What are effective treatments for community-acquired pneumonia (CAP)?

From the Guidelines

Community-acquired pneumonia (CAP) should be treated with antibiotics tailored to the likely pathogens and the patient's risk factors, with the most recent guidelines from the American Thoracic Society and Infectious Diseases Society of America (1) recommending initial treatment strategies based on the level of severity and risk for drug resistance.

Key Considerations

• For outpatient treatment of healthy adults, alternatives like doxycycline or azithromycin can be considered, but the choice of antibiotic should be guided by local resistance patterns and patient-specific factors.
• Patients with comorbidities or recent antibiotic use may require broader coverage, such as a respiratory fluoroquinolone or a combination of amoxicillin-clavulanate plus a macrolide.
• Severe cases requiring hospitalization often need intravenous antibiotics, such as ceftriaxone plus azithromycin, or a respiratory fluoroquinolone alone.

Treatment Options

• For non-severe inpatient cases, a beta-lactam (e.g., cefotaxime or ceftriaxone) plus a macrolide (e.g., azithromycin) or a respiratory fluoroquinolone (e.g., levofloxacin) is recommended (1).
• For severe inpatient cases, a beta-lactam plus a macrolide or a respiratory fluoroquinolone, with consideration for adding coverage for MRSA and P. aeruginosa, is recommended (1).

Supportive Care

• Adequate hydration, rest, and fever control with acetaminophen or NSAIDs are also important components of CAP treatment.
• Most patients show improvement within 48-72 hours of starting antibiotics, and treatment should be tailored to the individual patient's response and risk factors.

Evidence-Based Recommendations

• The 2019 guidelines from the American Thoracic Society and Infectious Diseases Society of America (1) provide the most recent and comprehensive recommendations for CAP treatment, and should be consulted for specific guidance on antibiotic selection and treatment duration.

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

Effective treatments for community-acquired pneumonia (CAP) include:

• Levofloxacin for 7 to 14 days for CAP due to methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae (including MDRSP), Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae, Legionella pneumophila, or Mycoplasma pneumoniae 2
• Levofloxacin for 5 days for CAP due to Streptococcus pneumoniae (excluding MDRSP), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasma pneumoniae, or Chlamydophila pneumoniae 2
• Azithromycin for CAP due to Chlamydia pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, or Streptococcus pneumoniae in patients appropriate for oral therapy 3

From the Research

Effective Treatments for Community-Acquired Pneumonia (CAP)

• The treatment of CAP depends on the severity of the disease and the presence of underlying medical conditions 4.
• For outpatients with CAP, empirical treatment with a macrolide, doxycycline, or a respiratory fluoroquinolone is recommended 4.
• A single 2.0-g dose of azithromycin microspheres was found to be as effective and well-tolerated as a 7-day course of extended-release clarithromycin in the treatment of adults with mild-to-moderate CAP 5.
• For hospitalized patients with CAP, treatment with a fluoroquinolone or a combination of beta-lactam plus macrolide antibiotics is recommended 4.
• Patients with severe infection requiring admission to the intensive care unit require dual antibiotic therapy, including a third-generation cephalosporin plus a macrolide alone or in combination with a fluoroquinolone 4.
• The use of doxycycline has been found to be a viable treatment option for mild-to-moderate CAP, with clinical cure rates comparable to macrolides or fluoroquinolones 6.
• A combination of ceftriaxone and azithromycin has been shown to be at least equivalent in efficacy and safety to a comparator regimen of ceftriaxone and clarithromycin or erythromycin for hospitalized patients with CAP 7.
• The choice of initial antibiotic therapy should be based on the epidemiology and clinical manifestations of atypical pathogens, antibiotic resistance, and new antibiotics 8.

Treatment Options for Specific Patient Populations

• Patients with risk factors for Pseudomonas species should be treated with an antipseudomonal antibiotic and an aminoglycoside, plus azithromycin or a fluoroquinolone 4.
• Patients with risk factors for methicillin-resistant Staphylococcus aureus should be given vancomycin or linezolid, or ceftaroline in resistant cases 4.
• Older adults or those with comorbidities should be treated with erythromycin plus trimethoprim-sulfamethoxazole, a second- or third-generation cephalosporin, or a new macrolide 8.

Additional Considerations

• The use of corticosteroids within 36 hours of hospital admission for patients with severe CAP has been found to decrease the risk of adult respiratory distress syndrome and length of treatment 4.
• Vaccinations, such as the 23-valent pneumococcal polysaccharide and 13-valent pneumococcal conjugate vaccinations, are recommended for adults 65 years and older to decrease the risk of invasive pneumococcal disease, including pneumonia 4.