What are the different medications for Community-Acquired Pneumonia (CAP) inpatients?

From the Guidelines

For inpatient treatment of community-acquired pneumonia (CAP), the recommended regimen typically includes a beta-lactam plus a macrolide or fluoroquinolone, with consideration of MRSA and Pseudomonas coverage in severe cases. The choice of antibiotics depends on the severity of the disease and the risk of drug-resistant pathogens. For non-severe CAP, the recommended regimen includes:

• Ampicillin-sulbactam 1.5-3g IV every 6 hours, or
• Ceftriaxone 1-2g IV daily Plus
• Azithromycin 500mg IV or orally daily 1. For severe CAP, the recommended regimen includes:
• Ceftriaxone 2g IV daily, or
• Cefepime 2g IV every 8-12 hours Plus
• Azithromycin 500mg IV daily And consider adding
• Vancomycin 15-20mg/kg IV every 8-12 hours (for MRSA coverage) 1. It is essential to note that the 2019 guidelines from the American Thoracic Society and Infectious Diseases Society of America provide the most recent and highest quality evidence for the treatment of CAP 1. The treatment duration is typically 5-7 days, but may be extended based on clinical response. These regimens provide broad-spectrum coverage against common CAP pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms like Mycoplasma pneumoniae and Legionella pneumophila. Adjust therapy based on culture results if available, and monitor for clinical improvement to consider switching to oral antibiotics when the patient shows signs of recovery, typically after 2-3 days of IV therapy 1. In cases where Pseudomonas infection is suspected, an antipneumococcal, antipseudomonal beta-lactam such as piperacillin-tazobactam, cefepime, imipenem, or meropenem should be used, along with either ciprofloxacin or levofloxacin, or an aminoglycoside and azithromycin or an antipneumococcal fluoroquinolone 1. However, the most recent guidelines from 2019 should be prioritized over the 2007 guidelines 1.

From the FDA Drug Label

1.2 Community-Acquired Pneumonia: 7 to 14 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of community-acquired pneumonia due to methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae (including multi-drug-resistant Streptococcus pneumoniae [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae, Legionella pneumophila, or Mycoplasma pneumoniae

1.3 Community-Acquired Pneumonia: 5 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of community-acquired pneumonia due to Streptococcus pneumoniae (excluding multi-drug-resistant isolates [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasma pneumoniae, or Chlamydophila pneumoniae

The medications for Community-Acquired Pneumonia (CAP) inpatients include:

• Levofloxacin: for the treatment of CAP due to various pathogens, including methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and others.
• Ceftriaxone: mentioned as a comparator in the treatment of CAP, often used in combination with other antibiotics.
• Cefuroxime axetil: used in combination with ceftriaxone for the treatment of CAP.
• Erythromycin or doxycycline: may be added to the treatment regimen if an infection due to atypical pathogens is suspected or proven. Other medications may be used as well, but the provided drug labels only mention these options. 2 2 2

From the Research

Medications for Community-Acquired Pneumonia (CAP) Inpatients

The following medications are recommended for the treatment of CAP inpatients:

• A respiratory fluoroquinolone (levofloxacin, gemifloxacin, or moxifloxacin) 3
• A beta-lactam antibiotic plus a macrolide 3, 4
• For patients with severe CAP or those admitted to the intensive care unit, a beta-lactam antibiotic plus azithromycin or a respiratory fluoroquinolone is recommended 3
• For patients with risk factors for Pseudomonas, a beta-lactam antibiotic (piperacillin/tazobactam, imipenem/cilastatin, meropenem, doripenem, or cefepime) plus an aminoglycoside and azithromycin or an antipseudomonal fluoroquinolone (levofloxacin or ciprofloxacin) is recommended 3
• For patients with risk factors for methicillin-resistant Staphylococcus aureus, vancomycin or linezolid is recommended 3

Specific Medication Regimens

Some specific medication regimens that have been studied include:

• Levofloxacin 500 mg PO or IV q24h 4
• Azithromycin 500 mg IV q24h for ≥ 2 days plus ceftriaxone 1 g IV q24h for 2 days, followed by an optional transition to azithromycin 500 mg PO q24h 4
• A 750-mg, 5-day course of levofloxacin, which has been shown to be effective in treating atypical CAP 5

Guidelines and Recommendations

The Infectious Diseases Society of America/American Thoracic Society guidelines recommend the use of a respiratory fluoroquinolone or a beta-lactam antibiotic plus a macrolide for the treatment of CAP inpatients 3 The Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group recommends the use of a macrolide, doxycycline, or an oral beta-lactam with good activity against pneumococci for outpatient treatment of CAP, and an intravenous beta-lactam plus a macrolide or a new fluoroquinolone for inpatient treatment 6