What is the recommended treatment for community-acquired pneumonia?

Treatment for Community-Acquired Pneumonia

The recommended first-line treatment for community-acquired pneumonia (CAP) is a β-lactam (such as ceftriaxone 1-2 g IV daily) plus azithromycin 500 mg IV/PO daily, with treatment stratified based on severity and setting of care. 1

Severity Assessment and Treatment Algorithm

Outpatient Treatment (Mild CAP)

• For patients without comorbidities:

  • Amoxicillin 1 g three times daily (strong recommendation) 1
  • Doxycycline 100 mg twice daily (conditional recommendation) 1
  • Macrolide (azithromycin 500 mg on day 1, then 250 mg daily for 4 days) only in areas with pneumococcal resistance to macrolides <25% 1

• For patients with comorbidities:

  • Combination therapy with a β-lactam (amoxicillin/clavulanate 875 mg/125 mg twice daily OR cefpodoxime 200 mg twice daily OR cefuroxime 500 mg twice daily) PLUS a macrolide OR doxycycline 100 mg twice daily 1
  • Alternative: Respiratory fluoroquinolone monotherapy (levofloxacin 750 mg once daily for 5 days) 1, 2

Inpatient Treatment (Moderate-Severe CAP)

• Non-ICU patients:

  • β-lactam (ceftriaxone 1-2 g IV daily) plus azithromycin 500 mg IV/PO daily 1, 3
  • Alternative: Respiratory fluoroquinolone monotherapy (levofloxacin 750 mg IV/PO daily) 1, 2

• ICU patients:

  • Ceftriaxone, cefotaxime, ampicillin-sulbactam, or piperacillin-tazobactam PLUS a fluoroquinolone or macrolide 1

• For patients at risk of Pseudomonas infection:

  • Antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, meropenem) plus either ciprofloxacin/levofloxacin or an aminoglycoside plus a respiratory fluoroquinolone/macrolide 1

• For patients with β-lactam allergy:

  • Aztreonam plus either levofloxacin or moxifloxacin, with or without an aminoglycoside 1
  • For severe penicillin allergy: Aztreonam plus either azithromycin 500 mg IV daily or a respiratory fluoroquinolone 1

Treatment Duration

• Standard duration: 5-7 days for most patients 1
• Minimum treatment duration: 5 days 1
• For IV therapy: At least 2 days of IV azithromycin (500 mg daily), then transition to oral therapy to complete a 7-10 day course 3
• Treatment should generally not exceed 8 days in a responding patient 1

Criteria for IV to Oral Switch

• Afebrile for 48-72 hours 1
• No more than one sign of clinical instability 1
• Improvement in cough and dyspnea 1
• The timing of the switch should be at the physician's discretion based on clinical response 3

Special Considerations

Atypical Pathogens

• Legionella spp.: Levofloxacin (preferred), moxifloxacin, or macrolide (azithromycin preferred) 1
• Mycoplasma pneumoniae: Azithromycin 500 mg on day 1, then 250 mg daily for 4 days 1
• Chlamydophila pneumoniae: Doxycycline, macrolide, levofloxacin, or moxifloxacin 1

Antibiotic Resistance

• Consider recent antibiotic exposure when selecting therapy 1
• Choose an agent from a different class if the patient has received antibiotics within the past 3 months 1

Common Pitfalls to Avoid

1. Inappropriate antibiotic selection: Not considering local resistance patterns or patient's recent antibiotic exposure
2. Prolonged IV therapy: Avoid when oral therapy would be appropriate 1
3. Inappropriate use of steroids: Not recommended in routine treatment of pneumonia 1
4. Delaying treatment: Do not delay treatment based solely on absence of leukocytosis when other clinical features suggest pneumonia 1
5. Excessive treatment duration: Treating beyond 5-7 days when patient has shown appropriate clinical response 1
6. Failure to cover atypical pathogens: Especially important in certain populations or geographic areas 1

Recent Evidence

The most recent evidence from JAMA (2024) confirms that hospitalized patients without risk factors for resistant bacteria can be treated with β-lactam/macrolide combination therapy, such as ceftriaxone combined with azithromycin, for a minimum of 3 days 4. This aligns with the current guidelines that recommend this combination as first-line therapy for inpatient treatment of CAP.