What is the recommended treatment for pneumonia?

Treatment for Pneumonia

The recommended first-line treatment for community-acquired pneumonia (CAP) is a beta-lactam antibiotic (such as amoxicillin 1g three times daily) plus a macrolide (such as azithromycin), or a respiratory fluoroquinolone as monotherapy, with the specific regimen determined by severity of illness and patient risk factors. 1

Treatment Algorithm Based on Setting and Severity

Outpatient Treatment (CURB-65 score 0-1, PSI classes I-II)

• First-line options:
  • Amoxicillin 1g three times daily (strong recommendation) 1
  • Doxycycline 100mg twice daily (conditional recommendation) 1
  • Macrolide (azithromycin 500mg on day 1, then 250mg daily for 4 days) in areas with pneumococcal resistance to macrolides <25% 1
  • Respiratory fluoroquinolone monotherapy (e.g., levofloxacin 750mg once daily for 5 days) 1

Inpatient Treatment (Non-ICU, CURB-65 score 2-3)

• Recommended therapy:
  • Combination therapy with a beta-lactam antibiotic and a macrolide 2
  • Alternative: Respiratory fluoroquinolone monotherapy 2, 1
  • Avoid tigecycline due to increased all-cause mortality (FDA boxed warning) 2

ICU Treatment (Severe CAP)

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

Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP)

• Low risk of multidrug-resistant organisms (MDROs):
  • Options include piperacillin/tazobactam, cefoperazone/sulbactam, ceftazidime, cefepime, imipenem, meropenem, or fluoroquinolones 2
• High risk of MDROs:
  • Same antibiotics as above plus aminoglycosides or colistin 2
• High risk of MRSA:
  • Add vancomycin, teicoplanin, or linezolid to gram-negative coverage 2

Pathogen-Specific Treatment

• Chlamydophila pneumoniae: Doxycycline, macrolide, levofloxacin, or moxifloxacin 1
• Legionella spp.: Levofloxacin (preferred), moxifloxacin, or macrolide (azithromycin preferred) ± rifampicin 1
• Mycoplasma pneumoniae: Macrolide (azithromycin 500mg on day 1, then 250mg daily for 4 days) 1
• Pseudomonas aeruginosa: Options include piperacillin-tazobactam, cefoperazone/sulbactam, ceftazidime, cefepime, carbapenems, or fluoroquinolones; consider combination therapy for unstable patients 2

Duration of Treatment

• Minimum treatment duration for CAP is 5 days 1
• Treatment should not exceed 8 days in a responding patient 1
• Before discontinuation, patient should be afebrile for 48-72 hours and have no more than 1 CAP-associated sign of clinical instability 1

Important Considerations and Caveats

1. Timing of antibiotics: Initiate antibiotics immediately after diagnosis, especially in severe cases 1
2. Azithromycin warnings: Be aware of potential for QT prolongation, hepatotoxicity, and allergic reactions (including rare but potentially fatal reactions) 3
3. Resistance concerns:
   • Low-level pneumococcal resistance to penicillin is not associated with adverse outcomes 1
   • Macrolide resistance may be relevant in moderate to severe pneumonia 1
   • In areas with high prevalence of resistant S. pneumoniae (MIC ≥4 mg/L), alternative agents may be needed 1
4. Supportive care: Ensure adequate hydration, oxygen therapy if needed, proper positioning for respiratory function, and management of fever and cough 1
5. Avoid common pitfalls:
   • Do not delay treatment based solely on absence of leukocytosis when other clinical features suggest pneumonia 1
   • Avoid prolonged IV therapy when oral therapy would be appropriate 1
   • Avoid inappropriate use of steroids as they are not recommended in routine treatment of pneumonia 1
   • Do not focus solely on time to first antibiotic dose, as this can lead to misdiagnosis and overtreatment 1

By following these evidence-based recommendations and considering patient-specific factors such as severity of illness, risk factors for specific pathogens, and local resistance patterns, optimal outcomes for patients with pneumonia can be achieved.