What are the treatment options for community-acquired pneumonia (CAP)?

From the Guidelines

Community-acquired pneumonia (CAP) should be treated with antibiotics for a duration of 5-7 days, with the specific regimen depending on the severity of illness and patient factors, as supported by the most recent evidence from 2023 1. The treatment options for CAP vary based on the severity of the disease and patient factors.

• For outpatient treatment of healthy adults without comorbidities, amoxicillin 1 gram three times daily for 5-7 days is recommended as first-line therapy, as per the guidelines from the American Thoracic Society and Infectious Diseases Society of America 1.
• Alternatives include doxycycline 100 mg twice daily or azithromycin 500 mg on day one followed by 250 mg daily for 4 more days.
• For patients with comorbidities or recent antibiotic use, a respiratory fluoroquinolone like levofloxacin 750 mg daily or a combination of amoxicillin-clavulanate plus a macrolide is appropriate.
• Hospitalized patients with non-severe CAP should receive either a respiratory fluoroquinolone alone or a beta-lactam (like ceftriaxone 1-2 g daily) plus a macrolide, as outlined in the 2019 guidelines 1.
• Severely ill patients requiring ICU admission should be treated with a beta-lactam plus either a macrolide or a respiratory fluoroquinolone.
• The choice of antibiotics targets the most common causative organisms including Streptococcus pneumoniae, Haemophilus influenzae, and atypical pathogens like Mycoplasma pneumoniae, while considering local resistance patterns.
• Supportive care including adequate hydration, oxygen supplementation if needed, and antipyretics for fever is also important.
• The most recent evidence from 2023 suggests that short-course antibiotic therapy (≤ 6 days) is as effective as long-course therapy for CAP, with fewer serious adverse events and low mortality 1.
• This is supported by 14 RCTs including >8400 patients, which found that short-duration therapy was at least as effective as long-duration therapy.
• Therefore, treatment duration should be guided by clinical improvement, with a typical duration of 5-7 days for most patients.

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 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 1.5 Community-acquired Pneumonia Piperacillin and Tazobactam for Injection is indicated in adults for the treatment of community-acquired pneumonia (moderate severity only) caused by beta-lactamase producing isolates of Haemophilus influenzae.

Treatment options for community-acquired pneumonia (CAP) include:

• Levofloxacin tablets for the treatment of CAP due to various bacteria, including methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and others, with treatment regimens of 7 to 14 days or 5 days depending on the specific bacterial isolates 2
• Piperacillin and Tazobactam for Injection for the treatment of CAP (moderate severity only) caused by beta-lactamase producing isolates of Haemophilus influenzae 3

From the Research

Treatment Options for Community-Acquired Pneumonia (CAP)

The treatment options for CAP depend on various factors, including the severity of the disease, the presence of comorbidities, and the risk of drug-resistant pathogens.

• For outpatients with CAP, treatment options include:
  • Macrolides (e.g., azithromycin, clarithromycin) or doxycycline 4, 5, 6
  • Respiratory fluoroquinolones (e.g., levofloxacin, moxifloxacin) 4, 5
  • Oral beta-lactam antibiotics (e.g., cefuroxime axetil, amoxicillin) plus a macrolide 5, 6
• For inpatients with CAP, treatment options include:
  • Respiratory fluoroquinolones (e.g., levofloxacin, moxifloxacin) 5
  • Beta-lactam antibiotics (e.g., ceftriaxone, cefotaxime) plus a macrolide (e.g., azithromycin) 5
  • For patients with severe CAP or those admitted to the intensive care unit, treatment options include:
    • Beta-lactam antibiotics (e.g., piperacillin/tazobactam, imipenem/cilastatin) plus an aminoglycoside and azithromycin or an antipseudomonal fluoroquinolone (e.g., levofloxacin, ciprofloxacin) 5
    • Vancomycin or linezolid for patients with risk factors for methicillin-resistant Staphylococcus aureus (MRSA) 5

Special Considerations

• Patients with risk factors for drug-resistant pathogens (e.g., Pseudomonas aeruginosa, MRSA) may require different treatment regimens 5, 7, 8
• The use of extended-spectrum antibiotics should be guided by clinical judgment and evidence-based guidelines to minimize the risk of overuse and resistance 7
• Hospitalized patients may be switched from intravenous to oral antibiotics after clinical improvement and ability to tolerate oral medications 5