Treatment of mild to moderate community-acquired pneumonia in previously healthy children: an Italian intersociety consensus (SIPPS-SIP-SITIP-FIMP-SIAIP-SIMRI-FIMMG-SIMG)

Italian paediatric intersociety (SIPPS, SIP, SITIP, FIMP, SIAIP, SIMRI, FIMMG, SIMG) · 2024 · Italy

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Authors: Daniele Donà, Giulia Brigadoi, Roberto Grandinetti et al.
Title: Treatment of mild to moderate community-acquired pneumonia in previously healthy children: an Italian intersociety consensus (SIPPS-SIP-SITIP-FIMP-SIAIP-SIMRI-FIMMG-SIMG)
Journal: Italian Journal of Pediatrics, 2024
DOI: 10.1186/s13052-024-01786-8
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC11491012

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Results and recommendations

In children under five with a complete immunization schedule and mild-moderate CAP, amoxicillin prescription is recommended.Quality of evidence: Low/very low; Strength of the recommendation: Strong recommendation in favor of the intervention; Consensus panel: 100%
In children over five years of age with a complete immunization schedule and mild-moderate CAP, treatment with amoxicillin is recommended.Quality of evidence: Low/very low; Strength of the recommendation: Strong recommendation in favor of the intervention; Consensus panel: 100%
In children who remain well-appearing and do not require hospitalization, macrolide therapy is recommended if there is no clinical improvement after 48 h of amoxicillin treatment.Quality of evidence: Low/very low; Strength of the recommendation: Strong recommendation in favor of the intervention; Consensus panel: 100%
In children who are either unimmunized or have incomplete immunization against S. pneumoniae but are immunized for H. influenzae (having received more than two doses of hexavalent vaccine but less than two doses of pneumococcal vaccine) and present with mild-moderate CAP, monotherapy with amoxicillin is recommended as the first-line therapy.Quality of evidence: Low; Strength of the recommendation: Strong recommendation in favor of the intervention; Consensus panel: 100%
For children who are either unimmunized or have incomplete immunization coverage for both H. influenzae and S. pneumoniae (having received less than two doses of hexavalent and pneumococcal vaccines), first-line therapy with amoxicillin-clavulanate or second or third-generation cephalosporins is recommended.Quality of evidence: Low; Strength of the recommendation: Weak recommendation in favor of the intervention; Consensus panel: 100%
In patients with CAP and a suspected allergy to amoxicillin, who have not undergone allergological workup, the selection of alternative antibiotics (such as third-generation cephalosporins or macrolides) should be guided by meticulous risk stratification.Quality of evidence: Very low; Strength of the recommendation: Strong recommendation in favor of the intervention; Consensus panel: 100%
In patients with CAP suspected of having an allergy to amoxicillin and deemed to be at low risk of allergic reaction, a second or third-generation cephalosporin (such as cefuroxime or cefpodoxime proxetil) is recommended as an alternative therapy. The utilization of macrolides (like clarithromycin) or clindamycin should be reserved for patients at high risk of allergic reaction, with consideration given to levofloxacin for older childrenQuality of evidence: Very low; Strength of the recommendation: Weak recommendation in favor of the intervention; Consensus panel: 100%
To treat mild-moderate CAP, we recommend administering amoxicillin at a dosage of 80–90 mg/kg/day divided into three separate doses (with a maximum of 1 g three times a day). However, to enhance compliance with antibiotic therapy, particularly in cases of mild pneumonia with close clinical follow-up, the number of daily administrations can be reduced to two instead of three.Quality of evidence: Moderate; Strength of the recommendation: Weak recommendation in favor of the intervention; Consensus panel: 100%
For the management of mild-moderate CAP, a 5-day course of antibiotic therapy with amoxicillin is recommended. Close clinical monitoring and reassessment are advised approximately 72 h after initiating antibiotic therapy to evaluate symptom resolution. If necessary, treatment may be extended for up to 7 days.Quality of evidence: Moderate; Strength of the recommendation: Strong recommendation in favor of the intervention; Consensus panel: 100%
In children experiencing clinical deterioration after 48 h of first-line therapy, hospitalization and treatment with broad-spectrum antibiotics are recommended.Quality of evidence: Very low; Strength of the recommendation: Weak recommendation in favor of the intervention; Consensus panel: 100%
Recommendation 1In children under five with a complete immunization schedule and mild-moderate CAP, amoxicillin prescription is recommended. (Very low quality of evidence for amoxicillin vs. broad-spectrum antibiotics, amoxicillin vs. macrolides, beta-lactams vs. beta-lactams plus macrolides, aminopenicillin vs. broad-spectrum antibiotics; low quality of evidence for beta-lactams vs. macrolides. Strong recommendation in favor of the intervention. 100% panel consensus).
Recommendation 3In children who are either unimmunized or have incomplete immunization against S. pneumoniaebut are immunized for H. influenzaetype b (having received at least two doses of hexavalent vaccine but less than two doses of pneumococcal vaccine) and present with mild-moderate CAP, monotherapy with amoxicillin is recommended as the first-line therapy.Low-quality evidence. Strong recommendation in favor of the intervention. Panel consensus 100%

Abstract

Community-acquired pneumonia (CAP) is an acute infection of the lung parenchyma acquired outside the hospital or other healthcare settings, typically affecting previously healthy individuals. This intersociety consensus aims to provide evidence-based recommendations for the antibiotic treatment of mild to moderate CAP in previously healthy children in Italy.

A systematic review was conducted to identify the most recent and relevant evidence. Embase, Scopus, PubMed, and Cochrane databases were systematically screened, with a date restriction from 2012 to April 2024, but without language limitations. The review included studies conducted in high-income countries on antibiotic therapy in children over 3 months of age diagnosed with mild-moderate CAP. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methods. The final recommendations were obtained through a Delphi consensus of an expert panel.

Amoxicillin is the first-line treatment if the child is at least immunized against Haemophilus influenzae type b (low/very low quality of evidence, strong recommendations), while amoxicillin-clavulanate or second- or third-generation cephalosporins should be prescribed for those unimmunized or with incomplete immunization coverage for both H. influenzae type b and Streptococcus pneumoniae (low/very low quality of evidence, strong recommendations). Macrolides should be considered in addition to amoxicillin in children over 5 years old, if symptoms persist and the clinical condition remains good after 48 h of therapy (low/very low quality of evidence, strong recommendations). The dosage of amoxicillin is 90 mg/kg/day divided in three doses, although two doses could be considered to improve compliance (moderate quality of evidence, weak recommendations). A five-day duration of therapy is recommended, with clinical monitoring and re-assessment approximately 72 h after the start of antibiotic treatment to evaluate symptom resolution (moderate quality of evidence, strong recommendations).

To improve the management of CAP in pediatric patients, we have developed this consensus based on a thorough review of the best available evidence and extensive discussions with an expert panel. However, further efforts are needed. Future research should focus on enhancing diagnostic accuracy, optimizing antibiotic utilization, comparing the efficacy of different antibiotic regimens, and determining the optimal dosage and duration of treatment in different setting.

Supplementary Information: The online version contains supplementary material available at 10.1186/s13052-024-01786-8.

Contents of the original publication

The section headings of the original.

Background
Methods
Results and recommendations
Recommendation 1
Recommendation 2
Recommendation 3
Recommendation 4
Recommendation 5
Recommendation 6
Recommendation 7
Discussion
Conclusions

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