Treatment Regimen for Moderate Risk Pneumonia
For patients with moderate risk pneumonia, the recommended treatment is a respiratory fluoroquinolone such as levofloxacin 750 mg IV or orally once daily for 5 days, or a combination of a beta-lactam plus a macrolide. 1
Assessment of Risk and Treatment Selection
Treatment selection should be based on risk stratification and local pathogen prevalence:
For Moderate Risk Community-Acquired Pneumonia (CAP):
- First-line options:
For Hospital-Acquired Pneumonia (HAP) with Moderate Risk:
If no risk factors for MRSA and not at high mortality risk:
- One of the following: piperacillin-tazobactam 4.5 g IV q6h, cefepime 2 g IV q8h, levofloxacin 750 mg IV daily, imipenem 500 mg IV q6h, or meropenem 1 g IV q8h 1
If risk factors for MRSA present but not at high mortality risk:
- Same antibiotics as above, plus consideration of MRSA coverage with vancomycin or linezolid 1
Duration of Therapy
- Standard duration: Treatment should generally not exceed 8 days in a responding patient 1
- Short-course high-dose option: Levofloxacin 750 mg daily for 5 days has been shown to be as effective as 500 mg daily for 10 days for CAP 2, 3
- Minimum duration: Patients should be treated for a minimum of 5 days, should be afebrile for 48-72 hours, and should have no more than 1 CAP-associated sign of clinical instability before discontinuation 1
Special Considerations
For suspected Pseudomonas infection: Use an antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750 mg dose) 1
For suspected MRSA: Add vancomycin or linezolid to the regimen 1
For aspiration pneumonia: Consider clindamycin plus a cephalosporin or a beta-lactam/beta-lactamase inhibitor 1
Transition from IV to Oral Therapy
Switch from IV to oral therapy when the patient is:
- Hemodynamically stable
- Showing clinical improvement
- Able to ingest medications
- Has a normally functioning gastrointestinal tract 1
Levofloxacin has excellent bioavailability, allowing for seamless IV to oral transition without dosage adjustment 4, 5
Common Pitfalls to Avoid
Inadequate coverage: Ensure coverage for both typical and atypical pathogens in CAP 6, 7
Delayed therapy: For hospitalized patients, administer the first antibiotic dose while still in the emergency department 1
Excessive treatment duration: Unnecessarily prolonged therapy increases risk of resistance and adverse effects; use short-course therapy when appropriate 2, 3
Failure to adjust for local resistance patterns: Base empiric regimens on local antibiogram data when available 1
Inappropriate use of azithromycin: Azithromycin should not be used as monotherapy in patients with moderate to severe illness or significant risk factors 6
The high-dose, short-course levofloxacin regimen (750 mg for 5 days) maximizes concentration-dependent antibacterial activity, decreases the potential for drug resistance, and improves patient compliance 7, 2, making it an excellent choice for moderate risk pneumonia when fluoroquinolones are appropriate.