What is the diagnosis and treatment for Community-Acquired Pneumonia (CAP)?

From the Guidelines

Community-acquired pneumonia (CAP) should be treated with antibiotics based on severity, with recent guidelines recommending a standard regimen of β-lactam plus a macrolide or respiratory fluoroquinolone for non-severe inpatients, as outlined in the 2019 American Thoracic Society and Infectious Diseases Society of America clinical practice guideline 1. When determining the appropriate treatment strategy, it is essential to consider the level of severity and risk for drug resistance.

• For non-severe inpatients, the recommended standard regimen is a β-lactam (such as ampicillin-sulbactam, cefotaxime, ceftriaxone, or ceftaroline) plus a macrolide (such as azithromycin or clarithromycin) or a respiratory fluoroquinolone (such as levofloxacin or moxifloxacin) 1.
• For severe inpatients, the recommended regimen is a β-lactam plus a macrolide or a β-lactam plus a fluoroquinolone, with additional coverage for MRSA and P. aeruginosa if necessary 1. It is crucial to note that the treatment strategy may need to be adjusted based on patient-specific factors, such as recent hospitalization, prior respiratory isolation, and risk factors for MRSA and P. aeruginosa 1. In addition to antibiotic treatment, supportive care, including adequate hydration, rest, fever control, and oxygen supplementation, is essential for managing CAP and preventing complications 1. The duration of treatment is typically 5-7 days for most patients, but may be extended to 14 days for more severe cases or certain pathogens 1. Prevention strategies, such as pneumococcal and influenza vaccinations, smoking cessation, and good hand hygiene, are also critical in reducing the risk of CAP and its complications 1.

From the FDA Drug Label

14.2 Community-Acquired Pneumonia: 7 to 14 Day Treatment Regimen

Adult inpatients and outpatients with a diagnosis of community-acquired bacterial pneumonia were evaluated in 2 pivotal clinical studies In the first study, 590 patients were enrolled in a prospective, multicenter, unblinded randomized trial comparing levofloxacin 500 mg once daily orally or intravenously for 7 to 14 days to ceftriaxone 1 to 2 grams intravenously once or in equally divided doses twice daily followed by cefuroxime axetil 500 mg orally twice daily for a total of 7 to 14 days Clinical and microbiologic evaluations were performed during treatment, 5 to 7 days posttherapy, and 3 to 4 weeks posttherapy 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%). The 95% CI for the difference of response rates (levofloxacin minus comparator) was [-6,19] In the second study, 264 patients were enrolled in a prospective, multi-center, non-comparative trial of 500 mg levofloxacin administered orally or intravenously once daily for 7 to 14 days. Clinical success for clinically evaluable patients was 93%

• Community-acquired pneumonia can be treated with levofloxacin.
• The recommended dosage is 500 mg once daily orally or intravenously for 7 to 14 days.
• Clinical success rates were 95% in the first study and 93% in the second study.
• The 95% CI for the difference of response rates was [-6,19] in the first study.
• Levofloxacin was effective against atypical pneumonia due to Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila, with clinical success rates of 96%, 96%, and 70%, respectively 2.

From the Research

Community Acquired Pneumonia Treatment

• Community-acquired pneumonia (CAP) is a common illness with high rates of morbidity and mortality, and its treatment is often empirical, covering both typical and atypical pathogens 3.
• The beta-lactams have historically been considered standard therapy for the treatment of CAP, but rising resistance rates are a primary concern, and fluoroquinolones are now recommended as an alternative 3.
• Levofloxacin is a fluoroquinolone that has a broad spectrum of activity against several causative bacterial pathogens of CAP, and its efficacy and tolerability are well established 4, 5.
• High-dose, short-course regimens of levofloxacin have been shown to be efficacious, safe, and tolerable in patients with CAP, and may represent a significant advance in the management of CAP 3, 5.

Antibiotic Choices

• For patients with comorbidities or recent antibiotic therapy, current guidelines recommend either combination therapy with a beta-lactam and a macrolide or an antipneumococcal fluoroquinolone alone 3.
• Levofloxacin monotherapy has been shown to be as effective as combination therapy with azithromycin and ceftriaxone in hospitalized patients with moderate to severe CAP 4.
• New antibiotics have been recently launched with direct agent-specific properties that have been shown to avoid the overuse of previous broad-spectrum antibiotics when treating patients with severe CAP 6.

Treatment Duration and Transition

• The duration of therapy for CAP is typically a minimum of 10 days, but high-dose, short-course regimens may be effective in some cases 4, 5.
• The transition from intravenous antibiotics to oral therapy is an important consideration in the management of CAP, and levofloxacin can be used orally or intravenously, with the option to switch between formulations 5.
• Effective policies of de-escalation are needed to avoid antibiotic resistance and the risk of developing subsequent infections, and should be based on informed clinical judgement and the application of biomarkers 6.