What is the treatment for community-acquired pneumonia (CAP)?

From the Guidelines

Community-acquired pneumonia (CAP) should be treated with antibiotics that cover both typical and atypical pathogens, with the specific regimen depending on the severity of illness and patient factors, as recommended by the most recent guidelines 1. The treatment of CAP typically involves the use of antibiotics, with the choice of antibiotic depending on the severity of the illness and the presence of any underlying medical conditions.

• For outpatient treatment of healthy adults without comorbidities, alternatives include doxycycline 100 mg twice daily or azithromycin 500 mg on day 1, then 250 mg daily for days 2-5.
• For patients with comorbidities or risk factors for drug-resistant pathogens, a respiratory fluoroquinolone (levofloxacin 750 mg daily or moxifloxacin 400 mg daily) or combination therapy with amoxicillin-clavulanate plus a macrolide is appropriate.
• Hospitalized patients typically receive intravenous antibiotics such as ceftriaxone 1-2 g daily plus azithromycin 500 mg daily, or a respiratory fluoroquinolone. The most recent guidelines recommend the use of empirical antibiotics to cover both typical and atypical pathogens in CAP when pulmonary bacterial co-infections occur 1.
• The choice of antibiotics targets the most common causative organisms including Streptococcus pneumoniae, Haemophilus influenzae, and atypical pathogens like Mycoplasma pneumoniae. Treatment duration is generally 5-7 days for most patients, though longer courses may be needed for complicated cases, and supportive care including adequate hydration, fever control, and oxygen supplementation if needed is also important 1. Patients should begin to improve within 48-72 hours of starting antibiotics; lack of improvement warrants reassessment, as recommended by the guidelines 1.

From the FDA Drug Label

In the treatment of pneumonia, azithromycin has only been shown to be safe and effective in the treatment of community-acquired pneumonia due to Chlamydia pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae or Streptococcus pneumoniae in patients appropriate for oral therapy Community Acquired Pneumonia (CAP) 5 Day Treatment Regimen To evaluate the safety and efficacy of a 5-day course of FACTIVE, 510 outpatient and hospitalized adults with clinically and radiologically determined mild to moderate community-acquired pneumonia were clinically evaluated in a double-blind, randomized, prospective, multicenter study comparing FACTIVE 320 mg for five days to FACTIVE 320 mg for seven days (Study OP-634-001).

Treatment of Community-Acquired Pneumonia

• Azithromycin can be used to treat community-acquired pneumonia due to Chlamydia pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, or Streptococcus pneumoniae in patients appropriate for oral therapy 2.
• Gemifloxacin (320 mg PO once daily for 5 days) is effective in treating mild to moderate community-acquired pneumonia, with clinical success rates of 95.0% in the clinically evaluable population 3.
• Gemifloxacin is also effective in treating community-acquired pneumonia due to multi-drug resistant Streptococcus pneumoniae (MDRSP), with clinical and bacteriological success rates of 82.9% 3.

From the Research

Treatment Approaches for Community-Acquired Pneumonia

• The treatment of community-acquired pneumonia (CAP) depends on the severity of the disease and may require outpatient, inpatient, or intensive care management 4.
• Successful treatment hinges on expedient delivery of appropriate antibiotic therapy tailored to both the likely offending pathogens and the severity of disease 4.
• Empiric therapy regimens are recommended for each site of care, and the antimicrobial and anti-inflammatory role of macrolides plays a significant role in CAP treatment 4.

Antibiotic Therapy for Severe Community-Acquired Pneumonia

• Severe CAP (sCAP) requires appropriate empirical antibiotic choices, timing regimens, and evidence for clinical effectiveness 5.
• Combination therapies, severity scores, and the difficulty of treating multidrug-resistant pathogens are important considerations in sCAP treatment 5.
• New antibiotics have been launched with direct agent-specific properties that can help avoid the overuse of broad-spectrum antibiotics when treating patients with sCAP 5.

Monotherapy versus Dual Therapy for Hospitalized Patients

• Several medical-specialty professional societies suggest that combination therapy with a beta-lactam plus a macrolide or doxycycline or monotherapy with a "respiratory quinolone" are optimal first-line therapies for patients hospitalized with CAP 6.
• The biological rationale for combination therapy or fluoroquinolone therapy includes the immunomodulatory effects of macrolides or more-optimal treatment of primary infection or coinfection with atypical pathogens 6.

Treatment Duration for Community-Acquired Pneumonia

• Usual guidelines for adults with CAP recommend 5-7 days of antibiotic treatment, but several studies and meta-analyses have demonstrated that treatment durations of 7 days or less are sufficient for CAP 7.
• Clinical and biological criteria, such as stability criteria and procalcitonin, can help clinicians reduce antibiotic treatment duration 7.
• Shortening treatment duration can help decrease antibiotic use and prevent the emergence of bacterial resistance 7.

Impact of Empirical Antibiotic Therapy without Respiratory Fluoroquinolones nor Third-Generation Cephalosporins

• Guidelines for inpatients with CAP propose using respiratory fluoroquinolone (RFQ) and/or third-generation cephalosporins (Ceph-3), but broad-spectrum antibiotic therapy is associated with the emergence of drug-resistant bacteria 8.
• A study found that CAP therapy without RFQ and Ceph-3 use was associated with a shorter length of hospital stay and fewer unfavorable outcomes 8.
• The use of combination therapy with amoxicillin-clavulanic acid (AMX-C) + roxithromycin (RX) or AMX + ofloxacin as empirical treatment for PSI III to V was effective in reducing unfavorable outcomes 8.