From the Guidelines
For inpatient community-acquired pneumonia (CAP), the recommended treatment is a combination of a beta-lactam (such as ceftriaxone 1-2g IV daily, ampicillin-sulbactam 1.5-3g IV every 6 hours, or cefotaxime 1-2g IV every 8 hours) plus a macrolide (azithromycin 500mg IV/PO daily) for non-severe cases, as outlined in the 2019 American Thoracic Society and Infectious Diseases Society of America guidelines 1.
When considering treatment options, several key factors influence the choice of antibiotics, including the severity of the pneumonia, recent hospitalization, and risk factors for drug-resistant organisms such as MRSA and P. aeruginosa.
- For non-severe inpatient CAP, a beta-lactam plus a macrolide or a respiratory fluoroquinolone is recommended 1.
- For severe inpatient CAP, the guidelines suggest using a beta-lactam plus a macrolide or a fluoroquinolone, with additional considerations for MRSA and P. aeruginosa coverage based on risk factors 1.
- MRSA coverage with vancomycin or linezolid should be added if risk factors exist, such as recent hospitalization or prior isolation of MRSA 1.
- Coverage for P. aeruginosa should include an antipseudomonal beta-lactam plus either a fluoroquinolone or an aminoglycoside for patients with specific risk factors like bronchiectasis or recent antibiotic use 1.
Treatment duration and the decision to switch from intravenous (IV) to oral antibiotics should be guided by clinical improvement, with most patients requiring 5-7 days of therapy 1.
- Patients should be afebrile for 48-72 hours and clinically stable before transitioning to oral antibiotics.
- Supportive care is crucial and includes oxygen supplementation to maintain SpO2 >90%, adequate hydration, and early mobilization to improve outcomes and reduce morbidity and mortality.
These recommendations are based on the most recent and highest quality evidence available, targeting the most common CAP pathogens while balancing broad coverage with antibiotic stewardship principles to minimize resistance and improve patient outcomes 1.
From the FDA Drug Label
14.2 Community-Acquired Pneumonia: 7 to 14 Day Treatment Regimen
Adult inpatients and outpatients with a diagnosis of community-acquired bacterial pneumonia were evaluated in 2 pivotal clinical studies In the first study, 590 patients were enrolled in a prospective, multicenter, unblinded randomized trial comparing levofloxacin 500 mg once daily orally or intravenously for 7 to 14 days to ceftriaxone 1 to 2 grams intravenously once or in equally divided doses twice daily followed by cefuroxime axetil 500 mg orally twice daily for a total of 7 to 14 days Patients assigned to treatment with the control regimen were allowed to receive erythromycin (or doxycycline if intolerant of erythromycin) if an infection due to atypical pathogens was suspected or proven. Clinical and microbiologic evaluations were performed during treatment, 5 to 7 days posttherapy, and 3 to 4 weeks posttherapy Clinical success (cure plus improvement) with levofloxacin at 5 to 7 days posttherapy, the primary efficacy variable in this study, was superior (95%) to the control group (83%).
The treatment guidelines for inpatient community-acquired pneumonia (CAP) include:
- Levofloxacin 500 mg once daily orally or intravenously for 7 to 14 days
- Ceftriaxone 1 to 2 grams intravenously once or in equally divided doses twice daily followed by cefuroxime axetil 500 mg orally twice daily for a total of 7 to 14 days
- Addition of erythromycin (or doxycycline if intolerant of erythromycin) if an infection due to atypical pathogens is suspected or proven 2
From the Research
Treatment Guidelines for Inpatient Community-Acquired Pneumonia (CAP)
- The treatment guidelines for inpatient CAP recommend the use of broad-spectrum antibiotics, such as a cephalosporin plus a macrolide, or a fluoroquinolone 3, 4, 5.
- The choice of antibiotic therapy should be based on the potential pathogens and likelihood of antimicrobial resistance 5, 6.
- Combination antibiotic therapy, including a macrolide, is recommended for patients with severe CAP, bacteremic pneumococcal CAP, or those who require mechanical ventilation 6.
- A short course (5 days) of a fluoroquinolone-sparing antibiotic regimen is recommended for uncomplicated cases of CAP 7.
- The use of chest computed tomography (CT) and sputum cultures should be discouraged unless there is suspicion for complications or resistant pathogens 7.
Antibiotic Regimens
- Ceftriaxone plus azithromycin is a recommended antibiotic regimen for inpatient CAP 3, 4.
- Levofloxacin is also a recommended antibiotic regimen, but its use should be limited to cases where it is necessary 3, 7.
- Macrolides, such as azithromycin, are recommended for their anti-inflammatory properties and wide coverage of atypical pneumonia, polymicrobial pneumonia, or resistant Streptococcus pneumoniae 6.