What antibiotics are recommended for treating pneumonia in patients without a penicillin (Penicillin) allergy?

From the Guidelines

For pneumonia in patients without penicillin allergy, amoxicillin 1 g three times daily is the recommended first-line antibiotic treatment. This recommendation is based on the American Thoracic Society and Infectious Diseases Society of America guidelines 1. The guidelines suggest that for healthy outpatient adults without comorbidities or risk factors for antibiotic-resistant pathogens, amoxicillin is a strong recommendation with moderate quality of evidence.

For outpatient adults with comorbidities, such as chronic heart, lung, liver, or renal disease, the guidelines recommend combination therapy with amoxicillin/clavulanate and a macrolide, or monotherapy with a respiratory fluoroquinolone 1. The combination therapy includes amoxicillin/clavulanate 500 mg/125 mg three times daily, or amoxicillin/clavulanate 875 mg/125 mg twice daily, and a macrolide such as azithromycin 500 mg on the first day then 250 mg daily.

Some key points to consider when treating pneumonia in patients without penicillin allergy include:

• The use of doxycycline 100 mg twice daily as an alternative to amoxicillin, although this is a conditional recommendation with low quality of evidence 1
• The use of macrolides, such as azithromycin, only in areas with pneumococcal resistance to macrolides of 25% or higher 1
• The use of fluoroquinolones, such as levofloxacin 750 mg daily, as monotherapy for more severe cases or those with comorbidities 1

It is essential to note that the treatment duration and antibiotic choice may vary depending on the severity of the infection, patient comorbidities, and local resistance patterns. Therefore, amoxicillin 1 g three times daily remains the first-line treatment for pneumonia in patients without penicillin allergy, with adjustments made based on individual patient factors and guidelines 1.

From the FDA Drug Label

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 Azithromycin Tablets, USP are indicated for the treatment of patients with mild to moderate infections (pneumonia: see WARNINGS) caused by susceptible strains of the designated microorganisms in the specific conditions listed below Community-acquired pneumonia due to Chlamydophila pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae or Streptococcus pneumoniae in patients appropriate for oral therapy

Antibiotics to use in pneumonia without penicillin allergy:

• Levofloxacin: for community-acquired pneumonia due to methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae, Legionella pneumophila, or Mycoplasma pneumoniae 2
• Azithromycin: for community-acquired pneumonia due to Chlamydophila pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae or Streptococcus pneumoniae in patients appropriate for oral therapy 3

From the Research

Antibiotics for Pneumonia Without Penicillin Allergy

• The recommended optimal in-hospital therapy for community-acquired pneumonia is a beta-lactam antibiotic (such as penicillin, aminopenicillin, cefotaxime, or ceftriaxone) administered with a macrolide or a fluoroquinolone agent for adjunctive treatment of infection with potential atypical pathogens 4.
• A combination of a third-generation cephalosporin (such as ceftriaxone) and a macrolide (such as azithromycin) is at least as efficacious as monotherapy with a fluoroquinolone for hospitalized patients with moderate to severe community-acquired pneumonia 5, 6.
• Levofloxacin monotherapy is also an effective treatment option for hospitalized adults with moderate to severe community-acquired pneumonia, with a clinical success rate of 94.1% in clinically evaluable patients 6.
• The use of carbapenems and fluoroquinolones may be considered as alternative antibiotics in patients with a documented penicillin and/or cephalosporin allergy 7.

Treatment Options

• Ceftriaxone plus azithromycin: a well-tolerated and effective combination for hospitalized patients with moderate to severe community-acquired pneumonia 5.
• Levofloxacin: a effective monotherapy option for hospitalized adults with moderate to severe community-acquired pneumonia 6.
• Cefotaxime or ceftriaxone: recommended beta-lactam antibiotics for the treatment of community-acquired pneumonia 4.

Considerations

• Patients without a penicillin allergy can be treated with penicillin or other beta-lactam antibiotics, which are often the first-line treatment options for pneumonia 4, 8.
• The presence of a penicillin allergy label is associated with worse clinical outcomes in bacterial pneumonia, including increased risks of hospitalization, acute respiratory failure, and mortality 8.