What is the recommended treatment for pneumonia?

Pneumonia Treatment

For non-severe community-acquired pneumonia in outpatients, start amoxicillin monotherapy immediately; for penicillin-allergic patients use a macrolide (azithromycin or clarithromycin); for severe pneumonia requiring hospitalization, initiate intravenous combination therapy with a broad-spectrum beta-lactam plus a macrolide. 1, 2

Outpatient Treatment (Non-Severe CAP)

First-Line Therapy

• Amoxicillin monotherapy is the preferred agent for previously healthy patients without recent antibiotic exposure who can be managed in the community 1, 2
• Treatment duration should be 5-7 days for uncomplicated cases 1, 2
• Oral therapy is appropriate from the beginning for ambulatory patients 1

Penicillin-Allergic Patients

• Macrolides are the recommended alternative: azithromycin or clarithromycin preferred over erythromycin 1, 2
• Alternative options include doxycycline or a respiratory fluoroquinolone (levofloxacin 500-750 mg daily or moxifloxacin) 2
• Important caveat: Azithromycin carries risks of QT prolongation, torsades de pointes, and hepatotoxicity; avoid in patients with known QT prolongation, bradyarrhythmias, uncorrected electrolyte abnormalities, or concurrent use of QT-prolonging drugs 3

Inpatient Treatment (Severe CAP)

Initial Therapy

• Immediate parenteral antibiotic administration is required for severe pneumonia 1
• Intravenous combination of a broad-spectrum beta-lactam plus a macrolide is the preferred regimen 1, 2
• Treatment duration is 10-14 days for severe cases 1, 2

Transition to Oral Therapy

• Switch from IV to oral when the patient is hemodynamically stable, clinically improving, and afebrile for 24-48 hours 1, 2
• Use the same antibiotic class when possible (sequential therapy) 2

Treatment Failure Management

When to Reassess (48-72 Hours)

• If no clinical improvement after 48-72 hours, reassess and adjust the treatment regimen 2, 4
• For non-severe pneumonia on amoxicillin monotherapy, add or substitute a macrolide to cover atypical pathogens (Mycoplasma, Chlamydophila, Legionella) 2, 4
• For non-severe pneumonia already on combination therapy, switch to a respiratory fluoroquinolone (levofloxacin 500-750 mg daily) 4
• For severe pneumonia not responding to combination therapy, consider adding rifampicin 4

Extended Duration Pathogens

• Legionella, staphylococcal, or Gram-negative enteric bacilli infections may require 14-21 days of treatment 2, 4
• For severe Legionella, rifampicin should be added to the macrolide regimen 2

Monitoring Response

Clinical Parameters

• Monitor body temperature, respiratory parameters, and hemodynamic parameters 1, 2
• C-reactive protein should be measured on days 1 and 3-4, especially in patients with unfavorable clinical parameters 1
• Patient should be afebrile for 48-72 hours before discontinuation of antibiotics 1, 4

Critical Pitfalls to Avoid

Timing and Selection

• Do not delay antibiotic administration while awaiting diagnostic test results; empiric therapy must begin immediately as early administration directly impacts mortality and morbidity 2
• Do not continue the same antibiotic regimen without reassessment if the patient fails to improve by 48-72 hours 2, 4
• Treatment duration should generally not exceed 8 days in a responding patient 2

Special Populations

• Azithromycin should not be used in patients with pneumonia requiring hospitalization, elderly or debilitated patients, those with cystic fibrosis, nosocomially acquired infections, known/suspected bacteremia, or significant underlying health problems 3
• Elderly patients may be more susceptible to drug-associated QT interval effects with macrolides 3

Prevention

• Influenza vaccination is recommended for elderly patients and those at high risk 1
• Pneumococcal vaccination is recommended for all those aged 2 years or older in whom pneumococcal infection is likely to be more common or serious 1