What is the treatment for pneumonia in pregnancy?

Treatment of Pneumonia in Pregnancy

For mild pneumonia in pregnancy, oral amoxicillin is the first-line antibiotic, while severe pneumonia requires immediate intravenous combination therapy with a broad-spectrum β-lactam (co-amoxiclav, cefuroxime, or ceftriaxone) plus a macrolide (azithromycin or erythromycin). 1, 2

Antibiotic Selection by Severity

Mild/Outpatient Pneumonia

• Oral amoxicillin is the preferred first-line agent targeting Streptococcus pneumoniae, the most common pathogen in community-acquired pneumonia during pregnancy 1, 2
• When a macrolide is required (for atypical pathogen coverage or penicillin allergy), azithromycin is the recommended macrolide in pregnancy rather than clarithromycin 3
• Clarithromycin should be avoided as first-line therapy due to animal studies showing increased birth defects and one human study documenting increased spontaneous abortion risk 3
• Treatment duration should be 7 days for uncomplicated pneumonia 1, 2

Severe/Hospitalized Pneumonia

• Immediate intravenous combination therapy is mandatory upon diagnosis to reduce maternal and fetal morbidity 1, 2
• The preferred regimen consists of:
  • A broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, or ceftriaxone) PLUS
  • A macrolide (azithromycin or erythromycin) 1, 2
• Treatment duration should be 10 days for severe pneumonia, or extended to 14-21 days if Legionella, staphylococcal, or gram-negative enteric bacilli are suspected 1, 4

Pregnancy-Specific Antibiotic Considerations

Safe Antibiotics

• Beta-lactam antibiotics (penicillins, cephalosporins) have not been associated with teratogenicity or increased toxicity and are safe throughout pregnancy 3
• Azithromycin did not produce birth defects in animal studies and is the preferred macrolide when this class is indicated 3
• Aminoglycosides may be used when needed, though streptomycin carries a 10% risk and kanamycin a 2% risk of fetal eighth nerve damage 3

Antibiotics to Avoid or Use with Caution

• Doxycycline is contraindicated during pregnancy due to increased hepatotoxicity and staining of fetal teeth and bones 3
• Fluoroquinolones can be used for serious respiratory infections when indicated, despite theoretical concerns about arthropathy; approximately 400 human pregnancy exposures have not shown increased birth defects or arthropathy 3
• However, fluoroquinolones should generally be avoided unless benefits clearly outweigh risks 1

Transition from IV to Oral Therapy

Switch from intravenous to oral antibiotics when:

• Clinical improvement is evident
• Temperature has been normal for 24 hours
• No contraindications to oral administration exist 1, 2, 4

Management of Treatment Failure

If the patient fails to improve after 48-72 hours:

• Conduct a thorough clinical review including examination, prescription verification, and all investigation results 1, 4
• Order additional investigations: repeat chest radiograph, inflammatory markers (CRP, white cell count), and further microbiological testing (sputum culture, blood cultures, urinary antigens) 1, 4

Antibiotic modification strategy:

• For non-severe pneumonia initially on amoxicillin monotherapy: add or substitute a macrolide (azithromycin or erythromycin) 1, 4
• For severe pneumonia not responding to combination therapy: consider adding rifampicin to the existing regimen 1, 4

Critical Pregnancy-Specific Monitoring

Preterm Labor Surveillance

• Pregnant women with pneumonia after 20 weeks of gestation should be monitored for evidence of contractions, as rates of preterm labor and preterm delivery are significantly increased 3
• Advanced gestational age is associated with increased pneumonia severity 5

Maternal Risk Factors

• Anemia increases the risk of contracting pneumonia and is associated with more severe disease 6, 5
• Asthma and preeclampsia are additional risk factors for severe pneumonia in pregnancy 6, 5

Common Pitfalls and Caveats

• Do not delay antibiotic administration—prompt treatment is essential to reduce maternal and fetal complications including respiratory failure, low birth weight, and preterm birth 1, 6
• Do not avoid chest radiography when pneumonia is suspected; appropriate shielding of the abdomen makes this safe and delayed diagnosis is a documented problem 3, 5
• Do not continue the same antibiotic without reassessment if the patient fails to improve by 48-72 hours 1, 4
• Be aware that misdiagnosis at admission occurs in approximately 10% of cases 7

Vaccination Considerations

• Pneumococcal vaccine can be administered during pregnancy with no adverse consequences reported, though it is not routinely recommended 3, 1
• Inactivated influenza vaccine is recommended for all pregnant women who will be pregnant during influenza season to prevent severe viral pneumonia 3
• Live attenuated influenza vaccine should not be used during pregnancy 3