What are the treatment options for pneumonia?

Treatment Options for Pneumonia

The recommended treatment for pneumonia should include a β-lactam antibiotic (such as amoxicillin, co-amoxiclav, or a cephalosporin) combined with a macrolide (such as clarithromycin or azithromycin), with treatment duration typically 7 days for non-severe cases and 10-14 days for severe cases. 1, 2

Initial Assessment and Treatment Selection

Treatment selection should be guided by:

1. Severity assessment:

   • Mild (outpatient): Oral antibiotics
   • Moderate (hospitalized): Oral or IV antibiotics
   • Severe (ICU): IV antibiotics 1

2. Empiric antibiotic options by setting:

   • Outpatient treatment:

     • First-line: High-dose amoxicillin or amoxicillin-clavulanate 2
     • Alternative: Doxycycline (for previously healthy patients without recent antibiotic use) 2
     • For penicillin allergic patients: Macrolide or respiratory fluoroquinolone 2

   • Hospitalized patients (non-ICU):

     • Preferred: β-lactam (ceftriaxone, cefuroxime, or ampicillin) plus macrolide 1, 2
     • Alternative: Respiratory fluoroquinolone (levofloxacin or moxifloxacin) 1

   • Severe pneumonia (ICU):

     • Non-antipseudomonal cephalosporin plus macrolide or
     • Moxifloxacin/levofloxacin ± non-antipseudomonal cephalosporin 1
     • If Pseudomonas risk: Antipseudomonal β-lactam plus either ciprofloxacin or macrolide + aminoglycoside 1

Treatment Duration

• Non-severe pneumonia: 7 days 1, 2
• Severe pneumonia: 10 days 1
• Specific pathogens may require longer treatment:
  • Legionella, staphylococcal, or Gram-negative pneumonia: 14-21 days 1, 2
  • Atypical pathogens: 10-14 days 2

Route of Administration

• Start with oral antibiotics for non-severe cases 1
• For hospitalized patients requiring IV therapy initially, switch to oral when:
  • Clinically improved
  • Temperature normal for 24 hours
  • Able to tolerate oral medications 1

Pathogen-Specific Treatment

When a specific pathogen is identified, adjust therapy accordingly:

• Streptococcus pneumoniae: Amoxicillin (preferred oral β-lactam) or ceftriaxone 2, 3
• Atypical pathogens (Mycoplasma, Chlamydophila):
  • Macrolide, doxycycline, or respiratory fluoroquinolone 2, 4
• Legionella: Levofloxacin or macrolide (preferably azithromycin) ± rifampicin 1
• Staphylococcus aureus: Consider vancomycin for suspected MRSA 2

Management of Treatment Failure

If a patient fails to improve within 48-72 hours:

1. Review clinical history, examination, and all investigation results 1, 2
2. Consider additional investigations (repeat chest radiograph, CRP, WBC, cultures) 1
3. Consider antibiotic adjustments:
   • For outpatients on amoxicillin: Add or switch to a macrolide 1
   • For hospitalized patients on combination therapy: Consider switching to a respiratory fluoroquinolone 1
   • For severe pneumonia not responding: Consider adding rifampicin 1

Important Considerations

• Antibiotic resistance: Monitor local resistance patterns to guide empiric therapy 2
• Timing: Initiate antibiotics as soon as possible after diagnosis 1
• Adjunctive therapies:
  • Early mobilization for all patients 1
  • Low molecular weight heparin for patients with respiratory failure 1
  • Consider non-invasive ventilation for patients with COPD or ARDS 1

Follow-up and Prevention

• Clinical review at 6 weeks post-treatment 2
• Chest radiograph at 6 weeks for patients with persistent symptoms or higher risk of malignancy 2
• Recommend influenza and pneumococcal vaccination for high-risk groups 1, 2

Common Pitfalls to Avoid

• Delaying antibiotic initiation
• Using macrolides alone in areas with high pneumococcal resistance 2, 3
• Failing to switch from IV to oral therapy when appropriate 2
• Overlooking potential drug interactions, particularly with macrolides 2
• Not considering local resistance patterns when selecting empiric therapy 2