What are the outpatient treatment options for Community-Acquired Pneumonia (CAP)?

From the Guidelines

Outpatient treatment for community-acquired pneumonia (CAP) should be guided by the patient's risk factors and the likely pathogens, with a macrolide such as azithromycin or doxycycline recommended for previously healthy adults and a respiratory fluoroquinolone or a combination of a beta-lactam and a macrolide recommended for patients with comorbidities or risk factors for drug-resistant pathogens 1.

Key Considerations

• The choice of antibiotic should be based on the patient's risk factors, such as comorbidities, recent antibiotic use, and age 1.
• Macrolides, such as azithromycin, are effective against most common CAP pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms like Mycoplasma pneumoniae 1.
• Doxycycline is a cost-effective alternative to macrolides and is active against 90%–95% of strains of S. pneumoniae 1.
• Respiratory fluoroquinolones, such as levofloxacin, are effective against a broad range of pathogens, including S. pneumoniae, H. influenzae, and atypical organisms, but their use should be reserved for patients with comorbidities or risk factors for drug-resistant pathogens due to concerns about resistance 1.
• Combination therapy with a beta-lactam and a macrolide is recommended for patients with comorbidities or risk factors for drug-resistant pathogens, as it provides broad coverage against a range of pathogens 1.

Treatment Recommendations

• Previously healthy adults: macrolide (azithromycin or clarithromycin) or doxycycline 1.
• Patients with comorbidities or risk factors for drug-resistant pathogens: respiratory fluoroquinolone (levofloxacin or moxifloxacin) or combination therapy with a beta-lactam (amoxicillin-clavulanate) and a macrolide (azithromycin) 1.

Duration of Treatment

• The recommended duration of treatment for CAP is 5 days, as it has similar efficacy to longer courses while reducing antibiotic resistance risk, side effects, and improving compliance 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 [see Dosage and Administration (2.1) and Clinical Studies (14.2)].

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 [see Dosage and Administration (2.1) and Clinical Studies (14.3)].

Outpatient treatment for Community-Acquired Pneumonia (CAP) is supported by the FDA drug label for levofloxacin.

• The recommended treatment regimens are:
  • 500 mg orally or intravenously once daily for 7 to 14 days
  • 750 mg orally or intravenously once daily for 5 days
• The approved pathogens for outpatient treatment of CAP include:
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Haemophilus parainfluenzae
  • Mycoplasma pneumoniae
  • Chlamydophila pneumoniae 2 2

From the Research

Outpatient Treatment for Community-Acquired Pneumonia (CAP)

• The treatment of CAP is often empirical and must cover a wide range of potential pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and intracellular microorganisms 3.
• Azithromycin has been shown to be effective in the treatment of CAP, including patients with macrolide-resistant S. pneumoniae infection, with a good clinical response achieved in 83.1% of patients and a microbiological response achieved in 78.3% of patients 4.
• Sparfloxacin has also been compared to amoxycillin-clavulanic acid and erythromycin in the treatment of CAP, with similar overall success rates for the three antibiotics tested 3.
• The outpatient management of CAP poses several challenges, including the difficulty in establishing the initial clinical diagnosis, risk stratification, and the empirical choice of antibiotics 5, 6.
• New molecular biology methods have changed the etiologic perspective of CAP, especially the contribution of viruses, and lung ultrasound and biomarkers may aid in diagnosis and severity stratification in the outpatient setting 5, 6.
• Antibiotic resistance is a growing problem, and prevention, especially the use of anti-pneumococcal vaccine, is instrumental in reducing the burden of disease 5, 6, 7.
• The choice of antibiotics should be based on the likely causative pathogen, the presence of risk factors for infection with resistant bacteria, and local resistance patterns 7.