Guidelines for Management of Community-Acquired Pneumonia in Adults in the Philippines
The recommended treatment for community-acquired pneumonia in adults in the Philippines should follow the IDSA/ATS guidelines, with empirical antibiotic therapy based on severity of illness and risk factors for specific pathogens.
Classification and Site of Care Decision
- Patients should be stratified into severity classes to determine appropriate site of care (outpatient vs. hospitalization vs. ICU) using clinical prediction rules 1
- Assessment should include evaluation of core and additional adverse prognostic features 1
Empirical Antibiotic Therapy
Outpatient Treatment
For previously healthy patients with no risk factors for drug-resistant S. pneumoniae (DRSP):
For patients with comorbidities or risk factors for DRSP:
Non-ICU Hospitalized Patients
Preferred regimen:
For penicillin-allergic patients:
ICU Hospitalized Patients
Standard therapy:
- A β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin or a fluoroquinolone 1
For suspected Pseudomonas infection:
- An antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin/levofloxacin or an aminoglycoside plus azithromycin 1
For suspected community-acquired MRSA:
- Add vancomycin or linezolid to standard therapy 1
Special Considerations
Pathogen-Directed Therapy
- Once a specific pathogen is identified, therapy should be directed at that pathogen 1
- For confirmed pneumococcal pneumonia with bacteremia, a β-lactam (penicillin G or amoxicillin) alone may be used if the isolate is penicillin-susceptible 1
- For Legionella pneumonia, azithromycin or a fluoroquinolone is preferred 1
Duration of Therapy
- Minimum duration: 5 days 1
- Patients should be afebrile for 48-72 hours and have no more than one CAP-associated sign of clinical instability before discontinuing therapy 1
- Longer duration may be needed if initial therapy was not active against the identified pathogen or if complicated by extrapulmonary infection 1
- Short-course antibiotic regimens (≤7 days) have been shown to be as effective as extended-course regimens for mild to moderate CAP 2
Transition from IV to Oral Therapy
- Switch from IV to oral therapy when patients are:
- Hemodynamically stable and improving clinically
- Able to ingest medications
- Have a normally functioning gastrointestinal tract 1
Management of Treatment Failure
- Use a systematic classification of possible causes of failure to respond 1
- Consider factors such as incorrect diagnosis, inappropriate antibiotic, unusual pathogens, or complications 1
- For patients who fail to improve as expected, reassess with additional diagnostic tests 1
Follow-up Care
- Clinical review should be arranged for all patients at around 6 weeks 1
- Chest radiograph need not be repeated prior to hospital discharge in patients who have made satisfactory clinical recovery 1
- A follow-up chest radiograph should be arranged for patients with persistent symptoms or physical signs, or those at higher risk of underlying malignancy 1
Important Considerations
- The first antibiotic dose should be administered while still in the emergency department for hospitalized patients 1
- Despite increasing S. pneumoniae resistance to penicillin in vitro, β-lactams remain effective for pneumococcal pneumonia as the serum and pulmonary levels achieved are several times higher than the MIC 3, 4
- Recent evidence suggests that ampicillin may be comparable to ceftriaxone for hospitalized CAP patients, with lower rates of C. difficile infection 5