What is the recommended treatment for pneumonia?

Treatment of Pneumonia

For pneumonia treatment, a beta-lactam antibiotic plus a macrolide is the recommended first-line therapy, with treatment duration of 5-7 days for non-severe cases and 10-14 days for severe cases. 1

Treatment Based on Setting and Severity

Outpatient (Non-Severe Community-Acquired Pneumonia)

• Amoxicillin monotherapy is the preferred agent for patients who can be managed in the community 1, 2
• For penicillin-allergic patients, a macrolide (erythromycin or clarithromycin) is recommended as an alternative 1, 2
• Treatment duration should be 7 days for uncomplicated community-managed pneumonia 1, 2

Hospitalized Patients (Non-ICU)

• Combination therapy with a beta-lactam antibiotic and a macrolide is recommended 3, 1
• Options include:
  • Beta-lactams: amoxicillin, co-amoxiclav, cefuroxime, ceftriaxone 3, 2
  • Macrolides: clarithromycin or erythromycin 3, 2
• When oral treatment is contraindicated, recommended parenteral choices include intravenous ampicillin or benzylpenicillin, together with erythromycin or clarithromycin 3, 2
• A fluoroquinolone (such as levofloxacin) is an alternative for those intolerant to penicillins or macrolides, but should not be used as a first-line agent 3, 4

Severe Pneumonia (ICU)

• Immediate parenteral antibiotic administration is required 3, 1
• An intravenous combination of a broad-spectrum β-lactamase stable antibiotic together with a macrolide is preferred 3
• Options include:
  • Beta-lactams: co-amoxiclav, cefuroxime, ceftriaxone, piperacillin/tazobactam, cefoperazone/sulbactam 3
  • Macrolides: clarithromycin or erythromycin 3, 2
• For patients with severe microbiologically undefined pneumonia, 10 days of treatment is recommended 3, 2
• Treatment should be extended to 14-21 days where legionella, staphylococcal, or gram-negative enteric bacilli pneumonia are suspected or confirmed 3, 2

Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP)

• For patients with low risk of multidrug-resistant organisms (MDROs) and stable hemodynamics, options include:
  • Piperacillin/tazobactam, cefoperazone/sulbactam, ceftazidime, cefepime, imipenem, meropenem, levofloxacin, or ciprofloxacin 3
• For patients with high risk of MDROs or unstable hemodynamics, consider adding:
  • Gentamicin, amikacin, or colistin 3
• For patients with high risk of MRSA infection, add:
  • Vancomycin, teicoplanin, or linezolid 3

Route of Administration and Duration

• Oral therapy is appropriate from the beginning for ambulatory patients 1
• Patients initially treated with parenteral antibiotics should be switched to oral therapy when they are hemodynamically stable, improving clinically, able to ingest medications, and have a normally functioning gastrointestinal tract 1, 2
• Minimum treatment duration should be 5 days 1
• Patient should be afebrile for 48-72 hours before discontinuation 1

Management of Treatment Failure

• For patients who fail to improve as expected, conduct a careful review of the clinical history, examination, prescription chart, and all available investigation results 3, 2
• Further investigations, including repeat chest radiograph, CRP, white cell count, and additional microbiological testing should be considered 3, 2
• When empirical antibiotic treatment change is necessary, a macrolide could be added to amoxicillin monotherapy for non-severe pneumonia 3, 2
• For those with non-severe pneumonia on combination therapy, changing to a fluoroquinolone with effective pneumococcal coverage is an option 3, 2
• The addition of rifampicin may be considered for those with severe pneumonia not responding to combination antibiotic treatment 3

Special Considerations

• Beta-lactams continue to be the drugs of choice for pneumococcal pneumonia, with fluoroquinolones as an excellent alternative therapy 5
• Patients with shock or severe sepsis should receive combination therapy with β-lactams plus a macrolide due to its immunomodulatory effect 5
• Azithromycin carries risks of QT prolongation which can be fatal in at-risk groups 6
• Levofloxacin is indicated for community-acquired pneumonia due to susceptible strains of common pathogens, but should not be used as first-line therapy 4
• Monitor response using simple clinical criteria, including body temperature, respiratory parameters, and hemodynamic parameters 1
• C-reactive protein should be measured on days one and three/four, especially in patients with unfavorable clinical parameters 1

Prevention Strategies

• Influenza vaccination is recommended for elderly patients and those at "high risk" of mortality from influenza or complicating pneumonia 1, 2
• 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, 2