What are the guidelines for treating pneumonia?

Guidelines for Treating Pneumonia

The treatment of pneumonia should be tailored to the setting (community-acquired vs. hospital-acquired), severity of illness, and risk factors for specific pathogens, with empiric therapy initiated promptly to reduce morbidity and mortality. 1

Community-Acquired Pneumonia (CAP)

Outpatient Treatment

• For previously healthy patients with no risk factors for drug-resistant pathogens, a macrolide (such as azithromycin or clarithromycin) or doxycycline is recommended as first-line therapy 1
• For patients with comorbidities or recent antibiotic use, either a respiratory fluoroquinolone with enhanced pneumococcal activity or combination therapy with a β-lactam plus a macrolide is recommended 1, 2
• Amoxicillin monotherapy is appropriate for patients who would otherwise be treated in the community setting 1

Non-Severe Hospitalized Patients

• Combined oral therapy with amoxicillin and a macrolide (erythromycin or clarithromycin) is preferred for patients requiring hospitalization for clinical reasons 1
• When oral treatment is contraindicated, recommended parenteral choices include intravenous ampicillin or benzylpenicillin, together with erythromycin or clarithromycin 1
• Patients should be switched from parenteral to oral antibiotics as soon as clinical improvement occurs and temperature has been normal for 24 hours 1
• For patients intolerant to β-lactams or macrolides, a respiratory fluoroquinolone (such as levofloxacin) is an alternative option 1, 3

Severe CAP Requiring Hospitalization

• Patients with severe pneumonia should be treated immediately after diagnosis 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
• For ICU patients, ceftriaxone, cefotaxime, ampicillin-sulbactam, or piperacillin-tazobactam in combination with either a fluoroquinolone or macrolide is recommended 1
• For patients intolerant to β-lactams or macrolides, a fluoroquinolone with enhanced pneumococcal activity (such as levofloxacin) plus intravenous benzylpenicillin is an alternative 1

Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP)

Risk Assessment and Empiric Therapy

• Initial empiric therapy should be based on risk factors for multidrug-resistant (MDR) pathogens, including prolonged hospitalization (≥5 days), admission from a healthcare facility, and recent antibiotic therapy 1
• Inappropriate initial therapy (failure of the etiologic pathogen to be sensitive to the administered antibiotic) is a major risk factor for excess mortality 1
• Initial antibiotic therapy should be given promptly as delays in administration may contribute to excess mortality 1

Treatment Recommendations

• For patients with low risk of MDR pathogens and stable hemodynamics, monotherapy with agents such as piperacillin/tazobactam, cefoperazone/sulbactam, ceftazidime, cefepime, imipenem, meropenem, or a respiratory fluoroquinolone is appropriate 1
• For patients with high risk of MDR pathogens or unstable hemodynamics, combination therapy is recommended, typically including an antipseudomonal β-lactam plus either a fluoroquinolone or an aminoglycoside 1, 4
• When MRSA infection is suspected, add vancomycin, teicoplanin, or linezolid to the regimen 1
• For VAP, protocol-directed therapy with appropriate initial broad-spectrum coverage followed by de-escalation based on culture results has been shown to improve outcomes 1

Duration of Therapy

• For non-severe CAP treated in the community or hospital, 7 days of appropriate antibiotics is recommended 1
• For severe CAP with undefined microbiology, 10 days of treatment is proposed 1
• For pneumonia caused by specific pathogens such as Legionella, Staphylococcus, or Gram-negative enteric bacilli, treatment should be extended to 14-21 days 1
• For HAP/VAP, limiting therapy to a 7-day course is appropriate for patients who respond clinically, with longer durations only for those with persistent signs of active infection 1

Route of Administration

• The oral route is recommended for non-severe pneumonia when there are no contraindications 1
• Patients initially treated with parenteral antibiotics should be transferred to oral therapy once clinical improvement occurs and temperature has been normal for 24 hours 1
• The choice of route should be reviewed daily, with ward pharmacists potentially playing a role in highlighting opportunities to switch from parenteral to oral therapy 1

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 additional investigations including repeat chest radiograph, CRP, white cell count, and further microbiological testing 1
• For non-severe pneumonia initially treated with amoxicillin monotherapy, add or substitute 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

Prevention

• Influenza vaccination is recommended for high-risk groups including those with chronic lung, heart, renal or liver disease, diabetes mellitus, immunosuppression, and those aged over 65 years 1
• Pneumococcal vaccination is recommended for those aged 2 years or older in whom pneumococcal infection is likely to be more common or serious 1

Common Pitfalls and Caveats

• New fluoroquinolones are not recommended as first-line agents or for community use for pneumonia but may provide a useful alternative in selected hospitalized patients 1
• When selecting empiric therapy for patients who have recently received antibiotics, use an agent from a different class to reduce the risk of inappropriate therapy and resistance 1
• Azithromycin should not be used in patients with pneumonia who are inappropriate for oral therapy due to moderate to severe illness or risk factors such as cystic fibrosis, bacteremia, or significant underlying health problems 5
• Be aware of QT prolongation risk with macrolides, particularly in elderly patients or those with cardiac conditions 5
• For HAP/VAP, local microbiology patterns and antibiotic resistance should guide protocol development for each ICU 1