What are the guidelines for managing community-acquired pneumonia (CAP)?

From the Guidelines

Community-acquired pneumonia (CAP) management should begin with risk stratification using tools like CURB-65 or Pneumonia Severity Index to determine the appropriate treatment setting, and the most recent guidelines from 2019 1 recommend empiric treatment based on the severity of illness and patient characteristics. The management of CAP involves several key steps, including:

• Risk stratification to determine the need for hospitalization
• Selection of empiric antibiotic therapy based on the severity of illness and patient characteristics
• Consideration of patient comorbidities and risk factors for resistant pathogens
• Use of supportive care measures such as hydration, oxygen supplementation, and antipyretics
• Reassessment of patients within 48-72 hours of starting therapy to ensure clinical improvement

For outpatient treatment of mild to moderate CAP, first-line therapy is amoxicillin 1g three times daily for 5 days, or doxycycline 100mg twice daily for 5 days if penicillin-allergic, as recommended by the 2019 guidelines 1. For patients with comorbidities or risk factors for resistant pathogens, amoxicillin-clavulanate 875/125mg twice daily plus azithromycin 500mg daily for 5 days is recommended. Hospitalized non-ICU patients should receive a respiratory fluoroquinolone like levofloxacin 750mg daily or a beta-lactam (ceftriaxone 1-2g daily) plus a macrolide (azithromycin 500mg daily) for 5-7 days, as recommended by the 2020 guidelines for treatment during the COVID-19 pandemic 1. Severely ill ICU patients require broader coverage with ceftriaxone 2g daily plus either azithromycin 500mg daily or levofloxacin 750mg daily. Treatment duration is typically 5 days for most patients, extending to 7 days for severe cases, with longer courses sometimes needed for complicated infections or certain pathogens. Prevention strategies include pneumococcal and influenza vaccination for at-risk populations, as recommended by the 2019 guidelines 1. The goal of therapy is to target the most likely pathogens while minimizing unnecessary antibiotic exposure, as Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms like Mycoplasma pneumoniae are the most common causative agents. It's worth noting that the 2020 guidelines 1 also address the treatment of CAP during the COVID-19 pandemic, and recommend empirical coverage for bacterial pathogens in patients with CAP without confirmed COVID-19, but not in all patients with confirmed COVID-19-related pneumonia. Additionally, the 2019 guidelines 1 provide a comprehensive approach to the management of CAP, including the use of risk stratification tools, selection of empiric antibiotic therapy, and supportive care measures. Overall, the management of CAP requires a thoughtful and individualized approach, taking into account the severity of illness, patient characteristics, and the most recent guidelines and evidence.

From the FDA Drug Label

1.2 Community-Acquired Pneumonia: 7 to 14 day Treatment Regimen Levofloxacin tablets are indicated in adult patients 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 [see Dosage and Administration (2.1) and Clinical Studies (14.2)].

The guidelines for managing community-acquired pneumonia (CAP) with levofloxacin include:

• Treatment duration: 7 to 14 days
• Coverage: methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae (including MDRSP), Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae, Legionella pneumophila, or Mycoplasma pneumoniae
• Dosage: as indicated in the dosage and administration section 2
• Patient population: adult patients Note that azithromycin is also an option for CAP, with a recommended dose of 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5 3.

From the Research

Guidelines for Managing Community-Acquired Pneumonia (CAP)

• The management of CAP involves the use of empirical antibiotic therapy, with the choice of antibiotics depending on the severity of illness and local resistance patterns 4, 5.
• Antibiotics with activity against pneumococci and atypical pathogens are preferred, with options including macrolides, doxycycline, and respiratory fluoroquinolones 5, 6.
• The use of broad-spectrum beta-lactams, such as carbapenems, and moxifloxacin has been shown to be effective against a wide range of pathogens, including multidrug-resistant bacteria 4.
• Azithromycin-containing regimens have been associated with low rates of nonresponsiveness, and the development of an antibiotic stewardship program is recommended to optimize CAP management 4.

Antibiotic Therapy

• Empirical antibiotic therapy should be started promptly, with the choice of antibiotics guided by local resistance patterns and the severity of illness 5, 6.
• Switch therapy from intravenous to oral antibiotics is recommended for hospitalized patients with CAP to facilitate early discharge and reduce hospital costs 5.
• The combination of a third-generation cephalosporin and a macrolide has been shown to be at least as efficacious as monotherapy with a fluoroquinolone for hospitalized patients with moderate to severe CAP 7.

Atypical Pathogen Coverage

• The need for empirical coverage of atypical pathogens in hospitalized patients with CAP is not well established, with some studies suggesting no benefit in terms of mortality or clinical efficacy 8.
• However, the use of antibiotics with activity against atypical pathogens, such as macrolides and fluoroquinolones, may be beneficial in certain cases, such as Legionella pneumophila infection 8.