What is the recommended treatment for inpatient pneumonia (pna)?

Recommended Treatment for Inpatient Pneumonia

For inpatient pneumonia, the recommended treatment is a combination of a beta-lactam (such as high-dose amoxicillin, ceftriaxone 1-2g daily) plus a macrolide (azithromycin 500mg daily or clarithromycin). 1

First-Line Treatment Options

Community-Acquired Pneumonia (CAP)

• Standard regimen:
  • Beta-lactam + macrolide combination:
    • Ceftriaxone (1-2g IV daily) + azithromycin (500mg IV/oral daily) 1, 2, 3
    • Higher ceftriaxone dose (2g) may be beneficial for patients requiring mechanical ventilation 4
  • Duration: Minimum 5 days, continue until patient is afebrile for 48-72 hours with no more than one sign of clinical instability, generally not exceeding 8 days 1

Nosocomial Pneumonia

• Standard regimen:
  • Piperacillin-tazobactam 4.5g IV every 6 hours 1, 5
  • For Pseudomonas aeruginosa: Add an aminoglycoside 5
  • Duration: 7-14 days 5

Pathogen-Specific Treatment

Pathogen	Treatment Options
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]
Coxiella burnetii	Doxycycline, levofloxacin, or moxifloxacin [1]
Pseudomonas aeruginosa	Piperacillin-tazobactam, cefoperazone/sulbactam, ceftazidime, cefepime, carbapenems, or fluoroquinolones; consider combination therapy for unstable patients [1]
Methicillin-susceptible S. aureus	Note: Standard ceftriaxone 1g daily may be inadequate; consider higher doses (2-4g daily) or alternative agents [6]

Dosage Adjustments for Renal Impairment

For Piperacillin-Tazobactam:

• Normal renal function:
  • Non-nosocomial pneumonia: 3.375g every 6 hours
  • Nosocomial pneumonia: 4.5g every 6 hours
• CrCl 20-40 mL/min:
  • Non-nosocomial pneumonia: 2.25g every 6 hours
  • Nosocomial pneumonia: 3.375g every 6 hours
• CrCl <20 mL/min:
  • Non-nosocomial pneumonia: 2.25g every 8 hours
  • Nosocomial pneumonia: 2.25g every 6 hours 5

Monitoring and Follow-up

• Monitor temperature, respiratory rate, pulse, blood pressure, mental status, and oxygen saturation at least twice daily 1
• Consider measuring CRP levels to assess treatment response 1
• Repeat chest radiograph in patients not progressing satisfactorily 1
• Clinical review should be arranged for all patients at around 6 weeks 1

Important Considerations

• Treatment duration: Minimum 5 days, continue until afebrile for 48-72 hours with no more than one sign of clinical instability 1
• Combination therapy: Beta-lactam plus macrolide has shown better outcomes than fluoroquinolone monotherapy for hospitalized CAP patients 2
• Ceftriaxone dosing: While 1g daily is common, 2g daily may be beneficial in severe cases requiring mechanical ventilation 4
• MSSA coverage: Standard ceftriaxone 1g daily may be inadequate for MSSA pneumonia; consider higher doses or alternative agents 6
• Pseudomonal coverage: For patients at risk for P. aeruginosa, use piperacillin-tazobactam or other anti-pseudomonal agents 1, 5

Supportive Care

• Adequate hydration
• Oxygen therapy if needed
• Positioning to optimize respiratory function
• Antipyretics for fever and discomfort
• Cough management if distressing 1