Treatment of Severe Pneumonia
For severe pneumonia, the recommended treatment is an intravenous combination of a broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone) plus a macrolide (clarithromycin or erythromycin). 1
Initial Antibiotic Therapy
- Parenteral antibiotics should be administered immediately after diagnosis to ensure prompt, high blood and lung concentrations 1
- For ICU or intermediate care patients with severe CAP without risk factors for Pseudomonas aeruginosa, use:
- Non-antipseudomonal cephalosporin III + macrolide OR
- Moxifloxacin or levofloxacin ± non-antipseudomonal cephalosporin III 2
- For patients with risk factors for P. aeruginosa, use:
- Antipseudomonal cephalosporin OR acylureidopenicillin/β-lactamase inhibitor OR carbapenem (meropenem preferred) PLUS
- Ciprofloxacin OR macrolide + aminoglycoside 2
Rationale for Combination Therapy
- Combination therapy provides coverage for both typical and atypical pathogens, particularly Legionella sp. 1
- Evidence indicates combination therapy is associated with better outcomes in severe pneumonia 1
- This approach ensures coverage against the most common pathogens including Streptococcus pneumoniae, Staphylococcus aureus, and less common but high-mortality Gram-negative organisms 1
Special Considerations
- Consider MRSA in patients hospitalized within the last few months 1
- For nosocomial pneumonia caused by P. aeruginosa, add an aminoglycoside to the regimen 1
- In patients at risk of gram-negative enteric bacteria with extended-spectrum β-lactamase, ertapenem may be used when P. aeruginosa is not a concern 2
- For aspiration pneumonia, consider:
- β-lactam/β-lactamase inhibitor OR
- Clindamycin OR
- IV cephalosporin + oral metronidazole OR
- Moxifloxacin 2
Duration of Treatment
- For severe microbiologically undefined pneumonia: 10 days of treatment 1, 3
- Extended treatment (14-21 days) is recommended for:
- Generally, treatment should not exceed 8 days in a responding patient 2
- Biomarkers, particularly procalcitonin, may guide shorter treatment duration 2, 1
Transitioning from IV to Oral Therapy
- Switch to oral therapy when:
- Clinical improvement is evident
- Temperature has been normal for 24 hours
- No contraindications to oral administration exist 1
- Sequential treatment should be considered in all hospitalized patients except the most severely ill 2
- Switch to oral treatment after reaching clinical stability is safe even in patients with severe pneumonia 2
Supportive Care
- All patients should receive early mobilization 2
- Low molecular weight heparin should be given in patients with acute respiratory failure 2
- Non-invasive ventilation can be considered, particularly in patients with COPD and ARDS 2
- Steroids are not recommended in the standard treatment of pneumonia 2
Monitoring Response to Treatment
- Response should be monitored using simple clinical criteria:
- Body temperature
- Respiratory parameters
- Hemodynamic parameters 2
- C-reactive protein should be measured on days one and three/four, especially in patients with unfavorable clinical parameters 2
Management of Treatment Failure
- If patient fails to improve, conduct a thorough review by an experienced clinician of:
- Clinical history and examination
- Prescription chart
- Results of all available investigations 1
- Consider additional investigations:
- Repeat chest radiograph
- CRP and white cell count
- Further specimens for microbiological testing 1
Common Pitfalls and Caveats
- Delaying antibiotic administration beyond 4 hours after admission increases mortality 1
- Failure to consider MRSA in recently hospitalized patients 1
- Prolonged IV therapy when oral therapy would be appropriate 1
- Tigecycline has no established experience in pneumonia treatment 2
- Levofloxacin has shown efficacy in some studies as monotherapy, but combination therapy is still preferred for severe cases 4