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, while hospitalized patients with severe pneumonia should receive intravenous combination therapy with a β-lactam (co-amoxiclav, cefuroxime, or ceftriaxone) plus azithromycin. 1

Outpatient Management (Mild Pneumonia)

• Oral amoxicillin is the preferred first-line agent targeting Streptococcus pneumoniae, the most common pathogen in community-acquired pneumonia during pregnancy 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 pregnancy 1

Inpatient Management (Severe Pneumonia)

• Initiate intravenous combination therapy immediately with a broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, or ceftriaxone) plus a macrolide 1
• Azithromycin is the recommended macrolide in pregnancy rather than clarithromycin, as clarithromycin should be avoided due to increased birth defects and spontaneous abortion risk 1
• For severe pneumonia, extend treatment duration to 10 days, or 14-21 days if legionella, staphylococcal, or gram-negative enteric bacilli are suspected 1, 2

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, 3
• This transition should be reviewed daily to avoid unnecessary parenteral therapy 3

Antibiotics to Avoid in Pregnancy

• Tetracyclines (including doxycycline) are contraindicated due to increased hepatotoxicity and staining of fetal teeth and bones 1, 4
• Aminoglycosides should not be prescribed due to nephrotoxicity and ototoxicity, except in life-threatening infections with gram-negative pathogens when other antibiotics have failed 4
• Clarithromycin should be avoided as first-line therapy due to teratogenic concerns 1

Fluoroquinolone Considerations

• Fluoroquinolones can be used for serious respiratory infections when indicated, despite theoretical concerns about arthropathy, as approximately 400 human pregnancy exposures have shown no increased birth defects or arthropathy 1
• However, they should generally be avoided unless benefits outweigh risks 1

Management of Treatment Failure

• If no improvement occurs after 48-72 hours, conduct a 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

Critical Pregnancy-Specific Monitoring

• Monitor pregnant women with pneumonia after 20 weeks of gestation for evidence of contractions, as rates of preterm labor and preterm delivery are significantly increased 1
• Pneumonia is the most common fatal non-obstetrical infection in pregnancy and is associated with poorer maternal and fetal outcomes 5

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 vaccine can be administered during pregnancy with no adverse consequences reported, though it is not routinely recommended 1

Common Pitfalls to Avoid

• Never delay antibiotic administration, as prompt treatment is essential to reduce maternal and fetal complications 1, 2
• Do not rely solely on clinical criteria without obtaining cultures when feasible, as this leads to overtreatment 2
• Avoid using the same antibiotic class the patient recently received, as this increases the risk of treatment failure 2