What is the recommended treatment for pneumonia?

Treatment for Pneumonia

For community-acquired pneumonia (CAP), the recommended first-line treatment is a combination of a beta-lactam antibiotic (such as amoxicillin, ceftriaxone, or cefotaxime) plus a macrolide (such as azithromycin or clarithromycin), with specific regimens determined by severity and treatment setting. 1

Treatment Algorithm Based on Setting and Severity

Outpatient Treatment (Non-severe CAP)

• First choice: Oral macrolide (azithromycin or clarithromycin) or doxycycline 1
• Alternative: Respiratory fluoroquinolone (levofloxacin or moxifloxacin) for patients with comorbidities or recent antibiotic use 1, 2
• Duration: Minimum 5 days, should be afebrile for 48-72 hours before discontinuation 1

Hospitalized Patients (Non-ICU)

• First choice: Intravenous beta-lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam) plus macrolide 1, 3
• Alternative: Respiratory fluoroquinolone monotherapy 1
• Duration: 7 days for uncomplicated cases 1
• Switch to oral: When patient is hemodynamically stable, improving clinically, able to take oral medications, and has normal GI function 1

Severe CAP (ICU Patients)

• First choice: Intravenous beta-lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam, or piperacillin-tazobactam) plus either a macrolide or a fluoroquinolone 1
• Duration: 10 days for microbiologically undefined pneumonia; extend to 14-21 days for Legionella, staphylococcal, or gram-negative enteric bacilli pneumonia 1

Special Considerations

Pseudomonas Risk

If Pseudomonas infection is suspected:

• Use an antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either:
  • Ciprofloxacin/levofloxacin, OR
  • Aminoglycoside plus azithromycin, OR
  • Aminoglycoside plus antipneumococcal fluoroquinolone 1

MRSA Risk

• Add vancomycin or linezolid if community-acquired MRSA is suspected 1

Aspiration Pneumonia

• Hospital ward: Beta-lactam/beta-lactamase inhibitor, clindamycin, or cephalosporin + metronidazole 1
• ICU: Clindamycin + cephalosporin 1

Pathogen-Directed Therapy

Once a specific pathogen is identified:

• Adjust therapy to target the identified organism 1
• For penicillin-allergic patients with pneumococcal pneumonia, use respiratory fluoroquinolones 1

Monitoring Response

• Monitor response using clinical criteria: temperature, respiratory and hemodynamic parameters 1
• C-reactive protein should be measured on days 1 and 3-4, especially in patients with unfavorable clinical parameters 1
• If patient fails to improve within 72 hours:
  1. Review clinical history, examination, and investigation results
  2. Consider further investigations (repeat chest radiograph, additional cultures)
  3. Consider changing antibiotics based on likely pathogens 1

Important Caveats

• First antibiotic dose should be administered while still in the emergency department for hospitalized patients 1
• Azithromycin should not be used in patients with pneumonia who are inappropriate for oral therapy (cystic fibrosis, suspected bacteremia, significant comorbidities) 4
• Be aware of QT prolongation risk with macrolides and fluoroquinolones, especially in elderly patients or those with cardiac risk factors 4
• Despite concerns about pneumococcal resistance to beta-lactams, documented treatment failures are rare compared to fluoroquinolones and macrolides 5
• Low-tidal-volume ventilation (6 cm³/kg) should be used for patients with diffuse bilateral pneumonia or ARDS 1

By following this evidence-based approach to pneumonia treatment, clinicians can optimize outcomes while minimizing antibiotic resistance and adverse effects.