What is the recommended treatment for pneumonia?

Pneumonia Treatment

The recommended first-line 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 by Patient Setting and Severity

Outpatient Treatment

• First-line: Amoxicillin monotherapy
• Alternative: Macrolide (erythromycin or clarithromycin)
• Duration: 5-7 days for uncomplicated cases

Hospitalized Non-Severe Patients

• First-line: Combined oral therapy with amoxicillin and a macrolide (erythromycin or clarithromycin)
• Alternative: IV ampicillin or benzylpenicillin, or fluoroquinolone (levofloxacin 750 mg once daily for 5-7 days)
• Duration: 7-10 days

Severe Cases/Hospitalized Patients

• First-line: IV combination of a broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, or ceftriaxone) plus a macrolide
• Duration: 7-14 days (extend to 14-21 days for legionella, staphylococcal, or gram-negative enteric bacilli pneumonia)

Nosocomial Pneumonia

• First-line: Piperacillin-tazobactam 4.5 g IV every 6 hours plus an aminoglycoside 2
• Duration: 7-14 days

Special Considerations

Pseudomonas Risk Factors

For patients with risk factors for Pseudomonas aeruginosa:

• Antipseudomonal cephalosporin or acylureidopenicillin/β-lactamase inhibitor or carbapenem
• Plus ciprofloxacin or macrolide + aminoglycoside

Dosing for Common Antibiotics

• Levofloxacin: 750 mg once daily for 5-7 days 1, 3
• Moxifloxacin: 400 mg once daily for 5-7 days 1
• Ceftriaxone: 1-2 g IV daily (1 g is as effective as 2 g for CAP) 4
• Piperacillin-tazobactam:
  • For community-acquired pneumonia: 3.375 g IV every 6 hours 2
  • For nosocomial pneumonia: 4.5 g IV every 6 hours plus an aminoglycoside 2

Renal Dose Adjustments

Piperacillin-Tazobactam Renal Adjustment

• CrCl >40 mL/min: No adjustment
• CrCl 20-40 mL/min: 2.25 g every 6 hours (CAP), 3.375 g every 6 hours (nosocomial)
• CrCl <20 mL/min: 2.25 g every 8 hours (CAP), 2.25 g every 6 hours (nosocomial)
• Hemodialysis: 2.25 g every 12 hours (CAP), 2.25 g every 8 hours (nosocomial) 2

Monitoring and Follow-up

• Clinical improvement should be evident within 48-72 hours

• If no improvement after 72 hours, consider:

  • Further diagnostic testing
  • Broadening antibiotic coverage
  • Evaluating for complications or alternative diagnoses 1

• Monitor every 12 hours (more frequently in severe cases):

  • Temperature
  • Respiratory rate
  • Pulse
  • Blood pressure
  • Mental status
  • Oxygen saturation 1

Supportive Care

• Oxygen therapy: Maintain SaO2 >92% (88-92% in COPD patients)
• Elevate head of bed 30-45° to prevent aspiration
• Early mobilization when possible
• Consider non-invasive ventilation for respiratory failure 1

Common Pitfalls and Caveats

1. Fluoroquinolone considerations:

   • May delay diagnosis of TB in at-risk patients
   • Can cause tendinopathy, QT prolongation, and CNS effects
   • Higher risk of Clostridium difficile infection 1

2. Treatment failure indicators:

   • Lack of clinical improvement within 72 hours
   • Persistent fever beyond 3-4 days
   • Worsening radiographic findings

3. Follow-up:

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

Remember that treatment should be adjusted based on culture results when available, and duration may need to be extended for certain pathogens or complicated cases.