What is the recommended treatment for pneumonia?

Treatment of Pneumonia

The recommended treatment for pneumonia depends on severity, setting, and patient factors, with empirical antibiotic therapy targeting the most likely pathogens while considering local resistance patterns. 1, 2

Classification and Initial Approach

• Pneumonia treatment should be tailored based on whether it is community-acquired (CAP), hospital-acquired, or aspiration pneumonia, with severity assessment guiding the choice between outpatient or inpatient management 1
• For patients admitted through the emergency department, the first antibiotic dose should be administered while still in the ED 1
• Initial adequate antibiotic therapy significantly improves survival outcomes, particularly in patients with Streptococcus pneumoniae infection or septic shock 3

Outpatient Treatment (Non-severe CAP)

• For non-severe community-acquired pneumonia treated in the outpatient setting, amoxicillin monotherapy is the first-line treatment 1, 2
• For patients with penicillin allergy, a macrolide (erythromycin or clarithromycin) is the recommended alternative 1, 2
• Oral therapy is appropriate from the beginning for ambulatory pneumonia 1
• Treatment duration should be 7 days for uncomplicated community-managed pneumonia 1, 2

Inpatient Treatment (Non-severe to Moderate CAP)

• For hospitalized patients with non-severe to moderate CAP, combination therapy with a β-lactam (amoxicillin, ampicillin, or cefuroxime) plus a macrolide (clarithromycin or erythromycin) is recommended 1, 2
• When oral treatment is contraindicated, recommended parenteral choices include intravenous ampicillin or benzylpenicillin, together with erythromycin or clarithromycin 1, 2
• For penicillin-allergic patients, a respiratory fluoroquinolone (levofloxacin) with aztreonam is an alternative 1, 4
• Sequential treatment (IV to oral) should be considered in all hospitalized patients except the most severely ill 1
• Switch to oral therapy when patients are hemodynamically stable, improving clinically, able to ingest medications, and have a normally functioning gastrointestinal tract 1

Treatment for Severe CAP (ICU Admission)

• Patients with severe pneumonia require immediate treatment with parenteral antibiotics 1
• An intravenous combination of a broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone) together with a macrolide (clarithromycin or erythromycin) is preferred 1, 2
• For Pseudomonas infection risk, use an antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin/levofloxacin or an aminoglycoside plus azithromycin 1
• For suspected community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), add vancomycin or linezolid 1

Special Considerations

• For aspiration pneumonia, treatment options include β-lactam/β-lactamase inhibitor, clindamycin, or cephalosporin plus metronidazole 1
• For suspected H5N1 influenza with pneumonia, treat with oseltamivir plus antibacterial agents targeting S. pneumoniae and S. aureus 1
• Patients with CAP who have persistent septic shock despite adequate fluid resuscitation should be considered for treatment with drotrecogin alfa activated within 24 hours of admission 1

Duration of Therapy

• Minimum treatment duration is 5 days for most cases of CAP 1, 5
• Patients should be afebrile for 48-72 hours and have no more than one CAP-associated sign of clinical instability before discontinuation of therapy 1, 2
• For severe microbiologically undefined pneumonia, 10 days of treatment is recommended 1
• Treatment should be extended to 14-21 days for legionella, staphylococcal, or gram-negative enteric bacilli pneumonia 1, 2
• Short-course antibiotic regimens (≤7 days) have been shown to be as effective as extended-course regimens for mild to moderate CAP 5

Management of Treatment Failure

• For patients who fail to improve as expected, conduct a careful review of clinical history, examination, prescription chart, and all available investigation results 1
• Consider further investigations including repeat chest radiograph, CRP, white cell count, and additional microbiological testing 1
• When empirical antibiotic treatment change is necessary, add a macrolide to amoxicillin monotherapy for non-severe pneumonia 1
• For those with non-severe pneumonia on combination therapy, changing to a fluoroquinolone with effective pneumococcal coverage is an option 1

Adjunctive Therapies

• All patients should receive early mobilization 1
• Low molecular weight heparin should be given to patients with acute respiratory failure 1
• Non-invasive ventilation can be considered, particularly in patients with COPD and ARDS 1
• Systemic corticosteroids within 24 hours of development of severe CAP may reduce 28-day mortality 6
• Steroids are generally not recommended for routine treatment of pneumonia 1

Prevention

• Influenza and pneumococcal vaccinations are recommended for high-risk groups including those with chronic lung, heart, renal and liver disease, diabetes mellitus, immunosuppression, and adults over 65 years 1, 2

Cautions and Monitoring

• Monitor for QT prolongation with macrolides like azithromycin, especially in elderly patients or those with cardiac risk factors 7
• Be aware of potential hepatotoxicity with azithromycin; discontinue immediately if signs of hepatitis occur 7
• Consider Clostridium difficile-associated diarrhea as a complication of antibiotic therapy 7, 4
• Response to treatment should be monitored by simple clinical criteria, including body temperature, respiratory and hemodynamic parameters 1