Do you treat left basilar infiltrate (pneumonia)?

From the Guidelines

A left basilar infiltrate should be treated with antibiotics, prioritizing coverage for common bacterial pathogens such as Streptococcus pneumoniae and Haemophilus influenzae. The choice of antibiotic depends on the severity of the pneumonia, patient comorbidities, and local resistance patterns. For community-acquired pneumonia, which often presents as a basilar infiltrate, first-line treatment includes amoxicillin 1g three times daily for 5 days, or doxycycline 100mg twice daily for 5 days if the patient has a penicillin allergy 1.

Key Considerations

• For more severe cases or patients with comorbidities, consider amoxicillin-clavulanate 875/125mg twice daily for 5-7 days or a respiratory fluoroquinolone like levofloxacin 750mg daily for 5 days 1.
• Patients should also rest, maintain adequate hydration, and use antipyretics for fever.
• Treatment should begin promptly after diagnosis, which is typically made through chest X-ray findings combined with clinical symptoms like cough, fever, and shortness of breath.
• Antibiotics are effective because most basilar infiltrates represent bacterial infections, which respond well to targeted antimicrobial therapy.

Hospital-Acquired Pneumonia Considerations

• For hospital-acquired pneumonia, initial empiric antibiotic therapy should be guided by the patient's risk of mortality and factors increasing the likelihood of MRSA, with options including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, and meropenem 1.
• Vancomycin or linezolid may be added for MRSA coverage in patients at high risk of mortality or with prior antibiotic use 1.

Latest Guidance

• The most recent guidelines from 2016 recommend a tailored approach to antibiotic selection based on patient-specific factors and local epidemiology 1.
• The use of levofloxacin 750mg daily for 5 days is supported by recent guidelines as a suitable option for community-acquired pneumonia and hospital-acquired pneumonia, depending on the patient's risk profile and local resistance patterns 1.

From the FDA Drug Label

Community-acquired pneumonia due to Chlamydia pneumoniae, Haemophilus influenzae, Legionella pneumophila, Moraxella catarrhalis, Mycoplasma pneumoniae, Staphylococcus aureus, or Streptococcus pneumoniae in patients who require initial intravenous therapy The answer is yes, azithromycin (IV) can be used to treat community-acquired pneumonia, which may include left basilar infiltrate, if caused by susceptible strains of the designated microorganisms 2.

• Key points:
  • Azithromycin (IV) is indicated for community-acquired pneumonia due to certain microorganisms.
  • It should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria.
  • The treatment should be adjusted according to culture and susceptibility test results 2.

From the Research

Treatment of Left Basilar Infiltrate

• The treatment of left basilar infiltrate, typically associated with community-acquired pneumonia (CAP), often involves the use of antibiotics.
• Studies have compared the efficacy of different antibiotic regimens, including macrolides, fluoroquinolones, and β-lactams, in treating CAP 3, 4, 5, 6.
• A retrospective nationwide database analysis found no significant differences in 28-day mortality and in-hospital mortality between azithromycin plus β-lactam and levofloxacin plus β-lactam for severe CAP patients 3.
• A prospective randomized trial found that oral levofloxacin was as effective as treatment with ceftriaxone plus azithromycin combination in patients with CAP who required hospitalization 4.
• A systematic review and network meta-analysis identified ceftaroline and piperacillin as the empiric antibiotics with the highest probability of being the best for cure rate, and ceftriaxone plus levofloxacin, ertapenem, and amikacin plus clarithromycin as the best for mortality rate in hospitalized patients with CAP 5.
• Another study found that levofloxacin was more effective than ceftriaxone and azithromycin in treating mild to moderate CAP, with improved signs and symptoms and reduced hospitalization length 6.

Antibiotic Regimens

• The choice of antibiotic regimen depends on various factors, including the severity of the disease, patient comorbidities, and local epidemiology 7.
• Early adequate antimicrobial therapy is crucial to improve patient outcomes, especially in those with sepsis or septic shock 7.
• The duration of therapy is usually 5-8 days, but may be longer depending on the underlying illness and the source of infection 7.