What is the recommended treatment for community-acquired pneumonia (CAP) in pregnancy?

Treatment of Community-Acquired Pneumonia in Pregnancy

For pregnant women with community-acquired pneumonia (CAP), a β-lactam (such as ampicillin-sulbactam, ceftriaxone, or cefotaxime) plus either a macrolide (azithromycin or clarithromycin) is the recommended first-line treatment. 1, 2

Pathogen Considerations in Pregnancy

• The most common bacterial pathogens in CAP during pregnancy are similar to non-pregnant adults: Streptococcus pneumoniae (most common, 15-20% of cases), Haemophilus influenzae, Mycoplasma pneumoniae, and Chlamydia pneumoniae 1, 2, 3
• Pregnancy increases the risk of complications from pneumonia, including respiratory failure, which can affect both maternal and fetal outcomes 2, 4

Treatment Recommendations

For Non-Severe CAP in Pregnant Patients:

• First-line therapy: β-lactam (ampicillin-sulbactam, ceftriaxone, or cefotaxime) plus a macrolide (azithromycin or clarithromycin) 1, 2
• Alternative for penicillin-allergic patients: A respiratory fluoroquinolone (levofloxacin or moxifloxacin), though these should be used with caution in pregnancy 1
• Doxycycline is generally avoided in pregnancy, particularly in the second and third trimesters due to potential effects on fetal bone and teeth development 1

For Severe CAP in Pregnant Patients:

• Hospitalization is recommended with initial intravenous therapy 5
• Treatment should include a β-lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam, or piperacillin-tazobactam) plus either a macrolide or a respiratory fluoroquinolone 1
• For suspected Pseudomonas infection: Use an antipneumococcal, antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin/levofloxacin or an aminoglycoside plus azithromycin 1

Administration Route and Duration

• Intravenous antibiotics should be used initially for hospitalized patients 1
• Switch from IV to oral therapy when the patient is hemodynamically stable, improving clinically, and able to ingest medications 1
• Minimum treatment duration of 5 days is recommended, with continuation until the patient is afebrile for 48-72 hours and has no more than one CAP-associated sign of clinical instability 1

Special Considerations

• Obtain blood cultures and sputum samples before initiating antibiotics when possible 1
• Procalcitonin levels may help guide antibiotic use but must be interpreted cautiously as they may be elevated due to inflammation rather than bacterial infection 1, 6
• Influenza vaccination is strongly recommended for pregnant women to reduce the risk of respiratory complications 2
• For pregnant patients with COVID-19 and suspected bacterial co-infection, the same antibiotic regimens apply as for non-COVID pneumonia 1, 6

Monitoring and Follow-up

• Most patients show clinical improvement within 3-5 days of appropriate antibiotic therapy 1
• Radiographic improvement typically lags behind clinical response 1
• Failure to respond may indicate incorrect diagnosis, inappropriate antibiotic choice, unusual pathogen, or complications such as empyema 1
• Close monitoring for respiratory compromise is essential, as pregnancy increases the risk of progression to respiratory failure 2, 4

Remember that prompt diagnosis and early initiation of appropriate antimicrobial therapy are crucial to reducing maternal morbidity and mortality from pneumonia in pregnancy 2.