What is the recommended treatment for pneumonia?

Treatment of Pneumonia

For community-acquired pneumonia (CAP), the recommended first-line treatment is either a beta-lactam plus macrolide combination therapy or respiratory fluoroquinolone monotherapy, with specific regimens determined by illness severity and patient risk factors. 1

Severity Assessment and Treatment Setting

1. Severity Assessment Tools:

   • Use CURB-65 criteria or Pneumonia Severity Index (PSI) to guide hospitalization decisions 1
   • Consider hospitalization for patients with:
     • CURB-65 score ≥2
     • PSI risk classes IV and V
     • Failure of outpatient therapy
     • Significant comorbidities
     • Inability to reliably take oral medication

2. ICU Admission Criteria:

   • Direct ICU admission required for:
     • Septic shock requiring vasopressors
     • Acute respiratory failure requiring mechanical ventilation
     • Presence of ≥3 minor criteria for severe CAP

Antibiotic Treatment by Setting and Severity

Outpatient Treatment (Mild-Moderate CAP)

1. Healthy 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) in areas with pneumococcal resistance to macrolides <25% 1

2. Patients with comorbidities or risk factors for drug-resistant pathogens:

   • Beta-lactam (amoxicillin-clavulanate or cefuroxime) plus a macrolide 1
   • OR respiratory fluoroquinolone monotherapy (levofloxacin 750 mg once daily for 5 days) 1, 2

Non-ICU Hospitalized Patients

• Beta-lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam) plus macrolide 1
• Ceftriaxone 1 g daily has been shown to be as effective as 2 g daily regimens for CAP 3
• Some studies suggest levofloxacin monotherapy may be as effective as combination therapy 4

ICU Patients (Severe CAP)

• Ceftriaxone, cefotaxime, ampicillin-sulbactam, or piperacillin-tazobactam PLUS a fluoroquinolone or macrolide 1
• For nosocomial pneumonia: piperacillin-tazobactam 4.5 grams every six hours plus an aminoglycoside 5
• For Pseudomonas aeruginosa infections: consider combination therapy for unstable patients 1

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: piperacillin-tazobactam, cefoperazone/sulbactam, ceftazidime, cefepime, carbapenems, or fluoroquinolones 1, 5
  • For P. aeruginosa nosocomial pneumonia: combination with an aminoglycoside is recommended 5

Treatment Duration and Monitoring

• Minimum treatment duration: 5 days 1
• Maximum treatment duration: 8 days in responding patients 1
• Clinical improvement indicators:
  • Fever should resolve within 2-3 days of antibiotic initiation 1
  • Before discontinuing antibiotics, ensure patient has been afebrile for 48-72 hours 1
  • Patient should have no more than 1 CAP-associated sign of clinical instability 1

Dosage Adjustments for Renal Impairment

• For patients with renal impairment (creatinine clearance ≤40 mL/min), adjust dosages accordingly:
  • For piperacillin-tazobactam: reduce dose based on creatinine clearance 5
  • For hemodialysis patients: administer additional dose following dialysis 5

Important Cautions and Pitfalls

• Avoid inadequate coverage for atypical pathogens, particularly when using beta-lactam monotherapy 1
• Avoid delayed antibiotic initiation beyond 4-8 hours from hospital arrival, as this is associated with increased mortality 1
• Avoid tigecycline due to increased all-cause mortality (FDA boxed warning) 1
• Avoid inappropriate use of steroids as they are not recommended in routine treatment of pneumonia 1
• Avoid prolonged IV therapy when oral therapy would be appropriate 1
• Routine follow-up chest radiography is not necessary for patients who respond to treatment 1

Supportive Care

• Adequate hydration (oral fluids as tolerated)
• Oxygen therapy if needed for comfort
• Positioning to optimize respiratory function
• Antipyretics for fever and discomfort
• Cough management if distressing to the patient 1