What is the treatment for resistant pneumonia?

From the Guidelines

For patients with resistant pneumonia, I recommend a combination therapy of a respiratory fluoroquinolone (levofloxacin 750mg daily or moxifloxacin 400mg daily) plus an anti-pseudomonal beta-lactam (piperacillin-tazobactam 4.5g IV every 6 hours, cefepime 2g IV every 8 hours, or meropenem 1g IV every 8 hours) as the initial empiric treatment, as suggested by the most recent guidelines 1.

Key Considerations

• The choice of antibiotics should be based on the local epidemiology and susceptibility patterns of the suspected pathogens.
• For MRSA coverage, adding linezolid 600mg IV/PO twice daily or vancomycin 15-20mg/kg IV every 8-12 hours is recommended.
• Treatment duration should typically be 7-14 days, depending on clinical response.
• Obtaining cultures before starting antibiotics is crucial to guide targeted therapy.
• Underlying factors like immunosuppression, structural lung disease, or atypical pathogens should be considered.

Mechanisms of Resistance

• Bacterial production of enzymes that inactivate antibiotics
• Changes in bacterial cell membrane permeability
• Biofilm formation that protects bacteria from antibiotic exposure

Supportive Care

• Oxygen therapy
• Adequate hydration
• Respiratory support

Additional Recommendations

• Chest imaging and possibly bronchoscopy may be necessary to identify complications or alternative diagnoses.
• Antibiotic restriction and cycling may help limit the spread of resistant pathogens, as suggested by earlier guidelines 1 and 1.
• However, the most recent and highest quality study 1 should be prioritized when making treatment decisions.

From the FDA Drug Label

Levofloxacin tablets are indicated for the treatment of community-acquired pneumonia due to methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae (including multi-drug-resistant Streptococcus pneumoniae [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae, Legionella pneumophila, or Mycoplasma pneumoniae [see Dosage and Administration (2.1) and Clinical Studies (14.2)]. MDRSP isolates are isolates resistant to two or more of the following antibacterials: penicillin (MIC ≥ 2 mcg/mL), 2nd generation cephalosporins, e.g., cefuroxime, macrolides, tetracyclines and trimethoprim/sulfamethoxazole.

The treatment for resistant pneumonia is levofloxacin, which is effective against multi-drug resistant Streptococcus pneumoniae (MDRSP).

• The clinical success rate for levofloxacin in treating community-acquired pneumonia caused by MDRSP is 95% 2.
• Levofloxacin is indicated for the treatment of community-acquired pneumonia due to MDRSP 2 2.

From the Research

Treatment Options for Resistant Pneumonia

• The treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia is vancomycin, with a desired trough concentration of 15 to 20 mg/L 3.
• However, a vancomycin regimen of 1 g i.v. every 12 hours in critically ill trauma patients with MRSA pneumonia and normal renal function is unlikely to achieve trough concentrations of 15 to 20 mg/L, and doses of at least 1 g i.v. every 8 hours are needed 3.
• For severe pneumonia, empirical antibiotic therapy should cover a broad spectrum of Gram-negative and Gram-positive bacteria, including Pseudomonas aeruginosa, and should be initiated promptly 4.
• Combination therapy with an anti-pseudomonal beta-lactam and a fluoroquinolone or an aminoglycoside is recommended for patients with severe pneumonia and risk factors such as underlying diseases, antibiotic pretreatment, or mechanical ventilation 4.
• Monotherapy regimens with appropriate beta-lactam antibiotics, such as cefepime, imipenem, meropenem, or piperacillin-tazobactam, can also be effective for the treatment of severe pneumonia 4.

Treatment of MRSA Pneumonia

• Linezolid may be a better choice than vancomycin for the treatment of MRSA ventilator-associated pneumonia, but further research is needed to define the best therapeutic approach for other forms of MRSA pneumonia 5.
• Several antibiotics are active against MRSA and can be used for the treatment of pneumonia, including telavancin, ceftaroline, and ceftobiprole, but more research is needed to determine their efficacy and safety 5, 6.
• A personalized approach to the treatment of MRSA pneumonia can be taken, considering the severity of the disease, the setting of occurrence, the patient's baseline risk of toxicity and drug interactions, and the possibility of oral therapy 6.

General Principles of Treatment

• Empirical antimicrobial therapy for pneumonia should be initiated promptly and should have a broad spectrum that covers all potential antimicrobial-resistant pathogens 7.
• Broad-spectrum therapy should be streamlined (i.e., de-escalated) as appropriate, based on microbiological data and clinical response, to minimize the emergence of resistance 7.
• Timely empirical therapy with highly effective agents that are rapidly bactericidal could minimize the emergence of resistance, and switching to narrower-spectrum therapy that is directed by culture results may minimize the emergence of resistance 7.