What is the treatment for pneumonia (PNA)?

Treatment of Pneumonia (PNA)

The treatment of pneumonia requires appropriate antibiotic therapy based on the severity of illness, with amoxicillin as first-line for community-acquired pneumonia in outpatients, and combination therapy with a beta-lactam plus a macrolide for hospitalized patients with severe pneumonia. 1, 2

Treatment Algorithm Based on Setting and Severity

Outpatient Treatment

• For previously untreated patients in the community, amoxicillin monotherapy is the first-line treatment 1, 2
• For children under 3 years, amoxicillin 80-100 mg/kg/day in three daily doses is recommended 1
• For children over 3 years with suspected pneumococcal infection, amoxicillin is recommended; if atypical pathogens are suspected, a macrolide is reasonable 1
• For adults with comorbidities or recent antibiotic therapy, combination therapy with amoxicillin and a macrolide (erythromycin or clarithromycin) is preferred 2, 3

Non-Severe Hospitalized Patients

• Combined oral therapy with amoxicillin and a macrolide (erythromycin or clarithromycin) is preferred 2
• When oral treatment is contraindicated, recommended parenteral choices include intravenous ampicillin or benzylpenicillin, together with erythromycin or clarithromycin 2
• The oral route is recommended when there are no contraindications to oral therapy 2
• Patients initially treated with parenteral antibiotics should be switched to oral regimens once clinical improvement occurs and temperature has been normal for 24 hours 2

Severe Hospitalized Patients

• Patients with severe pneumonia should be treated immediately with parenteral antibiotics 2
• 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 2, 4
• For patients intolerant to β-lactams or macrolides, a fluoroquinolone with enhanced pneumococcal activity (levofloxacin) plus intravenous benzylpenicillin is an alternative 2

Duration of Treatment

• For non-severe and uncomplicated pneumonia, 7 days of appropriate antibiotics is recommended 2
• For severe microbiologically undefined pneumonia, 10 days of treatment is proposed 2
• Treatment should be extended to 14-21 days for legionella, staphylococcal, or gram-negative enteric bacilli pneumonia 2
• For pneumococcal pneumonia, 7-10 days of treatment is typically sufficient 5
• For atypical pneumonia caused by Mycoplasma or Chlamydia, at least 14 days of treatment with a macrolide is recommended 1

Specific Pathogen Considerations

• Streptococcus pneumoniae: Penicillin/amoxicillin remains the drug of choice for most pneumococcal infections in the US 5, 6
• Haemophilus influenzae: Ampicillin or a co-generic is the drug of choice for non-β-lactamase-producing strains 5
• Mycoplasma pneumoniae or Chlamydia pneumoniae: Macrolides (erythromycin, clarithromycin) or tetracyclines are preferred 5, 7
• Legionella pneumophila: Erythromycin 2-4g daily for at least three weeks; alternatives include tetracyclines or quinolones 7

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 2
• Consider further investigations including repeat chest radiograph, CRP, white cell count, and additional microbiological testing 2
• For non-severe pneumonia treated with amoxicillin monotherapy, add or substitute a macrolide 2
• For non-severe pneumonia on combination therapy, consider changing to a fluoroquinolone with effective pneumococcal coverage 2
• For severe pneumonia not responding to combination treatment, consider adding rifampicin 2

Special Considerations

• Azithromycin should not be used in patients with pneumonia who are inappropriate for oral therapy due to moderate to severe illness or risk factors 8
• Risk factors include: cystic fibrosis, nosocomial infections, known/suspected bacteremia, requiring hospitalization, elderly/debilitated patients, or significant underlying health problems 8
• New fluoroquinolones are not recommended as first-line agents or for community use but may provide a useful alternative in selected hospitalized patients 2
• Combination antibiotic therapy achieves better outcomes compared to monotherapy, particularly in severe cases, bacteremic pneumococcal pneumonia, and patients requiring mechanical ventilation 9

Prevention

• Influenza vaccination is recommended for high-risk groups including those with chronic lung, heart, renal and liver disease, diabetes mellitus, immunosuppression, and adults over 65 years 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 2