Treatment of Extensive Pneumonia
For extensive pneumonia, the recommended first-line treatment is a β-lactam (cefotaxime, ceftriaxone, or ampicillin/sulbactam) PLUS a macrolide (preferably azithromycin) or doxycycline. 1
Treatment Algorithm Based on Severity
Non-Severe Community-Acquired Pneumonia (Outpatient)
- First-line: Oral therapy with:
Severe Community-Acquired Pneumonia (Hospitalized)
No risk factors for Pseudomonas aeruginosa:
- Non-antipseudomonal cephalosporin III (ceftriaxone) + macrolide
- OR Moxifloxacin or levofloxacin ± non-antipseudomonal cephalosporin III 2
With risk factors for Pseudomonas aeruginosa:
- Antipseudomonal cephalosporin OR acylureidopenicillin/β-lactamase inhibitor OR carbapenem (meropenem preferred)
- PLUS ciprofloxacin OR macrolide + aminoglycoside (gentamicin, tobramycin, or amikacin) 2
Antibiotic Selection for Specific Pathogens
| Pathogen | Recommended Antibiotics |
|---|---|
| Streptococcus pneumoniae | β-lactams (penicillin-susceptible); levofloxacin, high-dose amoxicillin, or ceftriaxone (penicillin-resistant) [1] |
| Chlamydophila pneumoniae | Doxycycline, macrolide, levofloxacin, or moxifloxacin [2] |
| Legionella spp. | Levofloxacin, moxifloxacin, or macrolide (azithromycin preferred) ± rifampicin [2] |
| Acinetobacter baumanii | Third-generation cephalosporin + aminoglycoside OR ampicillin-sulbactam [2] |
Dosing Considerations
- Ceftriaxone: 1g daily is as effective as 2g daily for community-acquired pneumonia 3
- Levofloxacin: 750mg once daily for 5 days is as effective as 500mg once daily for 10 days 4
- For children with severe community-acquired pneumonia, once-daily intramuscular ceftriaxone has shown 96.6% cure rate 5
Treatment Duration
- Generally should not exceed 8 days in a responding patient 2
- A minimum of 5 days is recommended, with the patient being afebrile for 48-72 hours and having no more than one sign of clinical instability before discontinuing therapy 1
- Biomarkers, particularly procalcitonin (PCT), may guide shorter treatment duration 2
IV to Oral Switch Criteria
- Consider switching from IV to oral therapy when:
- Improvement in cough and dyspnea
- Patient is afebrile
- Decreasing white blood cell count
- Patient can tolerate oral medication 1
- Switch to oral treatment after reaching clinical stability is safe even in patients with severe pneumonia 2
Monitoring Response
- Monitor response using:
- Body temperature
- Respiratory parameters
- Hemodynamic parameters
- C-reactive protein on days 1 and 3/4, especially in patients with unfavorable clinical parameters 2
- Do not change antibiotic therapy within the first 72 hours unless there is significant clinical deterioration 1
Special Considerations
Aspiration Pneumonia
Hospital ward, admitted from home:
- Oral or IV β-lactam/β-lactamase inhibitor
- OR Clindamycin
- OR IV cephalosporin + oral metronidazole
- OR Moxifloxacin 2
ICU or admitted from nursing home:
- Clindamycin + cephalosporin 2
Adjunctive Therapies
- Early mobilization for all patients 2
- Low molecular weight heparin for patients with acute respiratory failure 2
- Non-invasive ventilation can be considered, particularly in patients with COPD and ARDS 2
- Steroids are not recommended in the treatment of pneumonia 2
Treatment Efficacy Comparison
- Levofloxacin as single drug therapy has shown superior efficacy compared to the combination of ceftriaxone plus clarithromycin in moderate to severe pneumonia requiring hospitalization (mortality 6% vs 12%, p=0.024) 6
- Sequential IV to oral levofloxacin has demonstrated clinical success rates of 96% compared to 90% for ceftriaxone and/or cefuroxime axetil 7
Remember that local resistance patterns should guide antibiotic selection, and therapy should be narrowed once culture results are available to promote antibiotic stewardship.