What is the recommended treatment for pneumonia in pregnancy?

Treatment of Pneumonia in Pregnancy

For mild community-acquired pneumonia in pregnant women managed as outpatients, oral amoxicillin is the first-line antibiotic for 7 days; for severe pneumonia requiring hospitalization, intravenous combination therapy with a β-lactam (co-amoxiclav, cefuroxime, or ceftriaxone) plus azithromycin is recommended. 1

Outpatient Management (Mild Pneumonia)

• Oral amoxicillin is the preferred first-line agent targeting Streptococcus pneumoniae, the most common bacterial pathogen in pregnancy-associated pneumonia 1
• Treatment duration should be 7 days for uncomplicated cases 1, 2
• Beta-lactam antibiotics (penicillins and cephalosporins) have not been associated with teratogenicity or increased toxicity and are safe throughout all trimesters 1

Inpatient Management (Severe Pneumonia)

• Immediate intravenous combination therapy is essential for hospitalized pregnant patients with severe pneumonia 1
• The preferred regimen consists of:
  • A broad-spectrum β-lactamase stable antibiotic: co-amoxiclav, cefuroxime, or ceftriaxone 1
  • Plus azithromycin (the preferred macrolide in pregnancy) 1
• Azithromycin is safer than clarithromycin, which should be avoided due to increased risk of birth defects and spontaneous abortion 1
• Treatment duration for severe pneumonia should be 10 days, or 14-21 days if legionella, staphylococcal, or gram-negative enteric bacilli are suspected 1

Transition from IV to Oral Therapy

• Switch to oral antibiotics when clinical improvement is evident, temperature has been normal for 24 hours, and no contraindications to oral administration exist 1, 2
• This transition should be reviewed daily to minimize unnecessary parenteral therapy 2

Management of Treatment Failure

If the patient fails to improve after 48-72 hours of therapy, conduct the following 1:

• Perform thorough clinical review with repeat chest radiograph, inflammatory markers, and further microbiological testing 1
• For non-severe pneumonia initially treated with amoxicillin monotherapy, add or substitute a macrolide 1
• For severe pneumonia not responding to combination therapy, consider adding rifampicin 1

Antibiotics to Avoid in Pregnancy

• Doxycycline is contraindicated due to increased hepatotoxicity and staining of fetal teeth and bones 1
• Clarithromycin should be avoided as first-line therapy due to teratogenic concerns 1
• Fluoroquinolones should generally be avoided unless benefits outweigh risks, though approximately 400 human pregnancy exposures have shown no increased birth defects 1
• Tetracyclines should not be administered after the fifth week of pregnancy and are deemed contraindicated 3

Special Pathogen Considerations

• For atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae), azithromycin is preferred over doxycycline 2, 1
• Amphotericin B is the treatment of choice when antifungal therapy is needed, as fluconazole and other azole antifungals are teratogenic 1
• For Legionella species, fluoroquinolones (levofloxacin or moxifloxacin) are preferred, though pregnancy-specific risks must be weighed 2

Critical Pregnancy-Specific Monitoring

• Pregnant women with pneumonia after 20 weeks of gestation should be monitored for contractions, as rates of preterm labor and preterm delivery are significantly increased 1
• Anemia and preeclampsia are associated with increased severity of pneumonia in pregnancy 4
• Chest radiographs should be obtained promptly when pneumonia is suspected to facilitate early diagnosis 4

Vaccination Considerations

• Inactivated influenza vaccine is recommended for all pregnant women who will be pregnant during influenza season to prevent severe viral pneumonia 1
• Live attenuated influenza vaccine should not be used during pregnancy 1
• Pneumococcal vaccination is not routinely recommended during pregnancy, though it can be administered safely if indicated 1, 2

Common Pitfalls

• Avoid delaying antibiotic administration, as prompt treatment is essential to reduce maternal and fetal complications including respiratory failure, low birth weight, and preterm birth 1, 5
• Do not underestimate severity in late pregnancy—delayed diagnoses are common and maternal mortality can reach 17% in severe cases 4
• Termination of pregnancy is recommended for patients in their third trimester when respiratory function deteriorates progressively, though continuation may be reasonable in first or second trimester 4