What is the recommended treatment for pneumonia?

Treatment of Pneumonia

The recommended treatment for pneumonia depends on the setting (outpatient vs. inpatient), patient characteristics, and severity of illness, with outpatients without comorbidities typically treated with amoxicillin, doxycycline, or a macrolide, while hospitalized patients should receive combination therapy with a β-lactam plus a macrolide or a respiratory fluoroquinolone. 1, 2

Outpatient Treatment

For Healthy Adults Without Comorbidities:

• Amoxicillin 1 g three times daily (first-line therapy) 1
• Doxycycline 100 mg twice daily (alternative option) 1, 2
• A macrolide (azithromycin, clarithromycin, or erythromycin) if local pneumococcal resistance to macrolides is <25% 2, 3

For Adults With Comorbidities:

• Combination therapy with a β-lactam (amoxicillin/clavulanate or cephalosporin) plus a macrolide 2, 1
• OR a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin 750 mg) as monotherapy 2, 4

Inpatient Treatment (Non-ICU)

• A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin) 2
• OR a β-lactam (cefotaxime, ceftriaxone, or ampicillin) plus a macrolide 2, 1
• Recent evidence suggests that azithromycin may be superior to doxycycline when combined with β-lactams, with lower mortality and more hospital-free days 5

Inpatient Treatment (ICU)

• A β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin or a respiratory fluoroquinolone 2
• For suspected Pseudomonas infection: an antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either a fluoroquinolone or an aminoglycoside plus azithromycin 2
• For suspected MRSA: add vancomycin or linezolid to the regimen 2

Pathogen-Specific Treatment

• Streptococcus pneumoniae: β-lactams (penicillin G, amoxicillin, cefotaxime, or ceftriaxone) 2
• Haemophilus influenzae: Ampicillin for non-β-lactamase-producing strains; amoxicillin/clavulanate for β-lactamase producers 2
• Mycoplasma pneumoniae or Chlamydophila pneumoniae: A macrolide or doxycycline 2, 3
• Legionella pneumophila: A macrolide (preferably azithromycin) or a fluoroquinolone 2, 3
• Staphylococcus aureus (methicillin-sensitive): A penicillinase-resistant penicillin 2

Duration of Treatment

• Minimum of 5 days for most uncomplicated cases 2, 3
• Patient should be afebrile for 48-72 hours and have no more than one CAP-associated sign of clinical instability before discontinuation 2
• Uncomplicated S. pneumoniae pneumonia is typically treated for 7-10 days 2
• A longer duration may be needed if initial therapy was not active against the identified pathogen or if complicated by extrapulmonary infection 2

Switching from IV to Oral Therapy

• Switch when patient is hemodynamically stable, improving clinically, able to ingest medications, and has a normally functioning gastrointestinal tract 2
• Patients should be discharged as soon as they are clinically stable, have no other active medical problems, and have a safe environment for continued care 2

Special Considerations

• Consider local antimicrobial resistance patterns when selecting empiric therapy 2, 1
• For patients with recent antibiotic exposure, select an agent from a different class 1
• Azithromycin should not be used in patients with known QT prolongation, history of torsades de pointes, or uncompensated heart failure 6
• For influenza-associated pneumonia, add oseltamivir and target S. pneumoniae and S. aureus, the most common causes of secondary bacterial pneumonia 2

Common Pitfalls to Avoid

• Underestimating severity of pneumonia, which may lead to inappropriate outpatient treatment 1
• Using macrolide monotherapy in areas with high pneumococcal resistance (≥25%) 1
• Failing to consider atypical pathogens in empiric therapy 2, 3
• Not adjusting therapy based on culture and susceptibility results when available 2
• Continuing broad-spectrum antibiotics when a pathogen has been identified and targeted therapy is possible 2