Recommended Dosing Regimens for Pneumonia Treatment
For community-acquired pneumonia (CAP), the recommended dosing regimen depends on patient characteristics, with amoxicillin 1 g three times daily being the first-line treatment for healthy outpatients without comorbidities. 1
Outpatient Treatment Regimens
Healthy Adults Without Comorbidities
- First choice: Amoxicillin 1 g three times daily for 5-7 days (strong recommendation, moderate quality evidence) 1
- Alternatives:
- Doxycycline 100 mg twice daily for 5-7 days (conditional recommendation, low quality evidence) 1
- Macrolide (only in areas with pneumococcal resistance to macrolides <25%):
Adults With Comorbidities
(Chronic heart/lung/liver/renal disease, diabetes, alcoholism, malignancy, asplenia)
Option 1: Combination Therapy (strong recommendation, moderate quality evidence) 1
- β-lactam:
- Amoxicillin/clavulanate: 500/125 mg three times daily, OR
- Amoxicillin/clavulanate: 875/125 mg twice daily, OR
- Amoxicillin/clavulanate: 2,000/125 mg twice daily, OR
- Cefpodoxime 200 mg twice daily, OR
- Cefuroxime 500 mg twice daily
- PLUS one of:
- Azithromycin 500 mg on first day, then 250 mg daily, OR
- Clarithromycin 500 mg twice daily or extended-release 1,000 mg daily, OR
- Doxycycline 100 mg twice daily (conditional recommendation, low quality evidence)
Option 2: Monotherapy (strong recommendation, moderate quality evidence) 1
- Respiratory fluoroquinolone:
- Levofloxacin 750 mg daily, OR
- Moxifloxacin 400 mg daily, OR
- Gemifloxacin 320 mg daily
Inpatient Treatment Regimens
General Ward Patients (Moderate Severity)
- Ceftriaxone 1-2 g once daily OR cefotaxime 1 g three times daily, intravenously for 7-10 days 3
ICU Patients (Severe CAP)
- Ceftriaxone 2 g once daily OR cefotaxime 1 g three times daily, intravenously
- PLUS one of:
- Erythromycin 500 mg four times daily, OR
- Levofloxacin 500-1,000 mg once daily, OR
- Moxifloxacin 400 mg once daily
- Duration: 10-14 days 3
Special Considerations
Azithromycin Dosing
When azithromycin is selected for CAP treatment, the FDA-approved dosing is:
- 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5 2
- Alternative regimen: 500 mg once daily for 3 days 2
Amoxicillin/Clavulanate Considerations
- Standard dosing: 500/125 mg three times daily or 875/125 mg twice daily 1
- High-dose formulation: 2,000/125 mg twice daily - specifically designed for areas with high prevalence of drug-resistant S. pneumoniae 4
- The high-dose formulation has shown 92.3% efficacy against S. pneumoniae, including penicillin-resistant strains 5
Macrolide Addition
Recent evidence (2024) suggests that adding macrolides to β-lactam therapy (amoxicillin or co-amoxiclav) in hospitalized patients may not improve clinical outcomes, with no significant difference in 30-day mortality or time to discharge 6. This should be considered when deciding on combination therapy.
Duration of Therapy
- Outpatient treatment: 5-7 days 1
- Inpatient treatment (general ward): 7-10 days 3
- Severe pneumonia (ICU): 10-14 days 3
Monitoring Response
- Clinical improvement should be assessed within 48-72 hours
- Signs of improvement include decreased respiratory rate, reduced work of breathing, improved oxygen saturation, decreased fever, and improved feeding
- If no improvement is seen within 48-72 hours, reassessment and possible treatment adjustment is necessary
Common Pitfalls to Avoid
- Underdosing amoxicillin in areas with high pneumococcal resistance
- Using macrolides as monotherapy in areas with high pneumococcal resistance (>25%)
- Failing to adjust dosing for patients with severe renal impairment
- Not considering local resistance patterns when selecting empiric therapy
Remember that treatment should be tailored based on local antimicrobial resistance patterns, and therapy may need adjustment once culture results are available.