From the Guidelines
For elderly patients with community-acquired pneumonia who have a penicillin allergy, a respiratory fluoroquinolone such as levofloxacin (750 mg orally or IV once daily for 5-7 days) is typically the antibiotic of choice, as recommended by the Infectious Diseases Society of America/American Thoracic Society consensus guidelines 1. This recommendation is based on the guidelines' strong recommendation for the use of a respiratory fluoroquinolone in penicillin-allergic patients. The guidelines suggest that a respiratory fluoroquinolone and aztreonam are recommended for penicillin-allergic patients.
Some key points to consider when using fluoroquinolones in elderly patients include:
- Potential side effects such as tendon rupture, QT prolongation, and confusion
- Importance of adequate hydration
- Need for dose adjustments in patients with renal impairment
- Consideration of local resistance patterns and the patient's comorbidities when selecting an antibiotic
Alternative options, such as macrolides (e.g., azithromycin) or doxycycline, may be considered for less severe cases or in patients with specific comorbidities or resistance patterns 1. However, the choice of antibiotic should always prioritize the patient's safety and the effectiveness of the treatment against common pneumonia pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms.
From the FDA Drug Label
1.2 Community-Acquired Bacterial Pneumonia Teflaro is indicated in adult and pediatric patients 2 months of age and older for the treatment of community-acquired bacterial pneumonia (CABP) caused by susceptible isolates of the following Gram-positive and Gram-negative microorganisms: Streptococcus pneumoniae (including cases with concurrent bacteremia), Staphylococcus aureus (methicillin-susceptible isolates only), Haemophilus influenzae, Klebsiella pneumoniae, Klebsiella oxytoca, and Escherichia coli.
14.2 Community-Acquired Pneumonia: 7 to 14 Day Treatment Regimen Adult inpatients and outpatients with a diagnosis of community-acquired bacterial pneumonia were evaluated in 2 pivotal clinical studies In the first study, 590 patients were enrolled in a prospective, multicenter, unblinded randomized trial comparing levofloxacin 500 mg once daily orally or intravenously for 7 to 14 days to ceftriaxone 1 to 2 grams intravenously once or in equally divided doses twice daily followed by cefuroxime axetil 500 mg orally twice daily for a total of 7 to 14 days
The antibiotic of choice for elderly patients with a history of allergy to penicillin and community-acquired pneumonia (CAP) is levofloxacin.
- Key points:
- Levofloxacin is effective against a broad range of bacteria, including those that cause CAP.
- It has been shown to be effective in treating CAP in clinical studies.
- Teflaro (ceftaroline) is also an option, but it is not the first choice due to its limited spectrum of activity against certain bacteria that can cause CAP. 2 3
From the Research
Antibiotic Treatment for Elderly Patients with CAP and Penicillin Allergy
- The choice of antibiotic for elderly patients with community-acquired pneumonia (CAP) and a history of allergy to penicillin should be guided by the latest recommendations and consideration of local rates and patterns of antimicrobial resistance, as well as individual patient risk factors 4.
- Recommended empiric antimicrobial regimens generally consist of either a beta-lactam plus a macrolide or a respiratory fluoroquinolone alone, however, in patients with a penicillin allergy, a fluoroquinolone or a macrolide may be preferred 4.
- A third-generation fluoroquinolone preparation, such as levofloxacin or moxifloxacin, or a new macrolide such as clarithromycin or azithromycin, can be used as empirical antibiotic therapy for elderly patients with CAP 5.
- The use of beta-lactamase inhibitors and cotrimoxazole (trimethoprim-sulfamethoxazole) is also recommended, with ciprofloxacin as an alternative agent 6.
Considerations for Antibiotic Selection
- The clinical presentation of pneumonia in the elderly may be subtle, lacking the typical acute symptoms, and pneumonia should be suspected in all elderly patients who have fever, altered mental status, or a sudden decline in functional status 4.
- Age-related changes, predisposing risk factors, and causes of CAP should be considered when selecting an antibiotic regimen 4, 7.
- Monotherapy (single agent) should be used whenever possible, and adherence to established guidelines, along with customization of antimicrobial therapy based on local rates and patterns of resistance and patient-specific risk factors, likely will improve the treatment outcome of elderly patients with CAP 6, 4.