Should Plaquenil Be Held in Pneumonia?
No, hydroxychloroquine (Plaquenil) should NOT be held in patients with pneumonia who are already taking it for a rheumatic disease, as it may have potential therapeutic benefit and does not interfere with standard pneumonia treatment. However, it should not be initiated solely for pneumonia treatment based on current evidence.
Key Recommendations for Patients Already on Hydroxychloroquine
Continue hydroxychloroquine in patients with rheumatic diseases who develop pneumonia, as the Italian Society of Rheumatology specifically recommends not discontinuing this medication even during active infection 1
The rationale is that hydroxychloroquine may have some efficacy against certain viral pathogens and does not compromise bacterial pneumonia treatment 1
This is the one exception to the general rule of pausing immunosuppressive therapy during active infection in rheumatic patients 1
Standard Pneumonia Treatment Remains Essential
Regardless of hydroxychloroquine status, appropriate antibiotic therapy must be initiated based on pneumonia severity and setting:
For Hospitalized Non-ICU Patients:
- β-lactam (ceftriaxone, cefotaxime, or ampicillin-sulbactam) plus either azithromycin or a respiratory fluoroquinolone is the standard regimen 1
- This combination provides coverage for Streptococcus pneumoniae, Haemophilus influenzae, atypical pathogens, and Staphylococcus aureus 1
For ICU Patients with Severe Pneumonia:
- β-lactam plus either azithromycin or fluoroquinolone is the minimal recommended treatment 1
- Combination therapy is associated with lower mortality in severe cases, particularly with bacteremic pneumococcal pneumonia 1
For Neutropenic or Immunosuppressed Patients:
- Treat as healthcare-associated pneumonia with broad-spectrum coverage: β-lactam or carbapenem plus aminoglycoside or antipseudomonal fluoroquinolone 1
- Add vancomycin or linezolid if MRSA is suspected or in severe cases with hypoxia 1
Important Clinical Caveats
Hydroxychloroquine Should NOT Be Initiated for Pneumonia Treatment:
- Evidence does not support starting hydroxychloroquine for COVID-19 or bacterial pneumonia treatment 2
- A comparative study of 181 patients showed no benefit in survival, ICU transfer rates, or oxygen weaning when hydroxychloroquine was used for COVID-19 pneumonia (76% vs 75% survival without ICU transfer, weighted HR 0.9) 2
Cardiac Monitoring is Critical if Hydroxychloroquine is Continued:
- QTc prolongation is a significant risk, particularly when combined with azithromycin (21% developed QTc ≥500ms vs 19% with hydroxychloroquine alone) 3
- Baseline QTc ≥450ms (adjusted OR 7.11) and concurrent loop diuretics (adjusted OR 3.38) increase risk of dangerous QTc prolongation 3
- Monitor baseline and serial ECGs if continuing hydroxychloroquine during pneumonia treatment, especially with macrolide antibiotics 3
Procalcitonin Can Guide Antibiotic Decisions:
- Low procalcitonin values can help withhold or stop antibiotics early in confirmed viral pneumonia, reducing unnecessary antibiotic exposure 1
- This is particularly relevant in COVID-19 pneumonia where bacterial co-infection rates are lower than initially suspected 1
Practical Algorithm
- Patient already on hydroxychloroquine for rheumatic disease → Continue medication 1
- Initiate appropriate antibiotic therapy based on severity and risk factors 1
- Obtain baseline ECG before continuing hydroxychloroquine, especially if macrolide antibiotics are used 3
- Monitor QTc interval during treatment; discontinue hydroxychloroquine if QTc >500ms or increases >60ms from baseline 3
- Consider procalcitonin testing to guide antibiotic duration in less severe cases 1
- Do NOT initiate hydroxychloroquine for pneumonia treatment in patients not already taking it 2
The key pitfall to avoid is assuming hydroxychloroquine provides meaningful pneumonia treatment benefit—it does not based on current evidence, but continuing it in patients with underlying rheumatic disease is safe and recommended 1, 2.