What are the recommended take-home medications for a patient being discharged with pneumonia?

Take-Home Medications for Pneumonia Discharge

For patients being discharged with community-acquired pneumonia, prescribe oral amoxicillin (or amoxicillin-clavulanate) combined with a macrolide (azithromycin or clarithromycin) for a minimum treatment duration of 5 days, ensuring the patient has been afebrile for 48-72 hours before completing therapy. 1, 2

Antibiotic Selection Algorithm

First-Line Combination Therapy (Preferred)

• Amoxicillin 500-1000 mg orally every 8 hours PLUS azithromycin 1
  • Azithromycin dosing: 500 mg on day 1, then 250 mg daily for days 2-5 3
  • Alternative azithromycin regimen: 500 mg once daily for 3 days 3, 4
• Amoxicillin-clavulanate 1 g orally every 8 hours PLUS macrolide 1, 2
  • This combination is particularly appropriate for patients in long-term care facilities where beta-lactamase producing organisms are a concern 2

Alternative Monotherapy Options

When combination therapy is not feasible, consider these alternatives based on specific clinical scenarios:

• Amoxicillin monotherapy: For previously untreated patients or those admitted for non-clinical reasons (elderly, socially isolated) who would otherwise be managed in the community 1
• Macrolide monotherapy: May be suitable for patients who failed adequate amoxicillin therapy prior to admission, though combination therapy remains preferred 1
• Fluoroquinolone monotherapy (levofloxacin 750 mg daily): Reserved for patients intolerant of penicillins or macrolides, or where there are concerns about Clostridium difficile 1, 5

Treatment Duration

• Minimum 5-7 days of therapy for most bacterial pneumonia 1, 2
• Continue until afebrile for 48-72 hours with no more than one sign of clinical instability 2
• Extended duration (14-21 days) if Legionella pneumophila, Staphylococcus aureus, or Gram-negative enteric bacilli are suspected or confirmed 1
• Fever should resolve within 2-3 days of initiating antibiotics; if not, reassessment is required 1

Critical Pre-Discharge Considerations

Confirm Patient Stability

Before discharge, verify the patient meets these criteria:

• Ability to tolerate oral medications 2, 6
• Stable vital signs (respiratory rate <30 breaths/min, systolic BP >90 mmHg, oxygen saturation adequate) 1, 2
• Clinical improvement with resolution or improvement of fever 1, 2

First Dose Administration

Administer the first doses of both antibiotics while the patient is still in the hospital or emergency department 6

• This ensures prompt treatment initiation, which is associated with improved morbidity and mortality outcomes 6
• Observe for at least 30 minutes to ensure medication tolerance 6

Additional Discharge Medications

Symptomatic Management

While the evidence focuses primarily on antibiotics, consider:

• Antipyretics for fever management
• Cough suppressants if needed for patient comfort
• Ensure adequate hydration instructions

Follow-Up Planning

• Clinical review at 6 weeks with either the general practitioner or hospital clinic 1, 2
• Chest radiograph at 6 weeks for patients with persistent symptoms, physical signs, or higher risk of underlying malignancy (especially smokers and those over 50 years) 1, 2
• No need to repeat chest radiograph before discharge if the patient has made satisfactory clinical recovery 1
• Provide patient information leaflet about pneumonia at discharge 1

Common Pitfalls to Avoid

• Delaying antibiotic administration until after discharge: This increases mortality risk; always give the first dose in the hospital 6
• Inadequate treatment duration: Stopping antibiotics before the patient has been afebrile for 48-72 hours increases relapse risk 2
• Monotherapy in hospitalized patients: Combination therapy with beta-lactam plus macrolide is preferred for hospitalized patients to cover both typical and atypical pathogens 1, 7
• Failing to assess oral medication tolerance: Patients unable to tolerate oral medications should not be discharged 2, 6
• Not providing clear continuation instructions: Ensure patients understand the importance of completing the full antibiotic course 6

Special Populations

Severe Pneumonia (Should Not Be Discharged)

Patients with any of the following should remain hospitalized:

• Respiratory rate >30 breaths/min 1
• Systolic BP <90 mmHg or diastolic <60 mmHg 1
• Need for mechanical ventilation 1
• Severe respiratory failure or hemodynamic instability 1

Resistant Organism Risk

For patients with risk factors for multidrug-resistant organisms, fluoroquinolone therapy (levofloxacin 750 mg daily) may be more appropriate than standard beta-lactam/macrolide combination 1, 5