What is the recommended treatment for pneumonia?

Pneumonia Treatment

Treatment Selection Based on Patient Population and Setting

For community-acquired pneumonia (CAP), treatment should be stratified by age, severity, and care setting, with beta-lactams forming the backbone of therapy for bacterial pneumonia and macrolides added for atypical coverage.

Pediatric Patients (Outpatient)

Children under 5 years with presumed bacterial CAP should receive oral amoxicillin 90 mg/kg/day in 2 divided doses as first-line therapy. 1

• For children ≥5 years old, oral amoxicillin (90 mg/kg/day in 2 doses, maximum 4 g/day) remains the preferred agent 1
• When clinical features do not clearly distinguish bacterial from atypical CAP, add a macrolide to the beta-lactam 1
• For atypical pneumonia (suspected Mycoplasma or Chlamydophila), use azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 (maximum 500 mg day 1, then 250 mg days 2-5) 1
• Alternative macrolides include clarithromycin (15 mg/kg/day in 2 doses, maximum 1 g/day) or erythromycin (40 mg/kg/day in 4 doses) 1
• Treatment duration is typically 5-7 days for uncomplicated cases 1, 2

Pediatric Patients (Inpatient)

Hospitalized children who are fully immunized should receive ampicillin or penicillin G as first-line therapy; add vancomycin or clindamycin if community-acquired MRSA is suspected. 1

• For children not fully immunized or in areas with significant penicillin resistance, use ceftriaxone or cefotaxime 1
• Add azithromycin to the beta-lactam if atypical pneumonia diagnosis is uncertain 1
• Alternative macrolides include clarithromycin, erythromycin, or doxycycline for children >7 years 1

Adult Patients (Outpatient)

Adults with mild-to-moderate CAP should receive oral amoxicillin combined with a macrolide for 7 days in uncomplicated cases. 1, 3

• Oral treatment can be initiated from the beginning in ambulatory pneumonia 1
• Azithromycin or clarithromycin are preferred over erythromycin due to better tolerability and improved compliance with once or twice daily dosing 3
• High-dose amoxicillin dosing is necessary to cover drug-resistant Streptococcus pneumoniae 3
• Alternative: amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses, maximum 4000 mg/day) for enhanced coverage against beta-lactamase-producing organisms 1, 3

Adult Patients (Hospitalized, Non-Severe)

Hospitalized adults without risk factors for Pseudomonas aeruginosa should receive a non-antipseudomonal third-generation cephalosporin plus a macrolide, OR moxifloxacin or levofloxacin with or without a cephalosporin. 1

• Beta-lactam/beta-lactamase inhibitor combinations are acceptable alternatives 1
• Sequential therapy (IV to oral) should be considered in all patients except the most severely ill 1
• Switch to oral treatment when clinical stability is achieved, guided by resolution of prominent clinical features 1
• Treatment duration should generally not exceed 8 days in a responding patient 1

Adult Patients (Severe CAP/ICU)

Patients with severe pneumonia requiring ICU admission without Pseudomonas risk factors should receive a non-antipseudomonal third-generation cephalosporin plus a macrolide, OR a respiratory fluoroquinolone (moxifloxacin or levofloxacin 750 mg/24h). 1

For patients with risk factors for Pseudomonas aeruginosa, use an antipseudomonal cephalosporin OR acylureidopenicillin/beta-lactamase inhibitor OR carbapenem (meropenem preferred) PLUS ciprofloxacin OR PLUS macrolide plus aminoglycoside (gentamicin, tobramycin, or amikacin). 1

• Immediate parenteral antibiotic treatment is essential for severe cases 3
• Treatment duration is 10-14 days for severe cases 3
• Levofloxacin 750 mg/24h or 500 mg twice daily is an alternative that also covers Gram-positive bacteria 1
• Ceftazidime must be combined with penicillin G for adequate S. pneumoniae coverage 1

Special Populations: Pregnant Women

Pregnant women with non-severe pneumonia should receive combined oral therapy with amoxicillin and a macrolide for 7 days. 3

• For severe pneumonia, immediate parenteral antibiotics are required using a broad-spectrum beta-lactamase stable antibiotic plus a macrolide for 10 days 3
• Fluoroquinolones should be avoided during pregnancy unless benefits outweigh risks 3
• Switch to oral regimens once clinical improvement occurs 3

Aspiration Pneumonia

For aspiration pneumonia in patients admitted from home to a hospital ward, use oral or IV beta-lactam/beta-lactamase inhibitor, OR clindamycin, OR IV cephalosporin plus oral metronidazole, OR moxifloxacin. 1

• For ICU patients or those admitted from nursing homes, use clindamycin plus cephalosporin 1

Influenza Pneumonia

Children and adults with presumed influenza pneumonia should receive oseltamivir; zanamivir is an alternative for children ≥7 years old. 1

Treatment Duration and Monitoring

Treatment duration should generally not exceed 8 days in responding patients, with biomarkers like procalcitonin potentially guiding shorter courses. 1

• For uncomplicated cases: 5-7 days 1, 3
• For severe cases: 10-14 days 3
• Monitor response using clinical criteria including body temperature, respiratory parameters, and hemodynamic stability 1
• C-reactive protein should be measured on days 1 and 3-4, especially in patients with unfavorable clinical parameters 1

Management of Treatment Failure

For patients failing to improve on amoxicillin monotherapy, add or substitute a macrolide to cover atypical pathogens. 3

• Non-responding pneumonia in the first 72 hours is usually due to antimicrobial resistance, unusually virulent organisms, host defense defects, or wrong diagnosis 1
• Non-response after 72 hours is usually due to complications 1
• In unstable patients, perform full reinvestigation followed by a second empirical antimicrobial regimen 1
• Order repeat chest radiograph, CRP, white cell count, and additional microbiological specimens 3

Common Pitfalls and Caveats

• Avoid fluoroquinolones in children unless they have reached growth maturity or cannot tolerate macrolides due to risk of cartilage growth abnormalities 1
• Do not use doxycycline in children <7 years old due to tooth discoloration risk 1
• Azithromycin carries risks of QT prolongation and should be used cautiously in patients with known QT prolongation, bradyarrhythmias, or on QT-prolonging medications 4
• For bacteremic pneumococcal pneumonia, exercise particular caution in selecting alternatives to amoxicillin given potential for secondary sites of infection including meningitis 1
• Steroids are not recommended in the treatment of pneumonia 1