From the Guidelines
For patients with community-acquired pneumonia (CAP) who are allergic to penicillin, the most effective alternative antibiotic options are macrolides, doxycycline, and respiratory fluoroquinolones, as recommended by the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) guidelines 1.
Alternative Antibiotic Options
- Macrolides: azithromycin (500 mg on day 1, then 250 mg daily for 4 days) or clarithromycin (500 mg twice daily for 7-14 days) are good first-line choices for outpatient treatment.
- Doxycycline (100 mg twice daily for 7-14 days) is another effective option for outpatient treatment.
- Respiratory fluoroquinolones: levofloxacin (750 mg daily for 5-7 days) or moxifloxacin (400 mg daily for 7-14 days) are recommended for patients with comorbidities or risk factors for drug-resistant pathogens.
Hospitalized Patients
- For hospitalized non-ICU patients, monotherapy with a respiratory fluoroquinolone or combination therapy with a respiratory fluoroquinolone plus aztreonam (1-2 g every 8 hours) can be used 1.
- In ICU patients, consider combination therapy with a respiratory fluoroquinolone plus aztreonam, or in severe cases, linezolid or vancomycin plus aztreonam and an aminoglycoside 1.
Considerations
- The choice of alternative antibiotic depends on the severity of the penicillin allergy, local resistance patterns, patient comorbidities, and illness severity.
- These alternatives work by different mechanisms than penicillins, targeting bacterial protein synthesis, DNA replication, or other cellular processes, making them safe and effective options for penicillin-allergic patients.
- It is essential to note that the most recent guidelines from 2011 1 support the use of these alternative antibiotics, but the specific recommendations may vary depending on the patient population and clinical context.
From the FDA Drug Label
MDRSP isolates are isolates resistant to two or more of the following antibacterials: penicillin (MIC ≥ 2 mcg/mL), 2nd generation cephalosporins, e.g., cefuroxime, macrolides, tetracyclines and trimethoprim/sulfamethoxazole. Levofloxacin was effective for the treatment of community-acquired pneumonia caused by multi-drug resistant Streptococcus pneumoniae (MDRSP). Moxifloxacin hydrochloride tablets are indicated in adult patients for the treatment of Community Acquired Pneumonia caused by susceptible isolates of Streptococcus pneumoniae (including multi-drug resistant Streptococcus pneumoniae [MDRSP])
Alternative antibiotics for Community-Acquired Pneumonia (CAP) in patients allergic to Penicillin (PCN) are:
- Levofloxacin: effective against MDRSP, including those resistant to penicillin.
- Moxifloxacin: indicated for the treatment of CAP caused by susceptible isolates of Streptococcus pneumoniae, including MDRSP. 2 3 2
From the Research
Alternative Antibiotics for Community-Acquired Pneumonia (CAP) in Patients Allergic to Penicillin (PCN)
- For patients allergic to Penicillin (PCN), alternative antibiotics for the treatment of Community-Acquired Pneumonia (CAP) include fluoroquinolones, such as levofloxacin, gatifloxacin, and moxifloxacin 4, 5, 6, 7.
- These fluoroquinolones have been shown to be effective in treating CAP, including cases caused by Streptococcus pneumoniae, with clinical success rates of > 90% 4.
- Levofloxacin, in particular, has been found to be effective in treating CAP, including cases caused by macrolide-resistant S pneumoniae, and can be used as a monotherapy or in combination with other antibiotics 5, 6, 8.
- A high-dose, short-course regimen of levofloxacin (750 mg once daily for 5 days) has been approved for the treatment of CAP and has been shown to be noninferior to a 10-day regimen of levofloxacin 500 mg once daily 5, 6.
- A study comparing levofloxacin to a combination of ceftriaxone and azithromycin found that levofloxacin was more effective in improving symptoms and reducing hospitalization length, with a similar rate of side effects 8.
- The use of fluoroquinolones, such as levofloxacin, may be particularly beneficial in patients with CAP who are allergic to PCN, as they provide broad-spectrum coverage and have been shown to be effective in treating a range of bacterial pathogens, including those resistant to other antibiotics 4, 5, 6, 7.