Recommended Treatment for Pneumonia
The recommended treatment for pneumonia is empirical antimicrobial therapy based on severity assessment, with combination therapy of a beta-lactam plus a macrolide for hospitalized patients, and amoxicillin monotherapy for non-severe community-acquired pneumonia that can be managed in the outpatient setting. 1
Classification and Treatment Setting
- Severity assessment should classify pneumonia as mild, moderate, or severe to determine the most appropriate treatment setting (ambulatory, hospital ward, or ICU) 2
- Antimicrobial treatment should be initiated immediately after diagnosis of pneumonia 2, 1
- For patients with severe pneumonia requiring ICU admission, immediate parenteral antibiotic administration is essential 2, 1
Empirical Treatment Recommendations
Non-Severe Community-Acquired Pneumonia (Outpatient)
- Amoxicillin monotherapy is the preferred first-line agent for patients who can be managed in the community 1
- For penicillin-allergic patients, a macrolide (azithromycin or clarithromycin) is recommended as an alternative 1, 3
- Doxycycline is another alternative for penicillin-allergic patients 3
- Treatment duration should be 5-7 days for uncomplicated cases 1, 4
Non-Severe Community-Acquired Pneumonia (Hospitalized)
- Combined therapy with amoxicillin and a macrolide (erythromycin or clarithromycin) is preferred 2
- Alternative regimens include:
- Treatment duration should generally not exceed 8 days in responding patients 2
Severe Community-Acquired Pneumonia (ICU)
- Intravenous combination therapy with a broad-spectrum β-lactamase stable antibiotic plus a macrolide 2, 1
- Options include:
- For patients with risk factors for Pseudomonas aeruginosa:
- Antipseudomonal cephalosporin, acylureidopenicillin/β-lactamase inhibitor, or carbapenem PLUS ciprofloxacin OR macrolide plus aminoglycoside 2
Pathogen-Specific Considerations
- For Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella pneumophila (atypical pathogens):
- For Legionella species:
Monitoring Response to Treatment
- Monitor response using simple clinical criteria, including body temperature, respiratory parameters, and hemodynamic stability 1
- Patients should be switched from intravenous to oral therapy when they are hemodynamically stable and showing clinical improvement 1
- If no improvement is seen within 48-72 hours, reevaluation and possible change in antibiotic therapy is necessary 3
Special Considerations
- Biomarkers, particularly procalcitonin, may guide shorter treatment duration 2
- Patients should be afebrile for 48-72 hours before discontinuation of antibiotics 1
- Chest radiographs need not be repeated prior to hospital discharge in patients who have made satisfactory clinical recovery 2
- Clinical review should be arranged for all patients at around 6 weeks 2
Prevention Strategies
- Influenza vaccination is recommended for elderly patients and those at high risk of mortality from influenza or complicating pneumonia 1
- Pneumococcal vaccination is recommended for all those aged 2 years or older in whom pneumococcal infection is likely to be more common or serious 1
Common Pitfalls and Caveats
- Fluoroquinolones are not recommended as first-line agents for community use but may be useful alternatives in selected hospitalized patients 2
- Levofloxacin should not be used in patients with known QT interval prolongation, history of torsades de pointes, or uncompensated heart failure 5
- Azithromycin can cause serious allergic reactions and hepatotoxicity in rare cases; discontinue immediately if signs of hepatitis occur 4
- Delaying appropriate antibiotic therapy increases mortality; treatment should be initiated immediately after diagnosis 2, 6