What is the recommended treatment for pneumonia?

Pneumonia Treatment

For non-severe community-acquired pneumonia in outpatients, amoxicillin monotherapy is the preferred first-line treatment, with a duration of 5-7 days for uncomplicated cases. 1, 2

Outpatient Treatment (Non-Severe CAP)

First-Line Therapy

• Amoxicillin monotherapy is the preferred agent for patients without penicillin allergy who can be managed in the community 1, 2
• Treatment duration: 5-7 days for uncomplicated cases 1, 2

Alternative Agents (Penicillin Allergy or Comorbidities)

• Macrolides (azithromycin or clarithromycin preferred over erythromycin) for penicillin-allergic patients 1, 2
  • Azithromycin dosing: 500 mg on Day 1, then 250 mg daily on Days 2-5 3
• Doxycycline as an alternative option 2
• Respiratory fluoroquinolones (levofloxacin 500-750 mg daily or moxifloxacin) for patients with comorbidities or recent antibiotic use 2, 4

Inpatient Treatment (Severe CAP)

Immediate Management

• Immediate parenteral antibiotic administration is required for severe pneumonia 1
• Combination therapy with an intravenous broad-spectrum β-lactam plus a macrolide is preferred 1, 2

Treatment Duration

• 10-14 days for severe cases 1, 2
• Extended treatment to 14-21 days may be required for Legionella, staphylococcal, or Gram-negative enteric bacilli infections 2, 5

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 regimen 2, 5
• For non-severe pneumonia on amoxicillin monotherapy: add or substitute a macrolide to cover atypical pathogens (Mycoplasma, Chlamydophila, Legionella) 2, 5
• For non-severe pneumonia on combination therapy: switch to a respiratory fluoroquinolone (levofloxacin 500-750 mg daily) 5
• For severe pneumonia not responding: consider adding rifampicin to the existing combination 5

Pathogen-Specific Considerations

Atypical Pathogens

• For Mycoplasma, Chlamydophila, or Legionella: macrolides (azithromycin preferred for Legionella) or respiratory fluoroquinolones 2
• For severe Legionella: add rifampicin to the macrolide regimen 2

Drug-Resistant Streptococcus pneumoniae

• Levofloxacin is effective for macrolide-resistant S. pneumoniae 4, 6
• Respiratory fluoroquinolones maintain high clinical success rates (>90%) against S. pneumoniae 6

Monitoring Response

Clinical Parameters to Track

• Body temperature (patient should be afebrile for 48-72 hours before discontinuation) 1, 2
• Respiratory parameters (rate, oxygen saturation) 1, 2
• Hemodynamic parameters (blood pressure, heart rate) 1, 2
• C-reactive protein on days 1 and 3-4, especially in patients with unfavorable clinical parameters 1, 2

Critical Pitfalls to Avoid

• Do not delay antibiotic administration while awaiting diagnostic test results; begin empiric therapy immediately 2
• Do not continue the same regimen without reassessment if the patient fails to improve by 48-72 hours 2, 5
• Do not use azithromycin in patients with pneumonia who are judged inappropriate for oral therapy due to moderate-to-severe illness, hospitalization requirements, bacteremia, or significant comorbidities 3
• Consider QT prolongation risk with macrolides (especially azithromycin) in patients with known QT prolongation, bradyarrhythmias, electrolyte abnormalities, or concurrent QT-prolonging medications 3
• Treatment duration should generally not exceed 8 days in a responding patient 2

Prevention

• Influenza vaccination for elderly patients and those at high risk 1
• Pneumococcal vaccination for all those aged 2 years or older at increased risk 1