What is the recommended treatment for pneumonia?

Pneumonia Treatment

The recommended treatment for pneumonia is a combination of a β-lactam (such as amoxicillin, co-amoxiclav, cefuroxime, or ceftriaxone) plus a macrolide (such as clarithromycin or azithromycin), with the specific regimen determined by severity and treatment setting. 1

Treatment Based on Setting and Severity

Outpatient Treatment (Non-Severe)

• First-line: Amoxicillin monotherapy 2
• Alternative (for penicillin allergic patients): Macrolide (erythromycin or clarithromycin) 2

Hospitalized Patients (Non-Severe)

• First-line:
  • Oral therapy: Amoxicillin plus a macrolide (clarithromycin or azithromycin) 1, 2
  • IV therapy: Ampicillin or benzylpenicillin 2
• Alternative: Respiratory fluoroquinolone (levofloxacin 750mg daily or moxifloxacin 400mg daily) 1, 3
• For penicillin/macrolide intolerance: β-lactam plus doxycycline 100mg twice daily 1

Severe Pneumonia

• First-line: IV combination of a broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, or ceftriaxone) plus a macrolide (clarithromycin or erythromycin) 1
• Alternative: Respiratory fluoroquinolone with enhanced pneumococcal activity plus IV benzylpenicillin 1

Special Considerations

Aspiration Pneumonia

• First-line: Amoxicillin-clavulanate (provides coverage against both aerobic and anaerobic pathogens) 2
• Alternatives:
  • Clindamycin (excellent anaerobic coverage) - may require addition of a cephalosporin for broader coverage in severe cases 2
  • Moxifloxacin (for penicillin-allergic patients) 2
  • Combination of cephalosporin and metronidazole 2

Nosocomial Pneumonia

• Standard regimen: Piperacillin-tazobactam 4.5g IV every 6 hours plus an aminoglycoside 4
• For Pseudomonas aeruginosa: Continue aminoglycoside treatment 4

Duration of Treatment

• Non-severe, uncomplicated pneumonia: 7 days 1
• Severe pneumonia: 10 days (extend to 14-21 days for legionella, staphylococcal, or gram-negative enteric bacilli pneumonia) 1
• Aspiration pneumonia: 7 days for uncomplicated cases, 14-21 days for complicated cases 2

Route of Administration

• Non-severe: Oral route when possible 1
• Severe: Initial parenteral (IV) therapy with transition to oral when:
  • Clinical improvement occurs
  • Temperature has been normal for 24 hours
  • No contraindications to oral therapy exist 1

Monitoring Response

• Monitor temperature, respiratory rate, pulse, blood pressure, mental status, and oxygen saturation every 12 hours (more frequently in severe cases) 2
• Consider treatment failure if no improvement after 72 hours 2
• For patients failing to improve:
  • Review clinical history, examination, and investigation results
  • Consider additional investigations (repeat chest radiograph, CRP, WBC)
  • Consider changing antibiotics:
    • For non-severe pneumonia on amoxicillin monotherapy: Add or substitute a macrolide
    • For non-severe pneumonia on combination therapy: Change to a fluoroquinolone with effective pneumococcal coverage
    • For severe pneumonia not responding to combination treatment: Consider adding rifampicin 1

Dosing Considerations

• Ceftriaxone 1g daily is as effective as 2g daily for community-acquired pneumonia 5
• For levofloxacin, 750mg once daily for 5 days is as effective as 500mg once daily for 10 days 3
• For azithromycin, a 3-day course (500mg daily) is as effective as a 5-day course (500mg on day 1, then 250mg daily for 4 days) for atypical pneumonia 6

Follow-up

• Arrange clinical review for all patients at around 6 weeks
• Obtain follow-up chest radiograph for patients with persistent symptoms/signs or those at higher risk of underlying malignancy 2

By following these evidence-based recommendations, clinicians can effectively manage pneumonia across various settings while optimizing patient outcomes and minimizing complications.