The Center For Disease Dynamics, Economics & Policy

Acute Lower Respiratory Tract Infection: Mild-Moderate/Ambulatory (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. coli, C. trachomatis, S. aureus; older infants and children – S. pneumoniae, H. influenzae, S. aureus, M. catarrhalis, M. pneumoniae.

 

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

 

Neonate

All children younger than 1 month with mild/moderate or severe Acute Lower Respiratory Tract Infection should be admitted to hospital. See guidelines for severe Acute Lower Respiratory Infections.

Infant, Child & Adolescent

Preferred antibiotic choice
Drug Formulation Dosage Duration
Amoxicillin (PO) 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, maximum dose: 1.5 g 12 hourly 5 days
In case of poor response to preferred antibiotic choice
Amoxicillin + clavulanic Acid (PO) 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 NotesA below for guidance on dosing accurately)

5 days
In case of confirmed drug allergy or medical contraindication
Azithromycin (PO)B Capsule: 250 mg; 500 mg (anhydrous). Oral liquid: 200 mg/5 mL 10 mg/kg once daily, maximum dose 500 mg 3 – 5 days

 

A. 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.

B. In case of treatment failure with azithromycin, treat with clindamycin (6 mg/kg/dose 6 hourly, Maximum dose: 450 mg 6 hourly).

 

Notes:

  • Consider screening for HIV and TB in all patients presenting with Lower Respiratory Tract Infection.
  • S. pneumoniae should be suspected if there is empyema, pulmonary cavitation or pneumatocoele formation, or the presence of extrapulmonary pyogenic infections. Treatment should follow Acute Lower Respiratory Tract Infection: Severe/inpatient guidelines.