What is the recommended treatment for pneumonia?

Recommended Treatment for Pneumonia

For community-acquired pneumonia, the recommended first-line treatment is combination therapy with a beta-lactam antibiotic (amoxicillin, co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone) plus a macrolide (clarithromycin or erythromycin), with treatment duration of 5-7 days for non-severe cases and 10-14 days for severe cases. 1

Treatment Based on Severity and Setting

Non-Severe Community-Acquired Pneumonia (Outpatient)

• Amoxicillin monotherapy is the preferred agent for patients who can be managed in the community 2
• For penicillin-allergic patients, a macrolide (erythromycin or clarithromycin) is recommended as an alternative 2
• Treatment duration should be 7 days for uncomplicated community-managed pneumonia 1, 2
• Oral therapy is appropriate from the beginning for ambulatory patients 1

Non-Severe Community-Acquired Pneumonia (Hospitalized)

• Combined oral therapy with amoxicillin and a macrolide (erythromycin or clarithromycin) is preferred 1, 3, 2
• When oral treatment is contraindicated, recommended parenteral choices include intravenous ampicillin or benzylpenicillin, together with a macrolide 2
• For penicillin-allergic patients, a respiratory fluoroquinolone (levofloxacin) can be considered 1, 4
• Treatment duration should be 7 days for non-severe and uncomplicated pneumonia 1, 5

Severe Community-Acquired Pneumonia

• Immediate parenteral (IV) antibiotic administration is required 1
• An intravenous combination of a broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, cefotaxime, or ceftriaxone) together with a macrolide is preferred 1, 3
• For patients with risk factors for Pseudomonas aeruginosa, an antipseudomonal cephalosporin, acylureidopenicillin/β-lactamase inhibitor, or carbapenem plus ciprofloxacin or a macrolide plus aminoglycoside is recommended 1
• Treatment duration should be 10 days for severe microbiologically undefined pneumonia 1, 2
• Extended treatment (14-21 days) is recommended when legionella, staphylococcal, or gram-negative enteric bacilli pneumonia are suspected or confirmed 1, 2

Special Considerations

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 1, 2
• This switch can be made safely even in patients with severe pneumonia once clinical stability is achieved 1

Duration of Treatment

• Minimum treatment duration should be 5 days 1, 2
• Patient should be afebrile for 48-72 hours before discontinuation 1, 2
• Patient should have no more than one CAP-associated sign of clinical instability before discontinuation 1
• Short-course regimens (≤7 days) have been shown to be as effective as extended-course regimens for mild to moderate community-acquired pneumonia 5

Management of Treatment Failure

• For patients who fail to improve as expected, conduct a careful review of:
  • Clinical history and examination
  • Prescription chart
  • Available investigation results 1
• Further investigations should be considered, including:
  • Repeat chest radiograph
  • CRP and white cell count
  • Additional microbiological testing 1
• When empirical antibiotic treatment change is necessary:
  • For non-severe pneumonia on monotherapy, add a macrolide 1
  • For non-severe pneumonia on combination therapy, consider changing to a fluoroquinolone with effective pneumococcal coverage 1
  • For severe pneumonia not responding to combination therapy, consider adding rifampicin 1

Specific Pathogens and Special Situations

Atypical Pneumonia

• Erythromycin (2-4g daily) or doxycycline (200mg daily) for Mycoplasma pneumoniae and Chlamydia pneumoniae infections 6
• For Legionella pneumonia, erythromycin 2-4g daily for at least three weeks; alternatives include tetracyclines or quinolones 6

Aspiration Pneumonia

• For patients admitted from home to a hospital ward:
  • Oral or IV β-lactam/β-lactamase inhibitor
  • Clindamycin
  • IV cephalosporin + oral metronidazole
  • Moxifloxacin 1

Pandemic Influenza

• For patients with suspected H5N1 infection, treat with oseltamivir and antibacterial agents targeting S. pneumoniae and S. aureus 1
• For community-acquired methicillin-resistant Staphylococcus aureus infection, add vancomycin or linezolid 1

Monitoring Response to Treatment

• Monitor response using simple clinical criteria:
  • Body temperature
  • Respiratory parameters
  • Hemodynamic parameters 1
• C-reactive protein should be measured on days one and three/four, especially in patients with unfavorable clinical parameters 1

Prevention Strategies

• Influenza vaccination is recommended for elderly patients and those at "high risk" of mortality from influenza or complicating pneumonia 1, 3, 2
• Pneumococcal vaccination is recommended for all those aged 2 years or older in whom pneumococcal infection is likely to be more common or serious 1, 3, 2

Common Pitfalls and Caveats

• Monitor for Clostridium difficile-associated diarrhea, particularly with broad-spectrum antibiotics 1, 7
• Be aware of QT prolongation risk with macrolides like azithromycin, especially in elderly patients or those with cardiac conditions 7
• Fluoroquinolones should not be used as first-line agents but may provide a useful alternative in selected hospitalized patients who are intolerant to penicillins or macrolides 2, 4
• For patients admitted through the emergency department, the first antibiotic dose should be administered while still in the ED 1, 2