What are the treatment options for pneumonia?

Treatment Options for Pneumonia

The treatment of pneumonia should follow an approach based on the individual risk of mortality, with empirical antibiotics initiated immediately after diagnosis to reduce morbidity and mortality. 1

Classification and Initial Assessment

• Severity assessment is crucial to determine the appropriate treatment setting:

  • Mild: Ambulatory (outpatient) treatment
  • Moderate: Hospital ward treatment
  • Severe: ICU treatment 1

• Risk factors for multi-drug resistant (MDR) pathogens:

  • Recent antibiotic use within 90 days
  • Hospitalization >48 hours within past 90 days
  • Nursing home/long-term care facility residence
  • Long-term outpatient hemodialysis
  • Risk of aspiration 2

Empiric Antibiotic Treatment Options

1. Community-Acquired Pneumonia (CAP)

Outpatient Treatment:

• First-line options:
  • Respiratory fluoroquinolone (e.g., levofloxacin 750 mg once daily for 5-7 days) 2, 3
  • High-dose amoxicillin-clavulanate (875 mg/125 mg twice daily) plus a macrolide 2
  • Non-antipseudomonal cephalosporin (e.g., cefuroxime) plus macrolide 1

Hospitalized Patients (non-ICU):

• Recommended regimens:
  • Non-antipseudomonal cephalosporin (ceftriaxone or cefotaxime) plus macrolide 1, 4
  • Respiratory fluoroquinolone (levofloxacin or moxifloxacin) 1
  • Aminopenicillin/β-lactamase inhibitor ± macrolide 1

Severe CAP (ICU patients):

• Without Pseudomonas risk:

  • Non-antipseudomonal cephalosporin III + macrolide OR
  • Moxifloxacin or levofloxacin ± non-antipseudomonal cephalosporin III 1

• With Pseudomonas risk:

  • Antipseudomonal cephalosporin OR acylureidopenicillin/β-lactamase inhibitor OR carbapenem
  • PLUS ciprofloxacin OR macrolide + aminoglycoside 1

2. Healthcare-Associated Pneumonia (HCAP)

• Standard treatment:
  • Respiratory fluoroquinolone (levofloxacin 750 mg once daily for 5-7 days) 2
  • For Pseudomonas risk: consider ciprofloxacin 750 mg twice daily 2

Pathogen-Specific Treatment

Streptococcus pneumoniae:

• Penicillin-susceptible: β-lactam antibiotics
• Penicillin-resistant: levofloxacin, high-dose amoxicillin, or ceftriaxone 2

Atypical Pathogens:

• Chlamydophila pneumoniae: Doxycycline, macrolide, levofloxacin, or moxifloxacin 1
• Legionella spp.: Levofloxacin, moxifloxacin, or macrolide (azithromycin preferred) ± rifampicin 1
• Mycoplasma pneumoniae: Macrolides, fluoroquinolones 3, 4

Staphylococcus aureus:

• MSSA: Oxacillin, flucloxacillin, or 1st generation cephalosporin
• MRSA: Vancomycin or linezolid 2

Pseudomonas aeruginosa:

• Combination therapy with antipseudomonal β-lactam plus either fluoroquinolone or aminoglycoside 2

Duration of Treatment

• Standard duration: Generally should not exceed 8 days in responding patients 1
• Short-course therapy:
  • 5 days for uncomplicated CAP with levofloxacin 750 mg daily 3
  • 7 days for uncomplicated HCAP 2
• Extended therapy:
  • 10-14 days for MRSA or Pseudomonas infections 2

Route of Administration

• Ambulatory patients: Oral therapy from the beginning 1
• Hospitalized patients: Sequential IV-to-oral switch when clinically stable 1
• Switch criteria: Resolution of the most prominent clinical features at admission 1

Adjunctive Therapies

• Early mobilization for all patients 1
• Low molecular weight heparin for patients with acute respiratory failure 1
• Non-invasive ventilation can be considered, particularly in patients with COPD and ARDS 1
• Systemic corticosteroids may reduce 28-day mortality in severe CAP when administered within 24 hours 4
• Not recommended: Steroids are not recommended for routine treatment of pneumonia 1

Special Considerations

• Pregnant women: Consider broader coverage with piperacillin-tazobactam, cefepime, or meropenem 2
• Renal impairment: Dose adjustments needed for certain antibiotics like levofloxacin 2
• Penicillin allergy: Respiratory fluoroquinolones or macrolides are preferred alternatives 2

Prevention

• Pneumococcal and influenza vaccination
• Smoking cessation
• Measures to prevent aspiration 2

Common Pitfalls to Avoid

1. Delayed antibiotic initiation: Antibiotics should be started immediately after diagnosis 1
2. Inappropriate oral switch: Ensure clinical stability before switching from IV to oral therapy 1
3. Prolonged broad-spectrum therapy: De-escalate once culture results are available 2
4. Failure to reassess: Clinical response should be evaluated within 48-72 hours of initiating therapy 2
5. Overlooking resistance: Consider alternative pathogens or resistance if no improvement within 72 hours 2