What is the treatment for pneumonia?

Treatment of Pneumonia

The most effective treatment for pneumonia is a combination of a β-lactam (such as amoxicillin, ceftriaxone) plus a macrolide (such as azithromycin) for hospitalized patients, or amoxicillin, doxycycline, or a macrolide for outpatients with community-acquired pneumonia. 1

Classification and Initial Assessment

Treatment depends on the type of pneumonia and severity:

• Community-acquired pneumonia (CAP): Occurs outside healthcare settings
• Hospital-acquired pneumonia (HAP): Develops 48+ hours after admission
• Ventilator-associated pneumonia (VAP): Occurs 48-72+ hours after intubation
• Healthcare-associated pneumonia (HCAP): Occurs in patients with recent healthcare contact

Severity assessment should determine treatment setting (outpatient vs. inpatient vs. ICU).

Empiric Antibiotic Treatment

Outpatient Treatment (Non-severe CAP)

For healthy adults without comorbidities:

• First-line: Amoxicillin 1g PO TID, OR
• Alternatives: Doxycycline 100mg PO BID, OR azithromycin 500mg PO on day 1, then 250mg daily for days 2-5 1, 2

For adults with comorbidities:

• First-line: Amoxicillin/clavulanate PLUS a macrolide, OR
• Alternative: Respiratory fluoroquinolone (levofloxacin, moxifloxacin) 1

Inpatient Treatment (Non-ICU)

• Standard regimen: β-lactam (ceftriaxone 1-2g IV daily or ampicillin) PLUS macrolide (azithromycin 500mg daily) 3, 1, 4
• Alternative (for penicillin allergy or local C. difficile concerns): Respiratory fluoroquinolone with pneumococcal coverage 3

Severe CAP (ICU)

• Standard regimen: Intravenous combination of broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone) PLUS a macrolide 3, 1
• For suspected Pseudomonas: Antipseudomonal β-lactam (ceftazidime, cefepime) PLUS either ciprofloxacin OR macrolide + aminoglycoside 1

Special Considerations

Atypical Pathogens

For suspected atypical pathogens (Mycoplasma, Chlamydia, Legionella):

• Ensure coverage with a macrolide or doxycycline 1, 5
• For Legionella pneumonia: Extend treatment to 14-21 days 1

Aspiration Pneumonia

• Add anaerobic coverage with clindamycin 600mg IV q8h or metronidazole 500mg IV q8h 1

MRSA Risk

• Add vancomycin 15-20 mg/kg IV q8-12h or linezolid 600mg IV/PO q12h if MRSA is suspected 1

Duration of Treatment

• Minimum duration: 5 days, with patient afebrile for 48-72 hours and no more than one sign of clinical instability before discontinuation 1
• Standard CAP: 7-10 days typically 1
• Severe CAP: 10-14 days 3
• Legionella pneumonia: 14-21 days 3, 1

Treatment Response Assessment

• Outpatients: Evaluate at day 5-7 for symptom improvement 1
• Inpatients: Assess at day 2-3 for fever resolution and lack of progression of pulmonary infiltrates 1
• Fever should resolve within 2-3 days of starting appropriate antibiotics 1

Switching from IV to Oral Therapy

Patients initially treated with parenteral antibiotics should be switched to oral therapy when:

• Clinical improvement occurs
• Temperature has been normal for 24 hours
• No contraindications to oral route exist 3

Common Pitfalls to Avoid

1. Delaying antibiotics: Initiate treatment promptly after diagnosis, especially in severe cases 3
2. Inadequate coverage: Ensure empiric therapy covers the most likely pathogens based on setting and risk factors
3. Prolonged IV therapy: Switch to oral antibiotics as soon as clinically appropriate 3
4. Overuse of fluoroquinolones: Reserve for specific indications to prevent resistance development 3, 1
5. Ignoring local resistance patterns: Consider local antibiotic susceptibility when selecting empiric therapy

Prevention

• Pneumococcal and influenza vaccination
• Smoking cessation
• Measures to prevent aspiration
• Hand hygiene and infection control measures 1