What are the newest guidelines for managing pneumonia?

Community-Acquired Pneumonia Management Guidelines

The current standard of care for community-acquired pneumonia (CAP) management includes stratification based on illness severity, with combination therapy of a β-lactam plus a macrolide as the preferred regimen for hospitalized patients to ensure coverage of both typical and atypical pathogens. 1

Outpatient Treatment

• For previously healthy patients with no risk factors for drug-resistant Streptococcus pneumoniae (DRSP):

  • A macrolide (azithromycin, clarithromycin, or erythromycin) is recommended as first-line therapy 2, 1
  • Doxycycline is an alternative option 2

• For patients with comorbidities (chronic heart, lung, liver, renal disease, diabetes, alcoholism, malignancies, immunosuppression) or recent antibiotic use:

  • A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin 750 mg) 2, 1
  • OR a β-lactam plus a macrolide (high-dose amoxicillin 1g three times daily or amoxicillin-clavulanate 2g twice daily preferred) 2

• In regions with high rates (>25%) of macrolide-resistant S. pneumoniae, consider alternative agents even for patients without comorbidities 2

Inpatient Treatment (Non-ICU)

• Two equally effective options are recommended:

  • A respiratory fluoroquinolone as monotherapy 2, 1
  • OR a β-lactam (cefotaxime, ceftriaxone, or ampicillin) plus a macrolide 2, 1

• For penicillin-allergic patients, a respiratory fluoroquinolone should be used 2

• Doxycycline can be used as an alternative to macrolides when combined with a β-lactam 2, 1

• Recent evidence suggests that ceftriaxone 1g/day may be as effective as 2g/day for hospitalized CAP patients in areas with low prevalence of drug-resistant S. pneumoniae, with decreased rates of C. difficile infection and shorter hospital stays 3

Severe CAP (ICU Treatment)

• Immediate treatment with parenteral antibiotics is essential 1

• The recommended regimen is:

  • A β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin or a respiratory fluoroquinolone 2, 1

• For patients with risk factors for Pseudomonas infection:

  • An antipseudomonal, antipneumococcal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin/levofloxacin OR an aminoglycoside plus azithromycin OR an aminoglycoside plus an antipneumococcal fluoroquinolone 2
  • For nosocomial pneumonia with suspected Pseudomonas, piperacillin-tazobactam at a dosage of 4.5 grams every six hours plus an aminoglycoside is recommended 4

• For suspected community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), add vancomycin or linezolid 2

• For penicillin-allergic patients with severe CAP, a respiratory fluoroquinolone plus aztreonam is recommended 2, 1

Duration of Therapy

• Patients should be treated for a minimum of 5 days 2
• The patient should be afebrile for 48-72 hours and have no more than one CAP-associated sign of clinical instability before discontinuation of therapy 2
• For non-severe CAP, 5-7 days of therapy is generally sufficient 1
• For severe CAP without an identified pathogen, 10 days of therapy is recommended 1
• Extended treatment (14-21 days) is recommended for Legionella pneumonia, staphylococcal pneumonia, or gram-negative enteric bacilli pneumonia 2, 1

Switching from IV to Oral Therapy

• Patients should be switched from intravenous to oral therapy when they are:

  • Hemodynamically stable and improving clinically
  • Able to ingest medications
  • Have a normally functioning gastrointestinal tract 2, 1

• Early switch to oral therapy reduces hospital stay and complications 1

• Patients should be discharged as soon as they are clinically stable, have no other active medical problems, and have a safe environment for continued care 2

Management of Treatment Failure

• For patients failing to improve as expected:

  • Conduct a thorough clinical review by an experienced clinician 2
  • Consider additional investigations including repeat chest radiograph, CRP, WBC count, and further microbiological testing 2, 1

• When a change in empirical antibiotic treatment is necessary:

  • For non-severe pneumonia treated with amoxicillin monotherapy, add or substitute a macrolide 2, 1
  • For those on combination therapy in hospital, changing to a fluoroquinolone with effective pneumococcal coverage is an option 2

Special Considerations

• For pandemic influenza or suspected H5N1 infection:

  • Use oseltamivir plus antibacterial agents targeting S. pneumoniae and S. aureus 2
  • Implement appropriate infection control measures 2

• For patients with hypoxemia or respiratory distress, consider a cautious trial of non-invasive ventilation unless immediate intubation is required 2

• Patients with persistent septic shock despite adequate fluid resuscitation should be considered for treatment with drotrecogin alfa activated within 24 hours of admission 2

• The first antibiotic dose should be administered while still in the Emergency Department for patients being admitted to the hospital 2