What is the treatment for Community-Acquired Pneumonia (CAP)?

From the Guidelines

Community-acquired pneumonia (CAP) treatment should begin with empiric antibiotics based on severity and risk factors, with a minimum treatment duration of 5 days, as recommended by the 2021 American College of Physicians guidelines 1. For outpatient treatment of healthy individuals, a macrolide (azithromycin, clarithromycin, or erythromycin) or doxycycline is recommended, as stated in the 2007 Infectious Diseases Society of America/American Thoracic Society consensus guidelines 2. However, for patients with comorbidities or recent antibiotic use, a respiratory fluoroquinolone (levofloxacin 750mg daily) or a combination of a beta-lactam (such as amoxicillin-clavulanate 875/125mg twice daily) plus a macrolide (azithromycin 500mg on day 1, then 250mg daily for 4 days) is more appropriate, as suggested by the 2003 update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults 3. Some key points to consider when selecting empiric antibiotics for CAP include:

• The patient's severity of illness and risk factors for drug-resistant pathogens
• Local resistance patterns and individual risk factors for drug-resistant pathogens
• The most common pathogens involved in CAP, such as Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms
• The need for supportive care, including oxygen supplementation, hydration, and antipyretics, in addition to antibiotic therapy. Hospitalized non-ICU patients should receive a beta-lactam (ceftriaxone 1-2g daily or ampicillin-sulbactam 3g every 6 hours) plus a macrolide, while ICU patients require broader coverage with a beta-lactam plus either a respiratory fluoroquinolone or azithromycin, as recommended by the 2003 guidelines 3. The treatment duration should be extended if clinically indicated, with patients expected to show clinical improvement within 48-72 hours, as stated in the 2021 guidelines 1. Overall, the goal of CAP treatment is to provide effective antibiotic therapy while minimizing the risk of adverse events and promoting optimal patient outcomes, in terms of morbidity, mortality, and quality of life.

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

Levofloxacin is indicated for the treatment of community-acquired pneumonia (CAP) due to various susceptible microorganisms, including:

• Streptococcus pneumoniae (including multi-drug-resistant isolates)
• Haemophilus influenzae
• Moraxella catarrhalis
• Chlamydophila pneumoniae
• Legionella pneumophila
• Mycoplasma pneumoniae

The recommended treatment regimen for CAP is 7 to 14 days 4.

From the Research

CAP Treatment Overview

• Community-acquired pneumonia (CAP) is a common illness with high rates of morbidity and mortality, with nearly 80% of treatment provided in the outpatient setting 5.
• The predominant pathogen associated with bacterial CAP is Streptococcus pneumoniae, and treatment is often empirical, covering both typical and atypical pathogens 5.

Antibiotic Treatment Options

• Beta-lactams have historically been considered standard therapy for CAP, but rising resistance rates are a primary concern 5.
• Current guidelines recommend combination therapy with a beta-lactam and a macrolide or an antipneumococcal fluoroquinolone alone for patients with comorbidities or recent antibiotic therapy 5.
• Fluoroquinolones, such as moxifloxacin, gatifloxacin, and levofloxacin, have shown high clinical success rates (> 90%) in treating CAP due to S pneumoniae 5.
• Respiratory fluoroquinolone monotherapy has been shown to be as efficacious as beta-lactam-macrolide combination therapy in treating CAP patients 5, 6.

Treatment Considerations

• The use of azithromycin, telithromycin, and fluoroquinolones in short-course regimens has been shown to be efficacious, safe, and tolerable in patients with CAP 5.
• High-dose, short-course therapies may represent a significant advance in the management of CAP 5.
• Broad-spectrum antibiotics have been associated with increased risk of adverse drug events (ADEs) among otherwise healthy adults treated for CAP in the outpatient setting 7.
• Narrow-spectrum antibiotic regimens have been shown to confer similar risk of ADEs 7.

Severe CAP Treatment

• Severe CAP (sCAP) requires prompt and effective treatment, with consideration of new antibiotic treatments and multifaceted antibiotic stewardship interventions 8.
• Combination therapies, severity scores, and the difficulty of treating multidrug-resistant pathogens are important considerations in treating sCAP 8.
• New antibiotics with direct agent-specific properties have been launched to avoid the overuse of broad-spectrum antibiotics when treating patients with sCAP 8.