What is an alternative treatment to azithromycin (a macrolide antibiotic) for community-acquired pneumonia in a patient with a non-Immunoglobulin E (non-IGE) mediated hypersensitivity reaction to azithromycin?

From the Guidelines

For patients with a non-IgE mediated response to azithromycin who need treatment for community acquired pneumonia, doxycycline is an excellent alternative, as recommended by the Infectious Diseases Society of America/American Thoracic Society consensus guidelines 1. The recommended dosage is 100 mg orally twice daily for 5-7 days. Other options include fluoroquinolones such as levofloxacin (750 mg orally once daily for 5 days) or moxifloxacin (400 mg orally once daily for 5-7 days). For hospitalized patients, respiratory fluoroquinolones or beta-lactams like ceftriaxone (1-2 g IV once daily) combined with a macrolide other than azithromycin (such as clarithromycin) may be appropriate. When selecting an alternative, it's essential to consider that non-IgE mediated reactions to azithromycin typically don't indicate cross-reactivity with other antibiotic classes, as noted in the guidelines 1. The choice should be guided by the patient's clinical status, local resistance patterns, and comorbidities. These alternative antibiotics provide similar coverage against common pneumonia pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms like Mycoplasma pneumoniae and Chlamydia pneumoniae that azithromycin would typically target, as discussed in the update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults 1. Key considerations in selecting an alternative to azithromycin include:

• The patient's risk factors for drug-resistant Streptococcus pneumoniae (DRSP) infection
• The local prevalence of DRSP and other resistant organisms
• The patient's clinical status, including the presence of comorbidities and the severity of symptoms
• The potential for cross-reactivity with other antibiotic classes, although this is generally not a concern with non-IgE mediated reactions to azithromycin. By considering these factors and selecting an appropriate alternative antibiotic, clinicians can provide effective treatment for community-acquired pneumonia in patients with a non-IgE mediated response to azithromycin.