What are the guidelines for treating pneumonia?

From the Guidelines

Pneumonia treatment should involve a combination of antibiotics, supportive care, and monitoring, with empiric antibiotic therapy beginning promptly, typically with a macrolide or a respiratory fluoroquinolone for outpatients, and combination therapy with a beta-lactam plus a macrolide, or monotherapy with a respiratory fluoroquinolone for hospitalized patients, as recommended by the Infectious Diseases Society of America and the American Thoracic Society 1.

Treatment Guidelines

The treatment guidelines for community-acquired pneumonia (CAP) in adults are based on the severity of illness, pathogen probabilities, resistance patterns of S. pneumoniae, and comorbid conditions.

• For outpatients, the recommendation is administration of a macrolide, doxycycline, or fluoroquinolone with enhanced activity against S. pneumoniae 1.
• For patients who are hospitalized, the recommendation is administration of a fluoroquinolone alone or an extended-spectrum cephalosporin (cefotaxime or ceftriaxone) plus a macrolide 1.
• Patients hospitalized in the intensive care unit (ICU) should receive ceftriaxone, cefotaxime, ampicillin-sulbactam, or piperacillin-tazobactam in combination with a fluoroquinolone or macrolide 1.

Supportive Care

Supportive measures include:

• Adequate hydration
• Oxygen supplementation if saturation falls below 92%
• Antipyretics for fever
• Pain management
• Rest
• Maintenance of fluid intake
• Use of incentive spirometry to prevent complications

Treatment Duration and Assessment

• Treatment duration typically ranges from 5-7 days for uncomplicated cases to 10-14 days for severe infections.
• Treatment response should be assessed within 48-72 hours, with clinical improvement expected.
• The choice of antibiotics targets the most common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, atypical organisms) while considering local resistance patterns.
• Elderly patients and those with comorbidities may require broader coverage and longer treatment.
• Hospital admission is warranted for severe pneumonia, significant comorbidities, inability to maintain oral intake, or oxygen requirements. The most recent and highest quality study, published in 2007 by the Infectious Diseases Society of America and the American Thoracic Society, provides a unified guideline document for the management of CAP in adults 1.

From the FDA Drug Label

Adult Patients with Nosocomial Pneumonia: Initial presumptive treatment of patients with nosocomial pneumonia should start with piperacillin and tazobactam for injection at a dosage of 4.5 grams every six hours plus an aminoglycoside, totaling 18.0 grams (16.0 grams piperacillin and 2.0 grams tazobactam). Community-acquired pneumonia in adults (1.5)

The guidelines for treating pneumonia are as follows:

• Nosocomial Pneumonia: Initial presumptive treatment should start with piperacillin and tazobactam for injection at a dosage of 4.5 grams every six hours plus an aminoglycoside.
• Community-acquired Pneumonia: Piperacillin and Tazobactam for Injection is indicated for the treatment of community-acquired pneumonia in adults 2.
• Levofloxacin: For community-acquired pneumonia, levofloxacin can be administered orally or intravenously for 7 to 14 days, with a dosage of 500 mg once daily 3. Key considerations include:
• The choice of antibiotic and dosage may depend on the severity of the pneumonia, the patient's renal function, and the suspected or confirmed causative pathogen.
• Combination therapy with an aminoglycoside may be necessary for nosocomial pneumonia.
• The duration of treatment may vary depending on the clinical response and the causative pathogen.

From the Research

Guidelines for Treating Pneumonia

The guidelines for treating pneumonia are as follows:

• Initial evaluation should determine the need for hospitalization versus outpatient management using validated mortality or severity prediction scores 4, 5.
• Outpatients with community-acquired pneumonia can be treated empirically with a macrolide, doxycycline, or a respiratory fluoroquinolone 4, 5, 6.
• Inpatients not admitted to an intensive care unit should receive a respiratory fluoroquinolone, or a beta-lactam antibiotic plus a macrolide 4, 5.
• Patients with severe community-acquired pneumonia or who are admitted to the intensive care unit should be treated with a beta-lactam antibiotic, plus azithromycin or a respiratory fluoroquinolone 4, 5.
• Those with risk factors for Pseudomonas should be treated with a beta-lactam antibiotic (piperacillin/tazobactam, imipenem/cilastatin, meropenem, doripenem, or cefepime), plus an aminoglycoside and azithromycin or an antipseudomonal fluoroquinolone (levofloxacin or ciprofloxacin) 4, 5.
• Those with risk factors for methicillin-resistant Staphylococcus aureus should be given vancomycin or linezolid 4, 5.

Antibiotic Treatment Options

Some studies suggest the following antibiotic treatment options:

• Ceftriaxone is recommended as first-line antibiotic treatment (with the addition of macrolide) for hospitalized adults with community-acquired pneumonia (CAP) 7.
• Ampicillin may be associated with comparable clinical outcomes in comparison to ceftriaxone for patients who were hospitalized due to CAP, and was associated with significantly lower rate of Clostridioides difficile infection (CDI) 7.
• New fluoroquinolones with improved activity against S pneumoniae can also be used to treat adults with community-acquired pneumonia, but should be limited to adults for whom one of the above regimens has already failed, who are allergic to alternative agents, or who have a documented infection with highly drug-resistant pneumococci 6.

Prevention

Physicians should promote pneumococcal and influenza vaccination as a means to prevent community-acquired pneumonia and pneumococcal bacteremia 4, 5.