Treatment of Community-Acquired Pneumonia in Pregnancy
Pregnant women with community-acquired pneumonia should be treated with beta-lactam antibiotics (amoxicillin or ceftriaxone) combined with azithromycin, as these agents are safe in pregnancy and provide coverage for both typical and atypical pathogens. 1, 2
Outpatient Management
- For mild CAP in pregnancy managed as an outpatient, oral amoxicillin 500 mg three times daily (or high-dose amoxicillin 1 gram three times daily) combined with azithromycin 500 mg on day 1, followed by 250 mg daily for days 2-5 is recommended 3, 4, 1
- Azithromycin is FDA pregnancy category B and has been extensively studied in pregnancy with no evidence of teratogenicity 4, 5
- Beta-lactam antibiotics including amoxicillin and amoxicillin-clavulanate are considered safe throughout pregnancy 1, 2
Inpatient Management
- Hospitalized pregnant women with CAP should receive intravenous ceftriaxone (1-2 grams daily) or cefotaxime (1-2 grams every 8 hours) combined with azithromycin 500 mg intravenously daily 3, 6, 2
- This combination provides coverage for Streptococcus pneumoniae (the most common bacterial pathogen, identified in 15-20% of pregnancy CAP cases), Haemophilus influenzae, and atypical organisms including Mycoplasma pneumoniae and Chlamydia pneumoniae 1, 2
- For severe CAP requiring ICU admission, the same beta-lactam/macrolide combination should be used, with consideration of adding vancomycin if methicillin-resistant Staphylococcus aureus is suspected 3
Treatment Duration and Monitoring
- The minimum treatment duration is 5 days for azithromycin-based regimens, with patients requiring clinical stability (afebrile for 48-72 hours with no more than one sign of clinical instability) before discontinuation 3, 4
- For beta-lactam therapy, 7-10 days of treatment is standard 3
- Patients should demonstrate clinical improvement within 48-72 hours of initiating appropriate therapy 3, 7
Critical Pregnancy-Specific Considerations
Avoid fluoroquinolones (levofloxacin, moxifloxacin) in pregnancy due to potential effects on fetal cartilage development, despite their effectiveness for CAP in non-pregnant adults 3, 1
- Doxycycline should be avoided after the first trimester due to effects on fetal bone and teeth development 3, 1
- Pregnant women have reduced tolerance to hypoxemia due to physiological adaptations, requiring aggressive oxygen supplementation to maintain SpO2 >95% 8, 1
- Viral pneumonias (influenza, varicella, COVID-19) carry heightened severity in pregnancy and require specific antiviral therapy when identified 8, 1, 2
Testing and Diagnosis
- All pregnant women with suspected CAP should be tested for influenza and COVID-19 when these viruses are circulating in the community, as positive results alter management with antiviral therapy 6, 2
- Chest radiography should be performed with abdominal shielding when CAP is suspected, as the fetal radiation exposure is minimal (0.00005-0.00007 Gy) and the diagnostic benefit outweighs theoretical risks 8, 1
Prevention Strategies
- Pneumococcal vaccination (PPSV23 or PCV13) is recommended for pregnant women with risk factors including asthma, chronic lung disease, or immunosuppression 3, 1
- Influenza vaccination is strongly recommended for all pregnant women during influenza season, as it reduces respiratory hospitalizations and protects both mother and infant 1, 2
- COVID-19 vaccination is recommended during pregnancy to prevent severe pneumonia 8
Common Pitfalls to Avoid
- Do not delay antibiotic therapy while awaiting microbiological results, as only 40-60% of CAP cases in pregnancy have an identified pathogen 1, 2
- Do not use fluoroquinolone monotherapy despite its effectiveness in non-pregnant adults with severe CAP 3, 1
- Do not underestimate disease severity—pneumonia complicates 0.5-1.5 per 1,000 pregnancies and can lead to preterm delivery, low birth weight, and maternal respiratory failure 8, 1
- Coexisting asthma and anemia are significant risk factors that increase pneumonia risk and severity in pregnancy 8, 1