What are the characteristics and treatment options for pneumonia?

Hospitalization Criteria for Pneumonia

Patients with pneumonia should be hospitalized when they have moderate to severe disease based on severity assessment tools, with immediate initiation of empirical antibiotics as soon as the diagnosis is made. 1

Severity Assessment and Treatment Setting Decision

The decision to hospitalize depends on severity stratification, which directly determines the most appropriate treatment setting (ambulatory, hospital ward, or ICU). 1

Key factors indicating need for hospitalization include:

• Moderate to severe pneumonia based on clinical severity scoring 1
• Inability to take oral medications safely 1
• Septic shock or severe sepsis at presentation 1
• Acute respiratory failure requiring supplemental oxygen 1
• Significant underlying health problems that compromise ability to respond to illness, including immunodeficiency or functional asplenia 2
• Elderly or debilitated patients who may not tolerate outpatient management 2
• Known or suspected bacteremia 2
• Patients with cystic fibrosis 2

Empirical Antibiotic Treatment for Hospitalized Patients

Non-Severe Pneumonia (Hospital Ward)

For hospitalized patients without ICU-level severity and no risk factors for resistant organisms, combination therapy is preferred over monotherapy. 1

Recommended first-line regimens (in order of preference):

• β-lactam + macrolide combination: Ceftriaxone 1-2g daily OR cefotaxime 1-2g every 8 hours PLUS azithromycin 500mg daily OR clarithromycin 500mg twice daily 1, 3
• Alternative monotherapy: Levofloxacin 750mg daily OR moxifloxacin 400mg daily 1, 4
• For β-lactam/macrolide intolerance: β-lactam + doxycycline 100mg twice daily 1

Antibiotic administration timing is critical: Treatment must be initiated immediately after diagnosis, and in patients with septic shock, delays significantly worsen outcomes. 1

Severe Pneumonia (ICU or Intermediate Care)

Patients requiring ICU admission need broader empirical coverage with combination therapy. 1

Without Pseudomonas risk factors:

• Ceftriaxone 1-2g daily OR cefotaxime 1-2g every 8 hours PLUS azithromycin 500mg daily 1
• Alternative: Levofloxacin 750mg daily OR moxifloxacin 400mg daily ± non-antipseudomonal cephalosporin 1, 4

With Pseudomonas aeruginosa risk factors:

• Antipseudomonal β-lactam (piperacillin-tazobactam 4.5g every 6 hours 5 OR cefepime OR meropenem up to 6g daily in divided doses 1)
• PLUS ciprofloxacin 1
• OR PLUS azithromycin + aminoglycoside (gentamicin, tobramycin, or amikacin) 1, 2

Critical caveat: Levofloxacin 750mg daily can be used as an alternative to ciprofloxacin and also provides Gram-positive coverage, but must still be combined with an antipseudomonal β-lactam when Pseudomonas is suspected. 1, 4

Route of Administration and IV-to-Oral Switch

Initial IV therapy is recommended for hospitalized patients, but early transition to oral therapy is safe and appropriate. 1

Criteria for switching to oral therapy:

• Clinical stability achieved: Resolution of fever, normalization of vital signs, ability to eat, and normal mentation 1, 4
• Typically occurs within 48-72 hours of appropriate therapy 1
• Patients do not need to remain hospitalized after switching to oral therapy in most cases 1
• Switch is safe even in severe pneumonia once clinical stability is reached 1

Duration of Therapy

Treatment duration should generally not exceed 8 days in responding patients. 1, 4

• Minimum 3 days for hospitalized patients with bacterial CAP 3
• 5-day courses with levofloxacin 750mg are as effective as 10-day regimens 4
• Biomarkers (particularly procalcitonin) may guide shorter treatment duration 1
• Extended duration (14-21 days) only for Legionella, Staphylococcus aureus, or Gram-negative enteric bacilli 1, 4

Additional Supportive Therapies

Beyond antibiotics, several adjunctive measures improve outcomes in hospitalized pneumonia patients:

• Early mobilization for all patients 1
• Low molecular weight heparin for patients with acute respiratory failure 1
• Non-invasive ventilation can be considered, particularly in COPD patients 1
• Systemic corticosteroids within 24 hours may reduce 28-day mortality in severe CAP 3
• Steroids are NOT recommended for routine pneumonia treatment 1

Common Pitfalls to Avoid

Do not delay antibiotic initiation while awaiting diagnostic test results—empirical therapy must start immediately upon diagnosis. 1, 6

Do not use monotherapy with β-lactams alone for hospitalized patients—atypical pathogen coverage with macrolides or fluoroquinolones is essential. 1

Do not use levofloxacin as monotherapy when Pseudomonas is suspected—it must be combined with an antipseudomonal β-lactam. 1, 4

Do not continue IV antibiotics unnecessarily—switch to oral therapy once clinical stability is achieved, as this does not require continued hospitalization. 1

Do not extend treatment beyond 8 days in responding patients without specific indications, as this increases antibiotic resistance without improving outcomes. 1, 4