Treatment of Non-Severe Community-Acquired Pneumonia
For non-severe community-acquired pneumonia (CAP), oral amoxicillin at a higher dose than previously recommended is the preferred first-line treatment, with macrolides (erythromycin or clarithromycin) as an alternative for penicillin-allergic patients. 1, 2
Initial Assessment and Treatment Selection
- Severity assessment should guide treatment decisions, with tools like CURB-65 helping to identify patients who can be safely treated as outpatients 2
- For outpatients with non-severe CAP and no comorbidities, amoxicillin is the preferred agent 1
- A macrolide (erythromycin or clarithromycin) is recommended as an alternative for patients with penicillin allergies 1
- Doxycycline can also be considered as an alternative in patients without comorbidities 1, 3
Specific Antibiotic Recommendations
Patients without comorbidities:
- Amoxicillin at higher doses (e.g., 1g three times daily) 1, 2
- Alternative: Macrolide (clarithromycin or azithromycin) 1, 4
Patients with comorbidities:
- Combined therapy with amoxicillin and a macrolide is preferred 1, 2
- Alternative: Respiratory fluoroquinolone (e.g., levofloxacin) for those intolerant to penicillins or macrolides 1, 5
Duration of Treatment
- For patients with non-severe and uncomplicated pneumonia, treatment with appropriate antibiotics for 7 days is recommended 1, 2
- Newer evidence suggests patients can be treated for a minimum of 5 days if they are clinically stable 6, 7
- Patients should be afebrile for 48-72 hours and have no more than 1 CAP-associated sign of clinical instability before discontinuation of therapy 2
Route of Administration
- Most patients with non-severe CAP can be adequately treated with oral antibiotics 1, 8
- When oral treatment is contraindicated, recommended parenteral choices include intravenous ampicillin or benzylpenicillin, together with erythromycin or clarithromycin 1
- Patients initially treated with parenteral antibiotics should be transferred to an oral regimen as soon as clinical improvement occurs and temperature has been normal for 24 hours 1
Follow-up and Monitoring
- Clinical review should be arranged for all patients at around 6 weeks, either with their general practitioner or in a hospital clinic 1, 2
- A chest radiograph should be arranged at follow-up for patients with persistent symptoms or physical signs, or who are at higher risk of underlying malignancy (especially smokers and those over 50 years) 1, 6
- For patients who fail to improve as expected, there should be a careful review of the clinical history, examination, prescription chart, and results of all available investigations 6
Special Considerations
- Fluoroquinolones (like levofloxacin) should not be used as first-line agents but may provide a useful alternative in selected patients with CAP who are intolerant to penicillins or macrolides 1, 5
- Be aware of potential adverse effects: high-dose amoxicillin may cause more gastrointestinal side effects compared to other antibiotics 9
- For patients with suspected influenza and CAP, consider antiviral treatment in addition to antibacterial therapy 2
- Pneumococcal and influenza vaccination are recommended for prevention in high-risk groups 1, 3
Common Pitfalls to Avoid
- Overuse of broad-spectrum antibiotics when narrow-spectrum would suffice 1, 9
- Unnecessary use of intravenous antibiotics when oral therapy would be effective 8
- Prolonged antibiotic courses beyond what is necessary for clinical resolution 2, 7
- Failure to consider macrolide resistance in areas where this is prevalent (>25%) 1, 3
- Not arranging appropriate follow-up to ensure resolution of symptoms and radiographic findings 1, 2