What is the treatment for pneumonia in pregnancy?

Treatment of Pneumonia in Pregnancy

For pregnant women with pneumonia, the recommended first-line treatment is a beta-lactam antibiotic such as amoxicillin or amoxicillin-clavulanate, often combined with a macrolide like azithromycin or erythromycin. 1, 2

Antibiotic Selection Based on Severity

Non-Severe Community-Acquired Pneumonia

• For outpatient management of mild pneumonia in pregnancy, oral amoxicillin is the first-line agent, targeting the most common pathogen Streptococcus pneumoniae 3, 1
• Erythromycin monotherapy has been shown to be effective in most pregnant women with non-severe pneumonia 2
• Macrolides (azithromycin, erythromycin) are particularly important when atypical pathogens like Mycoplasma pneumoniae are suspected 1
• Duration of treatment should be 7 days for uncomplicated pneumonia 3

Severe Community-Acquired Pneumonia

• For hospitalized pregnant patients with severe pneumonia, intravenous combination therapy is recommended 3
• The preferred regimen is a broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, or ceftriaxone) plus a macrolide (clarithromycin or erythromycin) 3, 1
• For severe pneumonia, treatment duration should be extended to 10 days, or 14-21 days if legionella, staphylococcal, or gram-negative enteric bacilli are suspected 3

Special Considerations in Pregnancy

• Amphotericin B is the treatment of choice when antifungal therapy is needed during pregnancy, as fluconazole and other azole antifungals are teratogenic 3
• Fluoroquinolones should generally be avoided during pregnancy unless benefits outweigh risks 3, 1
• Pneumococcal vaccination is not recommended during pregnancy 3
• Influenza vaccination is recommended for pregnant women as it can reduce respiratory hospitalizations and complications 1

Route of Administration and Transition

• Patients with severe pneumonia should be treated immediately with parenteral antibiotics 3
• Transition from IV to oral therapy is appropriate when:
  • Clinical improvement is evident
  • Temperature has been normal for 24 hours
  • No contraindications to oral administration exist 3

Management of Treatment Failure

• If a patient fails to improve after 48-72 hours of therapy, conduct a thorough clinical review 3
• Consider additional investigations including repeat chest radiograph, inflammatory markers, and further microbiological testing 3
• For non-severe pneumonia initially treated with amoxicillin monotherapy, add or substitute a macrolide 3
• For severe pneumonia not responding to combination therapy, consider adding rifampicin 3

Monitoring and Complications

• Pneumonia in pregnancy is associated with increased risk of preterm birth and low birth weight 1, 4
• Respiratory insufficiency is a common complication that may progress to respiratory failure requiring mechanical ventilation 5
• Close monitoring is essential as pneumonia is the most common fatal non-obstetric infectious complication in pregnancy 1, 6

Common Pitfalls and Caveats

• Avoid delaying antibiotic administration, as prompt treatment is essential to reduce maternal and fetal complications 7, 5
• Be aware that normal physiological and anatomic changes of pregnancy can mask or mimic symptoms of pneumonia 6
• Consider hospitalization for most pregnant women with pneumonia - studies suggest only about 25% of pregnant women with pneumonia can be safely managed as outpatients 2
• Monitor for QT prolongation with macrolides, especially azithromycin, particularly in patients with cardiac risk factors 8