IV)

Amoxicillin + clavulanic acid- Powder for injection: 500 mg (as sodium) + 100 mg (as potassium salt); 1000 mg (as sodium) + 200 mg (as potassium salt) in vial. 30 mg/kg/dose of amoxicillin component 8 hourly, maximum dose 1.2 g 8 hourly 10 –14 days
Ceftriaxone- Powder for injection: 250 mg; 1 g (as sodium salt) in vial. 50 mg/kg once daily, maximum dose 1 g 10 – 14 days
Step down therapy to:
Amoxicillin (PO)

OR,

if treated with Amoxicillin + clavulanic acid (IV) or Ceftriaxone (IV),

then Amoxicillin + clavulanic acid (PO)B

Amoxicillin- Powder for oral liquid: 125 mg (as trihydrate)/5 mL; 250 mg (as trihydrate)/5 mL; Solid oral dosage form: 250 mg; 500 mg (as trihydrate).  

40-45 mg/kg/dose 12 hourly, 1.5 g 12 hourly

10 – 14 days

 

(Total treatment duration including IV therapy.)

Amoxicillin + clavulanic acid- Oral liquid: 125 mg amoxicillin + 31.25 mg clavulanic acid/5 mL; 250 mg amoxicillin + 62.5 mg clavulanic acid/5 mL . Tablet: 500 mg (as trihydrate) + 125 mg (as potassium salt). 40 – 45 mg/kg of amoxicillin component per dose 12 hourly, maximum dose of amoxicillin component: 875 mg 12 hourly.

(Refer to Other NotesB below for guidance on dosing accurately)

In case of confirmed drug allergy or medical contraindication
Ceftriaxone (IV) Powder for injection: 250 mg; 1 g (as sodium salt) in vial. 50 mg/kg/dose once daily, maximum dose 1 g 10 – 14 days

 

 

A. If cefotaxime is not available, use ceftriaxone (50 mg/kg/dose 12 hourly in neonates) in combination with benzylpenicillin or ampicillin except in neonates with jaundice and neonates receiving calcium-containing IV fluids.

B. Current widely available oral liquid formulations contain amoxicillin + clavulanic acid in a 4:1 ratio. To achieve 40-45 mg/kg/dose of amoxicillin component, when using the 4:1 formulation, prescribe amoxicillin + clavulanic acid 10-15 mg/kg/dose of amoxicillin component 12 hourly and separately prescribe amoxicillin 30-35 mg/kg/dose 12 hourly in order not to exceed the maximum recommended dose of clavulanic acid (10 mg/kg/day) thereby reducing the risk of antibiotic-associated diarrhoea. If oral liquid formulations with a higher dose of amoxicillin are available (7:1 ratio – 400 mg amoxicillin + 57.5 mg clavulanic acid/5 mL, or 14:1 ratio – 600 mg amoxicillin + 42.9 mg clavulanic acid/5 mL), these may be dosed at 40-45 mg/kg dose of amoxicillin component 12 hourly without a separate amoxicillin prescription (the clavulanic acid dose will not be exceeded). If the 7:1 ratio tablet formulation is available (875 mg amoxicillin + 125 mg clavulanic acid) it may be prescribed 12 hourly for children weighing 25 kg or more.

 

Principles of Stewardship:

  • Continue with IV antibiotics until there is evidence of good clinical response and/or laboratory markers of infection improve, and then consider switching to oral antibiotic therapy.
  • For suspected or confirmed Staphylococcal pneumonia or empyema with or without microbiological confirmation, adequate drainage of pus and prolonged treatment duration is recommended (minimum 10 – 14 days).

Notes:

  • If pertussis is suspected, add treatment with a macrolide e.g. azithromycin 10 mg/kg once daily for 3 – 5 days, maximum dose 500 mg.
  • Screen all patients for HIV and TB.
  • Add empiric treatment for pneumocystis pneumonia (PCP) in HIV-exposed or HIV-infected infants and children:
    • Trimethoprim + sulfamethoxazole (1:5) dosed according to trimethoprim component (Loading dose: 10 mg/kg IV followed by 5 mg/kg/dose IV or PO 6 hourly for 21 days.)
    • The addition of corticosteroids, usually prednisone 1 – 2 mg/kg once daily PO for 7 days, tapered over the next 7 days may be beneficial.