From the Guidelines
For pneumonia treatment after antibiotic failure in a patient with penicillin allergy, a respiratory fluoroquinolone and aztreonam are recommended. This approach is based on the guidelines from the Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults 1. The guidelines suggest that for penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are recommended for inpatient, ICU treatment.
Some key points to consider in the treatment of pneumonia in patients with penicillin allergy include:
- The use of cephalosporins should be avoided due to potential cross-reactivity with penicillin 1.
- Combination therapy with a respiratory fluoroquinolone plus either vancomycin or linezolid may be necessary for severe cases requiring hospitalization.
- The choice of antibiotic depends on the severity of the pneumonia, suspected pathogens, and the nature of the penicillin allergy.
- Treatment should be reassessed after 48-72 hours, with consideration for sputum cultures to identify the specific pathogen and its antibiotic sensitivities.
In terms of specific antibiotic regimens, options may include:
- Respiratory fluoroquinolones (such as levofloxacin 750mg daily)
- Aztreonam, which can be used in combination with a respiratory fluoroquinolone for penicillin-allergic patients 1. Supportive care, including adequate hydration, rest, and possibly supplemental oxygen, is also essential for recovery.
From the FDA Drug Label
1 INDICATIONS AND USAGE
To reduce the development of drug-resistant bacteria and maintain the effectiveness of levofloxacin tablets and other antibacterial drugs, levofloxacin tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy Levofloxacin tablets are indicated for the treatment of adults (≥ 18 years of age) with mild, moderate, and severe infections caused by susceptible isolates of the designated microorganisms in the conditions listed in this section
- 1 Nosocomial Pneumonia Levofloxacin tablets are indicated for the treatment of nosocomial pneumonia due to methicillin-susceptible Staphylococcus aureus, Pseudomonas aeruginosa, Serratia marcescens, Escherichia coli, Klebsiella pneumoniae, Haemophilus influenzae, or Streptococcus pneumoniae.
- 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
Treatment options for pneumonia post antibiotic failure in a patient with an allergy to penicillin:
- Levofloxacin tablets are indicated for the treatment of community-acquired pneumonia due to Streptococcus pneumoniae (including multi-drug-resistant Streptococcus pneumoniae [MDRSP]), which may be an option for patients with a penicillin allergy.
- The clinical success rate in patients with atypical pneumonia due to Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila were 96%, 96%, and 70%, respectively, in studies using levofloxacin 2.
- Levofloxacin was effective for the treatment of community-acquired pneumonia caused by multi-drug resistant Streptococcus pneumoniae (MDRSP), with 38 patients (95%) achieving clinical and bacteriologic success at post-therapy 3.
From the Research
Treatment Options for Pneumonia Post Antibiotic Failure with Penicillin Allergy
- For patients with pneumonia who have failed initial antibiotic treatment and have an allergy to penicillin, alternative treatment options must be considered 4.
- The use of fluoroquinolones, such as levofloxacin, is a viable option for treating community-acquired pneumonia, especially in patients with penicillin allergy 5, 6, 7.
- Combination therapy with a macrolide and a third-generation cephalosporin, such as ceftriaxone and azithromycin, may also be effective, but the presence of a penicillin allergy may limit the use of cephalosporins 8, 6.
- A study comparing levofloxacin to ceftriaxone and azithromycin for treating community-acquired pneumonia found that levofloxacin was associated with improved clinical symptoms and reduced hospitalization length, with a similar rate of side effects 7.
Considerations for Patients with Penicillin Allergy
- Patients with a documented penicillin and/or cephalosporin allergy are less likely to receive first-line beta-lactam antibiotic treatment for pneumonia, and may be more likely to receive alternative antibiotics such as carbapenems and fluoroquinolones 4.
- Inpatient allergy assessment may improve optimal antibiotic therapy for patients with pneumonia and a documented penicillin allergy 4.
Alternative Antibiotic Options
- Fluoroquinolones, such as levofloxacin, are a potential alternative for patients with penicillin allergy, and have been shown to be effective in treating community-acquired pneumonia 5, 6, 7.
- Macrolides, such as azithromycin, may also be used in combination with other antibiotics, but their use may be limited in patients with penicillin allergy due to concerns about resistance 8, 6.
- Carbapenems may be used as an alternative antibiotic option for patients with penicillin allergy, but their use should be reserved for patients with severe or complicated infections 4.