From the Guidelines
Community-acquired pneumonia (CAP) treatment should be guided by the most recent and highest quality evidence, which recommends a minimum of 5 days of antibiotics, with extension of therapy guided by validated measures of clinical stability 1.
Treatment Approach
For outpatient treatment of mild to moderate CAP, the following antibiotics are recommended:
- Amoxicillin 1g three times daily for 5-7 days as first-line therapy
- Alternatives include doxycycline 100mg twice daily or azithromycin 500mg on day one followed by 250mg daily for 4 more days For patients with comorbidities or risk factors for drug-resistant pathogens:
- Amoxicillin-clavulanate 875/125mg twice daily or a respiratory fluoroquinolone like levofloxacin 750mg daily for 5-7 days may be used
Hospitalized Patients
Severe CAP requiring hospitalization typically needs intravenous therapy with:
- A beta-lactam (ceftriaxone 1-2g daily or ampicillin-sulbactam 1.5-3g every 6 hours) plus a macrolide
- Or monotherapy with a respiratory fluoroquinolone
Key Considerations
- Treatment duration is generally 5-7 days for most patients, with longer courses sometimes needed for complicated cases
- Supportive care including adequate hydration, fever control, and oxygen supplementation if needed is essential
- Clinical improvement should occur within 48-72 hours; lack of improvement warrants reassessment for complications, resistant organisms, or alternative diagnoses According to the 2019 American Thoracic Society and Infectious Diseases Society of America guideline, initial treatment strategies for inpatients with community-acquired pneumonia should be based on the level of severity and risk for drug resistance 1.
From the FDA Drug Label
Clinical success rates (cure plus improvement) in the clinically evaluable population were 90.9% in the levofloxacin 750 mg group and 91.1% in the levofloxacin 500 mg group. Clinical success (cure plus improvement) with levofloxacin at 5 to 7 days posttherapy, the primary efficacy variable in this study, was superior (95%) to the control group (83%). For both studies, the clinical success rate in patients with atypical pneumonia due to Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila were 96%, 96%, and 70%, respectively.
The treatment of community-acquired pneumonia with levofloxacin has been shown to be effective, with clinical success rates ranging from 90.9% to 95% in different studies 2. The recommended treatment duration is 7 to 14 days, but a 5-day treatment regimen with a higher dose of levofloxacin (750 mg) has also been shown to be effective.
- Key points:
- Levofloxacin is effective against community-acquired pneumonia, including cases caused by atypical pathogens.
- Clinical success rates are high, ranging from 90.9% to 95%.
- The recommended treatment duration is 7 to 14 days, but a 5-day regimen with a higher dose may also be effective.
From the Research
Treatment Options for Community-Acquired Pneumonia (CAP)
- The treatment of CAP often involves empirical antibiotic therapy, covering both typical and atypical pathogens 3.
- Beta-lactams have been considered standard therapy for CAP, but rising resistance rates are a concern 3.
- For patients with comorbidities or recent antibiotic therapy, combination therapy with a beta-lactam and a macrolide or an antipneumococcal fluoroquinolone alone is recommended 3.
- Fluoroquinolones, such as moxifloxacin, gatifloxacin, and levofloxacin, have shown high clinical success rates (> 90%) in treating CAP due to S pneumoniae 3.
Comparison of Antibiotic Regimens
- A study comparing levofloxacin with ceftriaxone and azithromycin for treating CAP found that levofloxacin improved patients' signs and symptoms and reduced hospitalization length, with similar side effects 4.
- The Infectious Diseases Society of America (IDSA) guidelines recommend initial empiric antimicrobial therapy, with macrolides, doxycycline, and fluoroquinolones suggested for primary empiric therapy 5.
Considerations for Specific Patient Populations
- For immunocompromised patients with suspected CAP, a consensus statement provides general suggestions for initial treatment, including defining the population, site of care, likely pathogens, microbiologic workup, and empirical therapy for specific pathogens 6.
- The use of penicillins for treatment of pneumococcal pneumonia is still recommended, as in vitro resistance may not have direct clinical implications 7.