What is the recommended treatment for pneumonia?

Treatment of Pneumonia

Outpatient Community-Acquired Pneumonia (Non-Severe)

For patients with community-acquired pneumonia who can be managed in the community, amoxicillin monotherapy is the preferred first-line agent. 1

First-Line Therapy

• Amoxicillin monotherapy is recommended by the Infectious Diseases Society of America as the preferred agent for non-severe CAP in ambulatory patients 1
• Treatment duration should be 7 days for uncomplicated community-managed pneumonia 1
• Oral therapy is appropriate from the beginning for ambulatory patients 1

Alternative for Penicillin Allergy

• A macrolide (azithromycin or clarithromycin) is recommended as an alternative for penicillin-allergic patients 1
• Azithromycin dosing: 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2-5 2

Combination Therapy Option

• The American Thoracic Society recommends combination therapy with a beta-lactam antibiotic plus a macrolide for community-acquired pneumonia 1
• This approach provides broader coverage including atypical pathogens (Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila) 1
• Treatment duration of 5-7 days for non-severe cases 1

Severe Community-Acquired Pneumonia (Hospitalized Patients)

For severe community-acquired pneumonia requiring hospitalization, immediate parenteral antibiotic administration with an intravenous combination of a broad-spectrum β-lactamase stable antibiotic together with a macrolide is required. 1

Initial Parenteral Therapy

• An IV combination of a broad-spectrum β-lactamase stable antibiotic together with a macrolide is preferred 1
• Treatment duration should be 10-14 days for severe cases 1
• Legionella, staphylococcal, or Gram-negative enteric bacilli infections may require extended treatment to 14-21 days 3

Transition to Oral Therapy

• Switch from intravenous to oral therapy when the patient is hemodynamically stable and improving clinically 1
• Patient should be afebrile for 48-72 hours before discontinuation 1, 3
• Minimum treatment duration should be 5 days 1

Treatment Failure or Lingering Pneumonia

If pneumonia is not responding to initial therapy, add or substitute antibiotics to cover atypical pathogens or resistant organisms rather than continuing the same regimen. 3

For Non-Severe Pneumonia Previously on Amoxicillin

• Add or substitute a macrolide (clarithromycin or erythromycin) to cover atypical pathogens that may have been missed 3

For Non-Severe Pneumonia on Combination Therapy

• Switch to a respiratory fluoroquinolone with effective pneumococcal coverage (levofloxacin 500-750 mg daily) 3
• Levofloxacin is indicated for community-acquired pneumonia due to Streptococcus pneumoniae (including multi-drug-resistant strains), Haemophilus influenzae, Mycoplasma pneumoniae, and Chlamydophila pneumoniae 4

For Severe Pneumonia Not Responding

• Consider adding rifampicin to the existing combination antibiotic regimen 3

Monitoring Response to Treatment

• 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

Critical Safety Considerations

Azithromycin Warnings

• QT prolongation can occur and may be fatal in at-risk groups including patients with known prolonged QT interval, history of torsades de pointes, congenital long QT syndrome, bradyarrhythmias, or uncompensated heart failure 2
• Elderly patients may be more susceptible to drug-associated effects on the QT interval 2
• Serious allergic reactions including anaphylaxis and Stevens-Johnson Syndrome have been reported rarely 2
• Hepatotoxicity including hepatic failure resulting in death has been reported; discontinue immediately if signs of hepatitis occur 2

Levofloxacin Indications

• Azithromycin should not be used in patients with pneumonia who are judged inappropriate for oral therapy due to moderate to severe illness, including patients with cystic fibrosis, nosocomial infections, known or suspected bacteremia, requiring hospitalization, elderly or debilitated patients, or those with significant underlying health problems 2

Common Pitfalls to Avoid

• Do not continue the same antibiotic regimen without reassessment if the patient fails to improve, as this mandates investigation for alternative pathogens, complications, or non-infectious mimics of pneumonia 3
• Do not overlook the possibility of resistant organisms or nosocomial superinfection in elderly patients with prolonged hospitalization or recent healthcare exposure 3
• Do not use azithromycin alone for severe pneumonia requiring hospitalization 2