What is the recommended treatment for pneumonia?

Recommended Treatment for Pneumonia

The recommended treatment for pneumonia depends on the type (community-acquired vs. hospital-acquired), severity, and patient risk factors, with empiric antibiotic therapy tailored to cover the most likely pathogens based on these factors. 1

Community-Acquired Pneumonia (CAP)

Outpatient Treatment

• For previously healthy patients without recent antibiotic use:

  • Macrolide (azithromycin, clarithromycin) OR
  • Doxycycline 1

• For patients with comorbidities or recent antibiotic use:

  • High-dose amoxicillin + macrolide (azithromycin or clarithromycin) OR
  • Respiratory fluoroquinolone (levofloxacin, moxifloxacin) 1, 2

Hospitalized Patients (Non-ICU)

• Standard therapy:
  • β-lactam (ceftriaxone, ampicillin-sulbactam) + macrolide OR
  • Respiratory fluoroquinolone alone 1, 2
  • Duration: Minimum 5-7 days for uncomplicated infections 1

Severe CAP/ICU Patients

• Combination therapy:
  • β-lactam + either macrolide or respiratory fluoroquinolone 1
  • Consider systemic corticosteroids within 24 hours for severe CAP 2
  • Duration: 10-14 days 1

Hospital-Acquired Pneumonia (HAP)

Not at High Risk of Mortality and No MRSA Risk Factors

• One of the following:
  • Piperacillin-tazobactam 4.5g IV q6h
  • Cefepime 2g IV q8h
  • Levofloxacin 750mg IV daily
  • Imipenem 500mg IV q6h
  • Meropenem 1g IV q8h 3

Not at High Risk of Mortality but With MRSA Risk Factors

• Antipseudomonal β-lactam (as above) PLUS:
  • Vancomycin OR linezolid 3

High Risk of Mortality or Recent IV Antibiotics

• Two of the following (avoid using two β-lactams):
  • Antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, etc.)
  • Aminoglycoside (amikacin, gentamicin, tobramycin)
  • Antipseudomonal fluoroquinolone (ciprofloxacin, levofloxacin)
  • PLUS MRSA coverage:
    • Vancomycin (15mg/kg IV q8-12h) OR
    • Linezolid (600mg IV q12h) 3
  • Duration: 7-14 days 3, 4

Special Considerations

Pseudomonas Risk

• For patients with risk factors for Pseudomonas aeruginosa:
  • Antipseudomonal cephalosporin or acylureidopenicillin/β-lactamase inhibitor plus a macrolide 1
  • For HAP with suspected Pseudomonas: Add an aminoglycoside 3, 4

Atypical Pathogens

• For suspected atypical pathogens (Mycoplasma, Chlamydia, Legionella):
  • Include a macrolide or respiratory fluoroquinolone 1
  • Legionella pneumonia requires 14-21 days of therapy 1

Treatment Duration

• Standard CAP: 5-10 days 1, 2
• HAP: 7-14 days 3, 4
• Atypical pathogens: 10-14 days 1
• Legionella: 14-21 days 1

Monitoring and Follow-up

• Assess clinical response within 48-72 hours of initiating therapy 1
• Consider treatment failure if no improvement within 72 hours 1
• Switch from IV to oral therapy when clinically stable (afebrile for 24 hours with improving symptoms) 1
• Clinical review at 6 weeks post-treatment 1
• Chest radiograph at 6 weeks for patients with persistent symptoms or at higher risk of underlying malignancy 1

Common Pitfalls to Avoid

• Inappropriate antibiotic selection not accounting for local resistance patterns 1
• Inadequate duration of therapy 1
• Delayed switch from IV to oral therapy 1
• Overuse of broad-spectrum antibiotics leading to resistance 1
• Overlooking drug interactions, particularly with macrolides 1
• Failing to consider Pseudomonas coverage when indicated 3, 1
• Not adjusting dosage for patients with renal impairment 4

By following these evidence-based recommendations and adjusting therapy based on clinical response and culture results, optimal outcomes can be achieved for patients with pneumonia.