What is the treatment for bronchopneumonia?

Treatment of Bronchopneumonia

For community-acquired bronchopneumonia in adults without risk factors, oral amoxicillin 3 g/day (or 80-100 mg/kg/day in children under 30 kg) is the first-line treatment, as Streptococcus pneumoniae remains the most common pathogen and amoxicillin provides optimal coverage with proven efficacy. 1

Initial Treatment Selection Based on Age and Setting

Children Under 3 Years

• Amoxicillin 80-100 mg/kg/day divided into three daily doses is the reference treatment for pneumococcal pneumonia, which is the most frequent bacterial cause in this age group 1
• Treatment duration should be 10 days for pneumococcal pneumonia 1
• In cases of known beta-lactam allergy, hospitalization is preferable for appropriate parenteral therapy 1
• Do NOT use first, second, or third generation cephalosporins, trimethoprim-sulfamethoxazole, tetracyclines, or pristinamycin as first-line agents 1

Children Over 3 Years

• If clinical and radiological findings suggest pneumococcal infection: use amoxicillin as described above 1
• If findings suggest atypical bacteria (Mycoplasma pneumoniae or Chlamydia pneumoniae): macrolide therapy is reasonable as first-line treatment 1
• Treat atypical pneumonia for at least 14 days with macrolides 1

Adults Without Risk Factors (Outpatient or Non-Severe Hospital Cases)

Two evidence-based options exist:

• Oral amoxicillin 3 g/day for suspected pneumococcal origin, especially in adults over 40 years with or without underlying disease 1
• Oral macrolides (clarithromycin or erythromycin preferred over older macrolides) for pneumonia due to atypical bacteria in adults under 40 years without underlying disease, particularly in epidemic contexts 1
• Telithromycin represents an alternative to these two first-line therapies 1

Treatment duration: 7 days for uncomplicated cases 1

Adults With Risk Factors

• Treatment must account for the specific risk factors, patient condition, and potential pathogens while still considering pneumococcal origin 1
• Broader spectrum options include:
  • Amoxicillin-clavulanate 1
  • Parenteral 2nd or 3rd generation cephalosporin 1
  • Fluoroquinolone with enhanced S. pneumoniae activity (levofloxacin or moxifloxacin) 1

Severe Bronchopneumonia Requiring Hospitalization

Non-ICU Hospitalized Patients

Combination therapy is strongly recommended:

• Beta-lactam (ceftriaxone 1-2 g IV daily, cefotaxime, or ampicillin-sulbactam) PLUS macrolide (azithromycin 500 mg IV daily preferred) 1, 2
• Alternative: Respiratory fluoroquinolone monotherapy (levofloxacin 750 mg IV daily or moxifloxacin 400 mg IV daily) 1, 2

ICU-Level Severe Pneumonia

Escalate to intensive combination therapy:

• Non-antipseudomonal cephalosporin III (ceftriaxone 2 g IV daily or cefotaxime 1-2 g IV q8h) PLUS macrolide 1, 2
• OR moxifloxacin/levofloxacin ± non-antipseudomonal cephalosporin III 1

If Pseudomonas aeruginosa risk factors present:

• Antipseudomonal cephalosporin OR acylureidopenicillin/beta-lactamase inhibitor OR carbapenem (meropenem preferred) 1
• PLUS ciprofloxacin 1
• OR PLUS macrolide + aminoglycoside (gentamicin, tobramycin, or amikacin) 1

Critical Management Principles

Timing and Administration

• Administer first antibiotic dose immediately upon diagnosis—delays increase mortality in high-risk patients 2
• Obtain blood and sputum cultures before initiating antibiotics in all hospitalized patients 2
• Switch from IV to oral therapy when: hemodynamically stable, clinically improving, afebrile for 24-48 hours, able to take oral medications, and normal GI function 1, 2

Treatment Duration

• Standard CAP: 5-7 days once clinically stable 1, 2
• Pneumococcal pneumonia: 7-10 days 1
• Atypical pneumonia: minimum 14 days 1
• Extend to 14-21 days if: Legionella, Staphylococcus aureus, or gram-negative enteric bacilli confirmed 1, 2

Response Assessment

• Assess therapeutic efficacy after 2-3 days of treatment (or earlier if clinically serious) 1
• Primary criterion is fever resolution—apyrexia often achieved in <24 hours for pneumococcal pneumonia, but may require 2-4 days for other etiologies 1
• Do not change treatment within first 72 hours unless clinical worsening occurs 1
• Cough may persist longer than fever 1

Common Pitfalls to Avoid

• Avoid combination therapy with aminopenicillin + beta-lactamase inhibitor unless specific indications exist (children <5 years with inadequate H. influenzae type b vaccination or coexisting purulent acute otitis media) 1
• Do not use trimethoprim-sulfamethoxazole, tetracyclines, or first-generation oral cephalosporins due to inadequate activity against penicillin-resistant S. pneumoniae 1
• Avoid systematic use of beta-lactams alone in areas with high S. pneumoniae resistance unless local patterns support this 1
• Never prescribe antibiotics for acute bronchitis in healthy adults—there is no evidence that antibiotic therapy prevents superinfection 1

Special Considerations for Aspiration Pneumonia

Hospital ward patients admitted from home:

• Oral or IV beta-lactam/beta-lactamase inhibitor 1
• OR clindamycin 1
• OR IV cephalosporin + oral metronidazole 1
• OR moxifloxacin 1

ICU or nursing home-acquired:

• Clindamycin + cephalosporin 1