What is the recommended outpatient treatment for pneumonia?

From the Guidelines

The recommended outpatient treatment for pneumonia is amoxicillin 1 g three times daily, as it is a strong recommendation with moderate quality of evidence, according to the American Thoracic Society and Infectious Diseases Society of America guidelines 1. For healthy outpatient adults without comorbidities or risk factors for antibiotic-resistant pathogens, the following options are also available:

• Doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence) 1
• A macrolide (azithromycin 500 mg on the first day then 250 mg daily or clarithromycin 500 mg twice daily or clarithromycin extended release 1,000 mg daily) only in areas with pneumococcal resistance to macrolides, 25% (conditional recommendation, moderate quality of evidence) 1

For outpatient adults with comorbidities, such as chronic heart, lung, liver, or renal disease, the recommended treatment options include:

• Combination therapy with amoxicillin/clavulanate and a macrolide (strong recommendation, moderate quality of evidence) 1
• Monotherapy with a respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily, or gemifloxacin 320 mg daily) (strong recommendation, moderate quality of evidence) 1 It is essential to consider patient factors, such as comorbidities and risk factors for drug-resistant pathogens, when selecting an antibiotic regimen. Supportive care, including adequate hydration, rest, and fever control, is also crucial for optimal outcomes. Patients should be monitored for improvement within 48-72 hours of starting antibiotics, and reevaluation is necessary if symptoms worsen or do not improve.

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)].

The recommended outpatient treatment for pneumonia is levofloxacin tablets, which can be administered orally. The treatment regimen can be either 7 to 14 days or 5 days, depending on the specific type of pneumonia and the causative pathogen. The dosage is 500 mg once daily for the 7 to 14 day regimen or 750 mg once daily for the 5 day regimen 2.

• Community-acquired pneumonia can be treated with levofloxacin tablets for 7 to 14 days or 5 days.
• The 5 day treatment regimen is recommended for pneumonia caused by Streptococcus pneumoniae (excluding multi-drug-resistant isolates), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasma pneumoniae, or Chlamydophila pneumoniae.
• The 7 to 14 day treatment regimen is recommended for pneumonia caused by methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae (including multi-drug-resistant Streptococcus pneumoniae), Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae, Legionella pneumophila, or Mycoplasma pneumoniae.

From the Research

Recommended Outpatient Treatment for Pneumonia

The recommended outpatient treatment for pneumonia depends on various factors, including the severity of the disease, the presence of comorbidities, and the likelihood of antibiotic resistance.

• According to a study published in 2005 3, the beta-lactams have historically been considered standard therapy for the treatment of community-acquired pneumonia (CAP). However, the impact of rising resistance rates is now a primary concern facing physicians.
• For patients with comorbidities or recent antibiotic therapy, current guidelines recommend either combination therapy with a beta-lactam and a macrolide or an antipneumococcal fluoroquinolone alone 3.
• Fluoroquinolones are broad-spectrum antibiotics that exhibit high levels of penetration into the lungs and low levels of resistance 3.
• A study published in 2016 4 summarizes key principles in starting treatment and provides recommended empiric therapy regimens for each site of care.
• The use of azithromycin, telithromycin, and fluoroquinolones in short-course regimens has been shown to be efficacious, safe, and tolerable in patients with CAP 3.
• A study published in 2023 5 found that outpatient treatment of CAP in the absence of infectious disease doctors meant more broad-spectrum antibiotic prescription and more disregard for national guidelines.
• Another study published in 2004 6 suggests that combination therapy with a beta-lactam plus a macrolide or doxycycline or monotherapy with a "respiratory quinolone" are optimal first-line therapy for patients hospitalized with CAP.
• A recent study published in 2024 7 compared the risk of adverse drug events (ADEs) associated with antibiotic regimens for CAP treatment among otherwise healthy, non-elderly adults, and found that broad-spectrum antibiotics were associated with increased risk of ADEs.

Antibiotic Regimens

• Narrow-spectrum antibiotic regimens, such as macrolide monotherapy, are generally considered safe and effective for the treatment of CAP in otherwise healthy adults 7.
• Broad-spectrum antibiotic regimens, such as fluoroquinolones and beta-lactam plus macrolide combination therapy, are associated with increased risk of ADEs, including nausea, vomiting, abdominal pain, and non-Clostridioides difficile diarrhea 7.
• The choice of antibiotic regimen should be guided by the severity of the disease, the presence of comorbidities, and the likelihood of antibiotic resistance, as well as the potential risks and benefits of each regimen 3, 4, 7.