What are the management options for pneumonia?

Management of Community-Acquired Pneumonia

For patients with community-acquired pneumonia (CAP), empirical antibiotic therapy should be tailored to the severity of illness, with combination therapy of a β-lactam plus a macrolide recommended for hospitalized patients to ensure coverage of both typical and atypical pathogens. 1

Assessment and Classification

• Classify CAP based on severity and treatment setting:

  • Non-severe (outpatient)
  • Non-severe (inpatient)
  • Severe (typically requiring ICU admission)

• Key factors affecting treatment decisions:

  • Severity of illness
  • Presence of comorbidities (cardiopulmonary disease, diabetes, etc.)
  • Risk factors for drug-resistant pathogens
  • Local resistance patterns

Outpatient Management

First-Line Treatment Options

1. Previously healthy adults with no risk factors:

   • Amoxicillin 1g three times daily (high-dose preferred) 1
   • Doxycycline 100mg twice daily for 7-10 days (excellent for atypical coverage) 1
   • Macrolide (in areas with pneumococcal resistance <25%):
     • Azithromycin 500mg on day 1, then 250mg daily for 4 days
     • Clarithromycin 500mg twice daily

2. Adults with comorbidities or risk factors:

   • Combination therapy: Amoxicillin/clavulanate or cephalosporin plus macrolide or doxycycline 1
   • Alternative: Respiratory fluoroquinolone monotherapy (levofloxacin 750mg daily, moxifloxacin 400mg daily) 1, 2

Duration of Therapy

• 7 days for uncomplicated non-severe CAP 3, 1
• Longer duration (14-21 days) for specific pathogens like Legionella, staphylococcal, or gram-negative enteric bacilli pneumonia 3

Inpatient Management (Non-ICU)

Recommended Regimens

1. Standard approach:

   • IV β-lactam (ceftriaxone, cefotaxime, ampicillin/sulbactam) plus a macrolide 1, 4
   • Example: Ceftriaxone plus azithromycin 4

2. Alternative for penicillin-allergic patients:

   • IV respiratory fluoroquinolone (levofloxacin 750mg/day or moxifloxacin) 3, 1
   • Aztreonam plus a respiratory fluoroquinolone for severe penicillin allergy 1

Duration of Therapy

• Minimum of 5 days, with patient afebrile for 48-72 hours and no more than 1 CAP-associated sign of clinical instability before stopping 1
• Switch to oral therapy when clinically stable (afebrile for 24 hours and clinically improving) 3

Severe CAP Management (ICU)

Recommended Regimens

1. Standard approach:

   • IV combination of broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone) plus a macrolide 3

2. For patients with risk factors for Pseudomonas:

   • Piperacillin-tazobactam 4.5g IV q6h 1, 5
   • Cefepime 2g IV q8h 1
   • Consider adding an aminoglycoside for nosocomial pneumonia 5

3. For MRSA concerns:

   • Add vancomycin or clindamycin 3

Duration of Therapy

• 10 days for severe microbiologically undefined pneumonia 3
• 14-21 days for Legionella, staphylococcal, or gram-negative enteric bacilli pneumonia 3

Management of Treatment Failure

If a patient fails to improve as expected:

1. Review clinical history, examination, and all investigation results 3
2. Consider additional investigations (repeat chest radiograph, CRP, WBC count) 3
3. Consider changing antibiotics:
   • For non-severe pneumonia on monotherapy: Add or substitute a macrolide 3
   • For non-severe pneumonia on combination therapy: Consider changing to a fluoroquinolone 3
   • For severe pneumonia not responding: Consider adding rifampicin 3

Special Considerations

Influenza-Associated Pneumonia

• Add oseltamivir or zanamivir when influenza is suspected or confirmed 3, 1
• Start antiviral therapy within 36-48 hours of symptom onset for best results 3

Pleural Effusions

• Evaluate size of effusion and consider drainage based on size and clinical presentation 3
• Perform Gram stain and bacterial culture of pleural fluid when obtained 3

Prevention

• Recommend influenza vaccination for high-risk groups (chronic lung/heart/renal/liver disease, diabetes, immunosuppression, age >65) 3
• Recommend pneumococcal vaccination for those aged 2 years or older with risk factors 3

Common Pitfalls to Avoid

1. Inappropriate antibiotic selection:

   • Failing to cover both typical and atypical pathogens in hospitalized patients
   • Using fluoroquinolones as first-line when other options are available (to prevent resistance)

2. Inadequate duration of therapy:

   • Stopping antibiotics too early before clinical stability is achieved
   • Not extending treatment for specific pathogens requiring longer courses

3. Delayed switch from IV to oral therapy:

   • Continuing IV antibiotics when patients meet criteria for oral switch
   • Not reviewing antibiotic administration route daily

4. Overuse of broad-spectrum antibiotics:

   • Using unnecessarily broad coverage for non-severe CAP
   • Not de-escalating therapy when a pathogen is identified

By following these evidence-based recommendations, clinicians can optimize outcomes for patients with CAP while minimizing complications, reducing antibiotic resistance, and improving mortality and quality of life.