From the Guidelines
For community-acquired pneumonia (CAP) in immunocompromised hosts, the initial empiric regimen should include a combination of a beta-lactam (ceftriaxone 1-2 g daily, cefotaxime 1-2 g every 8 hours, or ampicillin-sulbactam 3 g every 6 hours) plus a macrolide (azithromycin 500 mg on day 1, then 250 mg daily) or a respiratory fluoroquinolone (levofloxacin 750 mg daily or moxifloxacin 400 mg daily), as recommended by the 2019 American Thoracic Society and Infectious Diseases Society of America guideline 1. The choice of antibiotics should be based on the severity of the disease, the risk of drug-resistant pathogens, and the patient's underlying medical conditions.
- For severely immunocompromised patients, consider adding coverage for Pseudomonas with piperacillin-tazobactam 4.5 g every 6 hours or meropenem 1 g every 8 hours, as suggested by the 2019 guideline 1.
- In patients with HIV, consider coverage for Pneumocystis jirovecii with trimethoprim-sulfamethoxazole if CD4 count is below 200 cells/μL.
- For transplant recipients, be mindful of drug interactions with immunosuppressants. The treatment duration typically ranges from 7-14 days depending on severity and clinical response.
- Adjust therapy based on culture results and clinical response, and consider early pulmonary consultation for bronchoscopy if the patient is not improving, as recommended by the 2019 guideline 1. It is essential to note that the microbial etiology of CAP is changing, and there is increased recognition of the role of viral pathogens, as mentioned in the 2019 guideline 1. However, the 2019 American Thoracic Society and Infectious Diseases Society of America guideline 1 provides the most recent and highest quality evidence for the treatment of CAP in immunocompromised hosts.
From the Research
Antibiotics for Immunocompromised Hosts with CAP
- The choice of antibiotics for immunocompromised hosts with community-acquired pneumonia (CAP) depends on various factors, including the severity of the infection, the patient's underlying condition, and the suspected or confirmed pathogen 2.
- For severe pneumonia patients with imipenem-resistant ceftazidime-susceptible Pseudomonas aeruginosa infection, piperacillin/tazobactam is still an option, especially when the MIC of piperacillin/tazobactam is very low 3.
- A study comparing the clinical benefits of piperacillin/tazobactam versus a combination of ceftriaxone and clindamycin in the treatment of early, non-ventilator, hospital-acquired pneumonia found that piperacillin/tazobactam was more effective than the combination of ceftriaxone and clindamycin 4.
- Another study comparing the efficacy and tolerability of piperacillin/tazobactam versus ceftazidime in association with amikacin for treating nosocomial pneumonia in intensive care patients found that the two regimens had similar efficacy and tolerability 5.
- In immunocompromised patients with severe community-acquired pneumonia, a wide range of pathogens can be responsible, and a standardized diagnosis strategy is necessary to increase the diagnosis rate and prescribe the appropriate treatment 6.
Specific Antibiotic Options
- Piperacillin/tazobactam is a broad-spectrum antibiotic that can be effective against Pseudomonas aeruginosa and other gram-negative bacteria 3, 4, 5.
- Ceftriaxone and clindamycin is another combination that can be used to treat CAP, but it may not be as effective as piperacillin/tazobactam in some cases 4.
- Ceftazidime is a broad-spectrum cephalosporin that can be used in combination with amikacin to treat nosocomial pneumonia 5.
- Amikacin is an aminoglycoside antibiotic that can be used in combination with other antibiotics to treat severe infections 5, 6.