What is the recommended treatment for community-acquired pneumonia?

Treatment of Community Acquired Pneumonia

For adults with community-acquired pneumonia (CAP), treatment should be tailored based on severity of illness, patient setting, and risk factors, with empiric therapy targeting the most common pathogens including Streptococcus pneumoniae and atypical organisms. 1

Outpatient Treatment

For Healthy Adults Without Comorbidities

• First-line therapy:
  • Amoxicillin 1 g three times daily (strong recommendation) 1
  • Doxycycline 100 mg twice daily (alternative option) 1
  • Macrolide (azithromycin 500 mg on first day then 250 mg daily or clarithromycin 500 mg twice daily) only in areas with pneumococcal resistance to macrolides <25% 1

For Adults With Comorbidities

Comorbidities include: chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia

• Preferred options:
  • Combination therapy:
    • β-lactam (amoxicillin/clavulanate 875/125 mg twice daily or 2,000/125 mg twice daily, or cefpodoxime 200 mg twice daily or cefuroxime 500 mg twice daily) PLUS
    • Macrolide (azithromycin 500 mg on first day then 250 mg daily or clarithromycin 500 mg twice daily) OR doxycycline 100 mg twice daily 1
  • Monotherapy alternative:
    • Respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily) 1

Inpatient Treatment (Non-ICU)

• Standard regimen:
  • β-lactam (ampicillin-sulbactam, ceftriaxone, or cefotaxime) PLUS macrolide (azithromycin) 1
  • OR respiratory fluoroquinolone monotherapy (levofloxacin 750 mg daily) 1

Severe CAP (ICU Patients)

• Recommended regimen:
  • β-lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam, or piperacillin-tazobactam) PLUS either:
    • Macrolide (azithromycin) OR
    • Respiratory fluoroquinolone 1

Special Considerations

For Patients With Risk Factors for MRSA or Pseudomonas

• Add appropriate coverage based on risk factors and obtain cultures to guide therapy 1
• Consider vancomycin or linezolid for MRSA coverage
• Consider antipseudomonal β-lactams for Pseudomonas coverage

For Pediatric Patients

• Outpatient treatment:
  • Children <5 years: Amoxicillin 90 mg/kg/day in 2 doses 1
  • Children ≥5 years: Amoxicillin 90 mg/kg/day in 2 doses (max 4 g/day) 1
  • For presumed atypical pneumonia: Azithromycin (10 mg/kg on day 1, then 5 mg/kg daily for 4 days) 1
• Inpatient treatment:
  • Ampicillin or penicillin G; alternatives: ceftriaxone or cefotaxime 1
  • Add azithromycin if atypical pneumonia is suspected 1

Duration of Therapy

• Outpatient treatment: 5-7 days for most patients
• Inpatient treatment: Minimum of 5 days, can extend based on clinical response
• Consider switching from IV to oral therapy when the patient is clinically improving, hemodynamically stable, and able to take oral medications 1

Monitoring Response

• Most patients should show clinical improvement within 3-5 days 1
• If no improvement after 72 hours, consider:
  • Incorrect diagnosis
  • Inappropriate antibiotic choice or dosing
  • Unusual or resistant pathogen
  • Development of complications (empyema, superinfection) 1

Common Pitfalls to Avoid

1. Delaying antibiotic administration - Initiate antibiotics within 8 hours of hospital admission for inpatients 1
2. Inappropriate empiric therapy - Consider local resistance patterns when selecting antibiotics
3. Failure to identify risk factors for resistant organisms - Recent hospitalization, prior antibiotic use, and immunosuppression require broader coverage
4. Overuse of fluoroquinolones - Reserve for patients with comorbidities or β-lactam allergies to minimize resistance development 1
5. Inadequate follow-up - Arrange clinical review for all patients around 6 weeks after treatment 1

By following these evidence-based recommendations, clinicians can optimize outcomes for patients with community-acquired pneumonia while minimizing the risk of treatment failure and antimicrobial resistance.