From the Guidelines
For hospitalized patients with community-acquired pneumonia (CAP), the recommended antibiotic regimen typically includes a beta-lactam (such as ceftriaxone 1-2g IV daily, cefotaxime 1-2g IV every 8 hours, or ampicillin-sulbactam 1.5-3g IV every 6 hours) plus a macrolide (azithromycin 500mg IV daily or clarithromycin 500mg IV twice daily), as supported by the most recent guidelines from the American Thoracic Society and Infectious Diseases Society of America 1.
Key Considerations
- The choice of antibiotic regimen should be based on the severity of the pneumonia and the risk of drug resistance, with consideration of local microbiological data.
- For patients with risk factors for Pseudomonas, an antipseudomonal beta-lactam (such as piperacillin-tazobactam 4.5g IV every 6 hours, cefepime 2g IV every 8 hours, or meropenem 1g IV every 8 hours) should be used, plus either a fluoroquinolone or an aminoglycoside 1.
- Alternatively, a respiratory fluoroquinolone alone (such as levofloxacin 750mg IV daily or moxifloxacin 400mg IV daily) can be used, particularly for patients with penicillin allergy or other contraindications to beta-lactam use 1.
Treatment Duration and Transition to Oral Therapy
- Treatment duration is typically 5-7 days for most patients, with longer courses for complicated infections.
- Therapy should be narrowed based on culture results when available, and patients should be transitioned to oral therapy once clinically stable with good gastrointestinal absorption.
Important Pathogens and Coverage
- The recommended regimens provide coverage against common CAP pathogens, including:
- Streptococcus pneumoniae
- Haemophilus influenzae
- Atypical organisms like Mycoplasma and Legionella
- Potential gram-negative bacteria in higher-risk patients It is essential to note that the 2019 guidelines from the American Thoracic Society and Infectious Diseases Society of America 1 supersede the 2007 guidelines 1, and should be followed for the management of hospitalized patients with CAP.
From the FDA Drug Label
CLINICAL PHARMACOLOGY Pharmacokinetics In patients hospitalized with community-acquired pneumonia receiving single daily one-hour intravenous infusions for 2 to 5 days of 500 mg azithromycin at a concentration of 2 mg/mL
The medication azithromycin (IV) is recommended for hospitalized patients with community-acquired pneumonia (CAP) 2.
From the Research
Medications for Hospitalized Patients with Community-Acquired Pneumonia (CAP)
The following medications are recommended for hospitalized patients with CAP:
- Ceftriaxone plus azithromycin 3, 4
- Ceftriaxone plus clarithromycin or erythromycin 3
- Levofloxacin 5, 4
- Cefotaxime 6
- Amoxicillin/clavulanate 6
- Cefuroxime 6, 4
Treatment Regimens
Different treatment regimens have been studied, including:
- Intravenous-to-oral sequential therapy with ceftriaxone and azithromycin 3, 4
- Intravenous-to-oral sequential therapy with ceftriaxone and clarithromycin or erythromycin 3
- Full-course oral levofloxacin 5
- Intravenous levofloxacin with step-down oral therapy 4
Patient Classification and Treatment
Patients with CAP can be classified into different risk categories, and treatment recommendations vary based on these categories:
- Group 1: patients under 65 years without co-morbidities, oral amoxicillin 1 g TID, 7 days 6
- Group 2: patients over 65 years and/or co-morbidities, oral amoxicillin/clavulanate 500/125 mg TID or 875/125 mg BID, or cefuroxime 500 mg BID, 7 days 6
- Group 3: patients admitted to general wards with criteria of moderate severity, ceftriaxone 1-2 g once a day or cefotaxime 1 g TID, IV, 7-10 days 6
- Group 4: patients with severe CAP that must be interned into ICU, ceftriaxone 2 g once a day or cefotaxime 1 g TID, IV, associated to erythromycin 500 QID, levofloxacin 500-1.000 mg once a day, or moxifloxacin 400 mg/once a day, IV, 10-14 days 6