Antibiotic Recommendations for Pneumonia in Patients with Penicillin Allergy
For patients with pneumonia and penicillin allergy, respiratory fluoroquinolones (particularly levofloxacin or moxifloxacin) are the recommended first-line treatment option. 1
Treatment Options Based on Setting and Severity
Outpatient Treatment
- Respiratory fluoroquinolones: Levofloxacin 750mg PO daily or moxifloxacin 400mg PO daily 1
- Macrolides: Azithromycin 500mg PO on day 1, then 250mg daily for 4 days or clarithromycin 500mg PO twice daily for at least 5 days (only in areas with low rates of resistant S. pneumoniae) 1
- Doxycycline: 100mg PO twice daily (alternative option) 1
Hospitalized Non-ICU Patients
- Respiratory fluoroquinolones: Levofloxacin 750mg IV/PO daily or moxifloxacin 400mg IV/PO daily 1
- Macrolides: IV/oral erythromycin 1g every 8 hours or clarithromycin 500mg twice daily (if local resistance patterns permit) 1
ICU Patients
- Respiratory fluoroquinolone plus aztreonam: For severe pneumonia in penicillin-allergic patients 1
- For suspected Pseudomonas infection: Aztreonam plus either ciprofloxacin or levofloxacin (750mg) plus an aminoglycoside 1
Considerations for Specific Pathogens
Streptococcus pneumoniae
- Respiratory fluoroquinolones: Levofloxacin 750mg IV/PO daily or moxifloxacin 400mg IV/PO daily 1, 2
- Fluoroquinolones maintain activity against both penicillin-susceptible and penicillin-resistant S. pneumoniae 3, 4
Atypical Pathogens (Mycoplasma, Chlamydophila, Legionella)
- Respiratory fluoroquinolones: Levofloxacin 750mg IV/PO daily or moxifloxacin 400mg IV/PO daily 1
- Macrolides: Azithromycin or clarithromycin as alternatives 1
Staphylococcus aureus
- For MSSA: Clindamycin 600mg IV/PO every 8 hours (if not contraindicated) 1
- For MRSA: Vancomycin 15-20mg/kg IV every 8-12 hours or linezolid 600mg IV/PO every 12 hours 1
Duration of Therapy
- 5-7 days for uncomplicated cases with good clinical response 1
- 10-14 days for severe infections or bacteremic pneumococcal disease 1
- Patients should be switched from IV to oral therapy when clinically stable, able to take oral medications, and have normal GI function 1
Important Clinical Considerations
Impact of Penicillin Allergy on Outcomes
- Patients with penicillin allergy labels have worse clinical outcomes in bacterial pneumonia, including higher risks of hospitalization (RR 1.23), respiratory failure (RR 1.14), and mortality (RR 1.08) 5
- Consider penicillin allergy testing when appropriate, as many patients with penicillin allergy labels can safely receive beta-lactams 5
Type of Penicillin Allergy
- For non-Type I hypersensitivity reactions (e.g., rash), cephalosporins may be considered 1
- For Type I hypersensitivity reactions (anaphylaxis), avoid all beta-lactams and use fluoroquinolones, macrolides, or other alternatives 1
Antibiotic Resistance Concerns
- Monitor local resistance patterns, especially for macrolides 1
- In regions with high rates (>25%) of macrolide-resistant S. pneumoniae, avoid macrolide monotherapy 1
- Fluoroquinolone resistance in S. pneumoniae remains relatively low but requires monitoring 6
Assessment of Response
- Evaluate clinical response within 48-72 hours for hospitalized patients 1
- For outpatients, assess improvement of symptoms at day 5-7 1
- If no improvement occurs, consider alternative diagnoses or resistant pathogens 1
Remember that early appropriate antibiotic therapy is crucial for reducing mortality, and the first dose should be administered promptly, especially in hospitalized patients 1.