What are my first-line medications for Community-Acquired Pneumonia (CAP)?

From the Guidelines

For community-acquired pneumonia (CAP), the first-line medications are amoxicillin 1 g three times daily, doxycycline 100 mg twice daily, or a macrolide, with the choice of medication depending on the patient's comorbidities and risk factors for antibiotic-resistant pathogens. When considering the treatment of CAP, it is essential to differentiate between patients with and without comorbidities.

• For healthy outpatient adults without comorbidities, amoxicillin 1 g three times daily is recommended as a strong option, with moderate quality of evidence 1.
• For outpatient adults with comorbidities, such as chronic heart, lung, liver, or renal disease, the recommendation is for combination therapy, including amoxicillin/clavulanate 500 mg/125 mg three times daily, or a cephalosporin, plus a macrolide, with strong recommendation and moderate quality of evidence 1. Some key points to consider when selecting a treatment regimen include:
• The presence of comorbidities, such as chronic heart, lung, liver, or renal disease, which may require combination therapy or alternative medications.
• The risk of antibiotic-resistant pathogens, which may influence the choice of medication.
• The severity of the pneumonia, which may require hospitalization or more intensive treatment. In general, respiratory fluoroquinolones, such as levofloxacin 750 mg daily, are also a viable option for patients with comorbidities, with strong recommendation and moderate quality of evidence 1. It is crucial to note that the treatment duration and choice of medication should be guided by clinical improvement and the patient's individual needs, rather than a one-size-fits-all approach.

From the FDA Drug Label

1. 2 Community-Acquired Pneumonia: 7 to 14 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of community-acquired pneumonia due to methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae (including multi-drug-resistant Streptococcus pneumoniae [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae, Legionella pneumophila, or Mycoplasma pneumoniae
2. 3 Community-Acquired Pneumonia: 5 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of community-acquired pneumonia due to Streptococcus pneumoniae (excluding multi-drug-resistant isolates [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasia pneumoniae, or Chlamydophila pneumoniae

First-line medications for Community-Acquired Pneumonia (CAP) may include levofloxacin as it is indicated for the treatment of CAP due to various pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, and others 22.

• Levofloxacin can be used for a 7 to 14 day treatment regimen or a 5 day treatment regimen, depending on the specific pathogens and patient conditions.
• The choice of first-line medication should be based on the specific pathogens, patient conditions, and local epidemiology and susceptibility patterns.

From the Research

First-Line Medications for Community-Acquired Pneumonia (CAP)

The following are first-line medications for CAP:

• Levofloxacin 500 mg IV q24h followed by 500 mg orally q24h 3
• Amoxicillin/clavulanate 500 mg/100 mg IV q8h with oral clarithromycin 500 mg q12h and then oral amoxicillin/clavulanate 250 mg/125 mg q8h with oral clarithromycin 500 mg q12h for 7-14 days 3
• Doxycycline 100 mg twice daily 4
• Azithromycin, telithromycin, and fluoroquinolones in short-course regimens 5
• Ceftriaxone 1-2 g once a day or cefotaxime 1 g TID, IV, 7-10 days for patients admitted to general wards with criteria of moderate severity 6
• Ceftriaxone 2 g once a day or cefotaxome 1 g TID, IV, associated to erythromycin 500 QID, levofloxacin 500-1.000 mg once a day, or moxifloxacin 400 mg/once a day, IV, 10-14 days for patients with severe CAP 6

Patient Classification and Treatment

Patients with CAP can be classified into four risk categories:

• Group 1: patients under 65 years without co-morbidities, in ambulatory attendance, treated with oral amoxicillin 1 g TID, 7 days 6
• Group 2: patients over 65 years and / or co-morbidities, in ambulatory attendance, treated with oral amoxicillin/clavulanate 500/125 mg TID or 875/125 mg BID, or cefuroxime 500 mg BID, 7 days 6
• Group 3: patients admitted to general wards with criteria of moderate severity, treated with ceftriaxone 1-2 g once a day or cefotaxime 1 g TID, IV, 7-10 days 6
• Group 4: patients with severe CAP that must be interned into ICU, treated with ceftriaxone 2 g once a day or cefotaxime 1 g TID, IV, associated to erythromycin 500 QID, levofloxacin 500-1.000 mg once a day, or moxifloxacin 400 mg/once a day, IV, 10-14 days 6

Comparison of Treatments

Studies have compared the effectiveness of different treatments for CAP, including:

• Levofloxacin vs. amoxicillin/clavulanate plus clarithromycin 3
• Levofloxacin vs. doxycycline 4
• Levofloxacin 750 mg daily vs. ceftriaxone 1000 mg plus azithromycin 500 mg daily 7 These studies have shown that levofloxacin is at least as effective as other treatments, and may have advantages in terms of length of hospital stay and cost 3, 4, 7