What is the recommended treatment for pneumonia?

Treatment for Pneumonia

Immediate Antibiotic Initiation

Antibiotic treatment should be initiated immediately after diagnosis of pneumonia, as early administration directly impacts mortality and morbidity outcomes 1, 2.

Treatment Based on Clinical Setting

Outpatient/Community-Managed Pneumonia (Non-Severe)

For patients who can be managed in the community:

• Amoxicillin monotherapy is the preferred first-line agent for non-severe community-acquired pneumonia 2
• For penicillin-allergic patients, use a macrolide (azithromycin or clarithromycin preferred over erythromycin) 1, 2
• Alternative options include doxycycline or a respiratory fluoroquinolone (levofloxacin 500-750 mg daily or moxifloxacin) 1, 3
• Treatment duration: 5-7 days for uncomplicated cases 2
• Oral therapy is appropriate from the start for ambulatory patients 2

Hospitalized Patients (Moderate Severity, Non-ICU)

Combination therapy with a beta-lactam plus a macrolide is the recommended approach for hospitalized patients 1, 2:

• Preferred regimens (in order of recommendation):

  • Ceftriaxone or cefotaxime (non-antipseudomonal cephalosporin) + macrolide 1
  • Ampicillin-sulbactam (aminopenicillin/β-lactamase inhibitor) + macrolide 1
  • Ampicillin + macrolide 1

• Alternative monotherapy options:

  • Levofloxacin 500-750 mg daily 1, 4
  • Moxifloxacin (has highest antipneumococcal activity among fluoroquinolones) 1

• Treatment duration: 7-10 days for non-severe hospitalized cases 2

Severe Pneumonia (ICU or Intermediate Care)

For severe pneumonia requiring ICU admission, immediate parenteral broad-spectrum combination therapy is mandatory 1, 2:

Without Pseudomonas Risk Factors:

• Non-antipseudomonal cephalosporin III (ceftriaxone/cefotaxime) + macrolide 1
• OR moxifloxacin or levofloxacin ± non-antipseudomonal cephalosporin III 1

With Pseudomonas Risk Factors:

• Antipseudomonal beta-lactam (cefepime, piperacillin-tazobactam, or meropenem up to 6g daily) 1

• PLUS ciprofloxacin 1

• OR PLUS macrolide + aminoglycoside (gentamicin, tobramycin, or amikacin) 1

• Treatment duration: 10-14 days for severe cases 2

• Extended treatment to 14-21 days may be required for Legionella, staphylococcal, or Gram-negative enteric bacilli infections 5

Transition to Oral Therapy

Switch from intravenous to oral therapy when the patient is hemodynamically stable, clinically improving, and has been afebrile for 24-48 hours 2, 5:

• Use the same antibiotic class when possible (sequential therapy) 1
• Minimum treatment duration should be 5 days total 2
• Patient should be afebrile for 48-72 hours before discontinuation 2, 5

Management of Treatment Failure

If the patient is not responding after 48-72 hours 5:

• For non-severe pneumonia on amoxicillin monotherapy: Add or substitute a macrolide to cover atypical pathogens (Mycoplasma, Chlamydophila, Legionella) 5
• For non-severe pneumonia on combination therapy: Switch to a respiratory fluoroquinolone (levofloxacin 500-750 mg daily) 5
• For severe pneumonia not responding to combination therapy: Consider adding rifampicin to the existing regimen 5
• Obtain repeat chest radiograph, CRP, white cell count, and additional microbiological specimens 5

Pathogen-Specific Considerations

Atypical Pathogens (Mycoplasma, Chlamydophila, Legionella):

• Macrolides (azithromycin preferred for Legionella) 1, 6
• Respiratory fluoroquinolones (levofloxacin or moxifloxacin, with most data available for levofloxacin in Legionella) 1, 4
• Doxycycline for Chlamydophila and Coxiella 1, 6
• For severe Legionella: Consider adding rifampicin to macrolide 1

Multi-Drug Resistant Streptococcus pneumoniae (MDRSP):

• Levofloxacin has demonstrated effectiveness against macrolide-resistant S. pneumoniae 4, 3
• Use 7-14 day treatment regimen for MDRSP 4

Critical Monitoring Parameters

Monitor response using 2:

• Body temperature (should normalize within 48-72 hours)
• Respiratory parameters (rate, oxygen saturation)
• Hemodynamic parameters (blood pressure, heart rate)
• C-reactive protein on days 1 and 3-4, especially in patients with unfavorable clinical parameters

Common Pitfalls to Avoid

• Do not delay antibiotic administration while awaiting diagnostic test results; empiric therapy should begin immediately 1, 2
• Do not continue the same antibiotic regimen without reassessment if the patient fails to improve by 48-72 hours 5
• Do not use azithromycin in patients with QT prolongation, bradyarrhythmias, or those on QT-prolonging medications due to risk of torsades de pointes 7
• Do not use fluoroquinolones as first-line in outpatients without comorbidities to preserve their effectiveness and minimize resistance 2, 3
• Do not overlook the possibility of Pseudomonas in patients with structural lung disease, recent hospitalization, or prior broad-spectrum antibiotic use 1

Duration Optimization

Treatment duration should generally not exceed 8 days in a responding patient 1:

• Biomarkers, particularly procalcitonin (PCT), may guide shorter treatment duration 1
• Uncomplicated community-managed cases: 5-7 days 2
• Non-severe hospitalized cases: 7-10 days 2
• Severe cases: 10-14 days 2
• Complicated infections (Legionella, Staphylococcus, Gram-negative bacilli): 14-21 days 5