What is the recommended treatment for pneumonia?

Recommended Treatment for Pneumonia

The recommended first-line treatment for pneumonia depends on the setting, severity, and risk factors, with community-acquired pneumonia (CAP) typically treated with a β-lactam (such as amoxicillin) for mild cases, while moderate to severe cases require combination therapy with a β-lactam plus a macrolide or a respiratory fluoroquinolone. 1

Classification and Treatment Setting

Treatment approach should be based on:

• Type of pneumonia (community-acquired vs. hospital-acquired)
• Severity assessment (mild, moderate, severe)
• Risk factors for drug-resistant pathogens
• Patient characteristics

Community-Acquired Pneumonia (CAP)

Outpatient Treatment (Mild CAP)

• First choice: Amoxicillin 1 g three times daily 1
• Alternatives for penicillin allergy:
  • Doxycycline 100 mg twice daily
  • Respiratory fluoroquinolone (levofloxacin 750 mg daily or moxifloxacin 400 mg daily)
  • Macrolide (if local pneumococcal resistance is low) 1

Hospitalized Non-ICU Patients (Moderate CAP)

• Standard regimen: β-lactam (ceftriaxone, cefotaxime, or ampicillin-sulbactam) plus either:
  • Azithromycin 500 mg daily, or
  • Respiratory fluoroquinolone 1
• Duration: 5-7 days (if afebrile for 48 hours and clinically stable) 1

ICU Patients (Severe CAP)

• No Pseudomonas risk: Non-antipseudomonal cephalosporin III + macrolide OR moxifloxacin/levofloxacin ± non-antipseudomonal cephalosporin III 2
• With Pseudomonas risk: Antipseudomonal cephalosporin OR acylureidopenicillin/β-lactamase inhibitor OR carbapenem PLUS ciprofloxacin OR macrolide + aminoglycoside 2

Hospital-Acquired Pneumonia (HAP)

Non-Ventilator-Associated HAP

• Not at high risk of mortality and no MRSA risk factors:

  • Piperacillin-tazobactam 4.5 g IV q6h, OR
  • Cefepime 2 g IV q8h, OR
  • Levofloxacin 750 mg IV daily, OR
  • Imipenem 500 mg IV q6h, OR
  • Meropenem 1 g IV q8h 2

• Not at high risk of mortality but with MRSA risk factors:

  • Above options PLUS vancomycin or linezolid 2

• High risk of mortality:

  • Two antibiotics from different classes (avoid two β-lactams)
  • PLUS vancomycin 15 mg/kg IV q8-12h or linezolid 600 mg IV q12h 2

Specific Pathogen Considerations

Atypical Pathogens

• Chlamydophila pneumoniae: Doxycycline, macrolide, levofloxacin, or moxifloxacin 2
• Legionella spp.: Levofloxacin, moxifloxacin, or macrolide (azithromycin preferred) ± rifampicin 2
• Coxiella burnetii: Doxycycline, levofloxacin, or moxifloxacin 2

Drug-Resistant Pathogens

• MRSA: Vancomycin or linezolid 2, 1
• Pseudomonas aeruginosa: Antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin/levofloxacin or aminoglycoside 1

Treatment Duration

• Standard duration: 5-7 days for most patients 1
• Minimum requirement for discontinuation: Afebrile for 48-72 hours and no more than one CAP-associated sign of clinical instability 1
• Biomarkers: Procalcitonin may guide shorter treatment duration 2

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
• Clinical review at approximately 6 weeks after treatment 1
• Chest radiograph at 6 weeks for patients with persistent symptoms or signs, or those at higher risk of underlying malignancy 1

Common Pitfalls and Caveats

1. Delayed antibiotic administration: Antibiotics should be initiated immediately after diagnosis of CAP, especially in patients with septic shock 2

2. Inadequate coverage: Failure to consider local resistance patterns can lead to treatment failure

3. Excessive broad-spectrum use: Unnecessary broad-spectrum antibiotics contribute to antimicrobial resistance

4. Failure to adjust for renal impairment: Dose adjustments are necessary for patients with creatinine clearance ≤40 mL/min 3

5. Missing atypical pathogens: Consider coverage for atypical pathogens, especially in severe cases or when standard therapy fails

6. Inadequate duration: Premature discontinuation before clinical stability can lead to relapse

7. Overlooking complications: Monitor for complications such as empyema, lung abscess, or metastatic infections

By following these evidence-based recommendations and considering patient-specific factors, clinicians can optimize pneumonia treatment outcomes while practicing responsible antibiotic stewardship.