What are the recommended treatment guidelines for pneumonia in the Philippines?

Philippine Guidelines for Pneumonia Treatment

Empirical Antibiotic Selection

For community-acquired pneumonia in the Philippines, use amoxicillin 90 mg/kg/day divided into three doses as first-line therapy for outpatients and non-severe hospitalized cases, with macrolide addition (azithromycin or clarithromycin) for hospitalized patients or those not responding after 48-72 hours. 1, 2

Outpatient Management (Non-Severe CAP)

• First-line: Amoxicillin 500 mg every 8 hours or 875 mg every 12 hours for adults 1, 3

  • Higher doses (90 mg/kg/day in children, up to 4 grams daily in adults) are recommended to cover penicillin-resistant Streptococcus pneumoniae 1

• Penicillin-allergic patients: Macrolide monotherapy (azithromycin 500 mg day 1, then 250 mg days 2-5; or clarithromycin) 1, 4

  • Alternative: Doxycycline 200 mg daily or respiratory fluoroquinolone (levofloxacin 500-750 mg daily or moxifloxacin) 1

Hospitalized Patients (Non-Severe CAP)

• Preferred regimen: Combination therapy with oral amoxicillin PLUS a macrolide (azithromycin or clarithromycin preferred over erythromycin) 1, 2

  • This dual coverage addresses both typical bacterial pathogens (S. pneumoniae) and atypical organisms (Mycoplasma, Chlamydophila, Legionella) 1, 5

• Alternative: Respiratory fluoroquinolone monotherapy (levofloxacin 750 mg daily or moxifloxacin) 1

• Most hospitalized patients can be treated with oral antibiotics from the start if no contraindications exist 1

Severe CAP (ICU or Intermediate Care)

Without Pseudomonas risk factors:

• Ceftriaxone 1-2 grams IV every 12-24 hours OR cefotaxime PLUS azithromycin 1
• Alternative: Moxifloxacin or levofloxacin 750 mg daily ± non-antipseudomonal cephalosporin 1

With Pseudomonas risk factors:

• Antipseudomonal beta-lactam (cefepime, ceftazidime, piperacillin-tazobactam, or meropenem) PLUS ciprofloxacin 1
• OR antipseudomonal beta-lactam PLUS macrolide PLUS aminoglycoside (gentamicin, tobramycin, or amikacin) 1

Treatment Duration

Standard duration is 5-7 days for uncomplicated cases showing clinical improvement, with treatment not exceeding 8 days in responding patients. 1, 2, 6, 7

• Non-severe CAP stabilized at day 3: 3 days of antibiotics 7
• Non-severe CAP stabilized at day 5: 5 days of antibiotics 2, 7
• Uncomplicated CAP: 7 days maximum 1, 6
• Severe CAP: 10 days 8, 2
• Extended duration (14-21 days): Required only for Legionella, staphylococcal, or Gram-negative enteric bacilli infections 8, 2

The patient must be afebrile for 48-72 hours before discontinuing antibiotics 8, 2

Route of Administration and IV-to-Oral Switch

• Oral therapy is appropriate from the start for outpatients and carefully selected hospitalized patients 1

• Switch from IV to oral when: Patient is hemodynamically stable, clinically improving, able to take oral medications, and afebrile for 24 hours 1, 2

  • Use the same antibiotic class when possible (sequential therapy) 1, 2
  • Most patients do not require continued hospitalization after switching to oral therapy 1

Management of Treatment Failure

If no clinical improvement after 48-72 hours, reassess immediately and modify therapy. 1, 8, 2

• For amoxicillin monotherapy failures: Add or substitute a macrolide to cover atypical pathogens 1, 8, 2

• For combination therapy failures: Switch to respiratory fluoroquinolone (levofloxacin 500-750 mg daily) 1, 8

• For severe pneumonia not responding: Consider adding rifampicin to existing combination regimen 1, 8

• Obtain repeat investigations: chest radiograph, C-reactive protein, white cell count, and additional microbiological specimens (sputum culture, blood cultures, urinary antigens for Legionella and S. pneumoniae) 1, 8

Pathogen-Specific Considerations

Atypical Pathogens (Mycoplasma, Chlamydophila, Legionella)

• First-line: Macrolides (azithromycin preferred for Legionella) or respiratory fluoroquinolones 1, 5
• Severe Legionella: Add rifampicin to macrolide regimen 1, 2
• Doxycycline 200 mg daily is an alternative for Mycoplasma and Chlamydophila 1, 5

Pneumococcal Pneumonia

• Beta-lactams (amoxicillin, ceftriaxone, cefotaxime) remain drugs of choice despite resistance concerns 1
• Macrolides and doxycycline have unpredictable activity against penicillin-resistant strains 1

Aspiration Pneumonia

• Hospital ward (from home): Beta-lactam/beta-lactamase inhibitor (amoxicillin-clavulanate or ampicillin-sulbactam) OR moxifloxacin 1
• ICU or nursing home: Clindamycin PLUS cephalosporin 1

Monitoring and Follow-Up

• Monitor temperature, respiratory rate, pulse, blood pressure, mental status, and oxygen saturation at least twice daily initially 1

• Measure C-reactive protein on days 1 and 3-4, especially in patients with unfavorable clinical parameters 1

• Clinical review at 6 weeks with repeat chest radiograph for patients with persistent symptoms, physical signs, or high malignancy risk (smokers over 50 years) 1, 8

• Chest radiograph need not be repeated before hospital discharge in patients with satisfactory clinical recovery 1

Common Pitfalls to Avoid

• Do not delay antibiotic administration while awaiting diagnostic results; empiric therapy must begin immediately as early treatment directly impacts mortality 2

• Do not continue the same regimen without reassessment if the patient fails to improve by 48-72 hours 8, 2

• Do not use cefuroxime or other second-generation cephalosporins as monotherapy; they have unpredictable activity against resistant pneumococci 1

• Do not overlook atypical pathogens in patients over 5 years old or those not responding to beta-lactam monotherapy 1, 2, 5

• Do not routinely use steroids for pneumonia treatment; they are not recommended 1

Additional Supportive Care

• Ensure adequate oxygenation with target PaO₂ >8 kPa and SaO₂ >92% 1
• Assess for volume depletion and provide IV fluids as needed 1
• Administer low molecular weight heparin in patients with acute respiratory failure 1
• Implement early mobilization for all patients 1