From the Guidelines
For a patient with community-acquired pneumonia (CAP) and diabetes mellitus (DM), combination therapy with amoxicillin/clavulanate and a macrolide, or monotherapy with a respiratory fluoroquinolone, is recommended.
Recommended Antibiotics
- Combination therapy:
- amoxicillin/clavulanate 500 mg/125 mg three times daily, or amoxicillin/clavulanate 875 mg/125 mg twice daily, or 2,000 mg/125 mg twice daily
- macrolide (azithromycin 500 mg on first day then 250 mg daily, clarithromycin [500 mg twice daily or extended release 1,000 mg once daily]) 1
- Monotherapy:
- respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily, or gemifloxacin 320 mg daily) 1
Rationale
The American Thoracic Society and Infectious Diseases Society of America recommend these antibiotics for outpatient adults with comorbidities, such as diabetes mellitus, due to the increased risk of antibiotic-resistant pathogens and more severe disease 1.
Important Considerations
- The choice of antibiotic should be based on the patient's specific comorbidities, risk factors, and local resistance patterns.
- The recommended antibiotics have a strong or conditional recommendation, with moderate to low quality of evidence, as stated in the guideline 1.
From the Research
Antibiotic Recommendations for CAP with Diabetes Mellitus
For patients with community-acquired pneumonia (CAP) and diabetes mellitus (DM), the choice of antibiotics is crucial due to the potential for increased resistance and complications.
- The use of broad-spectrum agents is often recommended for severe pneumonia, but narrow-spectrum agents can be as effective with less risk of "collateral damage" such as superinfection by resistant pathogens or selection of antibiotic resistance 2.
- For patients with comorbidities like diabetes, current guidelines recommend either combination therapy with a beta-lactam and a macrolide or an antipneumococcal fluoroquinolone alone 3.
- Fluoroquinolones, such as moxifloxacin, gatifloxacin, and levofloxacin, have been shown to be effective in the treatment of CAP due to S pneumoniae, with clinical success rates of > 90% 3.
- In diabetic patients, Klebsiella pneumoniae is a common causative pathogen, and bacteria isolated from these patients are often resistant to recommended antibiotics, but sensitive to Carbapenems 4.
- New antibiotics, such as delafloxacin, omadacycline, lefamulin, solithromycin, nemonoxacin, and ceftaroline, have been approved or are in development for the treatment of CAP, offering enhanced empiric treatment options for antibiotic-resistant bacterial pathogens 5.
Considerations for Antibiotic Selection
When selecting antibiotics for CAP patients with diabetes, considerations should include:
- The potential for antibiotic resistance, particularly in diabetic patients where bacteria may be more resistant to commonly used antibiotics 4.
- The effectiveness of fluoroquinolones and other broad-spectrum agents in treating CAP, including their ability to cover both typical and atypical pathogens 3.
- The importance of narrow-spectrum prescribing to minimize the risk of "collateral damage" and promote more targeted treatment 2.