Recommended Antibiotic Doses for Pneumonia in Pregnancy
For community-acquired pneumonia in pregnancy, initiate azithromycin 500 mg orally on day 1, followed by 250 mg once daily for days 2-5, or alternatively use erythromycin as monotherapy, which has decades of proven safety and efficacy in pregnant women. 1, 2
First-Line Antibiotic Regimens
Macrolide Monotherapy (Preferred)
Azithromycin dosing:
- 500 mg orally as a single dose on Day 1
- Followed by 250 mg once daily on Days 2 through 5
- Total 5-day course 1
Erythromycin alternative:
- Erythromycin monotherapy has been documented as adequate treatment in 99% of hospitalized pregnant women with pneumonia 2
- Specific dosing: standard erythromycin regimens (typically 500 mg orally every 6 hours or 250 mg every 6 hours) 3
Beta-Lactam Options (When Indicated)
Amoxicillin:
Ampicillin (for hospitalized patients):
Pathogen-Specific Dosing
For Streptococcus pneumoniae (Most Common)
If penicillin MIC <2 mg/mL:
If penicillin-resistant (MIC ≥2 mg/mL):
- Levofloxacin 750 mg IV/PO once daily (use with caution in pregnancy) 4
- Or Moxifloxacin 400 mg IV/PO once daily (use with caution in pregnancy) 4
For Atypical Pathogens
Mycoplasma pneumoniae:
- Azithromycin 500 mg orally on day 1, then 250 mg daily for 4 days 4, 1
- Alternative: Doxycycline 100 mg IV/PO twice daily for 7-14 days (avoid in pregnancy after first trimester) 4
Chlamydophila pneumoniae:
Legionella species:
- Levofloxacin 750 mg IV/PO once daily 4
- Alternative: Azithromycin 1000 mg IV day 1, then 500 mg IV/PO daily 4
Safety Considerations in Pregnancy
Preferred Antibiotics (Decades of Safety Data)
Beta-lactams and macrolides are the safest choices:
- Penicillins, cephalosporins, and erythromycin have documented pharmacokinetics and overall fetal safety 3
- These agents are most favored for susceptible infections in pregnancy 3
- Beta-lactam and macrolide antibiotics are considered safe and effective for most community-acquired pneumonia in pregnancy 5, 6
Antibiotics to Avoid or Use with Extreme Caution
Fluoroquinolones (levofloxacin, moxifloxacin):
- Should be avoided unless maternal necessity justifies fetal exposure 3
- Use only when no safer alternatives exist 4
Tetracyclines (doxycycline):
- Should be avoided unless maternal necessity justifies fetal toxicity 3
- Contraindicated after first trimester due to tooth discoloration and bone effects 6
Sulfonamides:
- Should be avoided in pregnancy unless absolutely necessary 3
Hospitalization Criteria and IV Therapy
Indications for hospitalization and IV antibiotics:
- Respiratory rate >24 breaths/min 4
- Systolic blood pressure <90 mmHg 4
- Arterial oxygen saturation <90% or pO₂ <60 mmHg 4
- Inability to maintain oral intake 4
- Coexisting maternal disease (asthma, anemia) 5
For hospitalized patients requiring IV therapy:
- Ampicillin 2 grams IV every 6 hours PLUS azithromycin 500 mg IV/PO daily 4, 7
- Or Ceftriaxone 1-2 grams IV every 12-24 hours PLUS azithromycin 4
Duration of Therapy
Standard treatment duration:
- 5-day course for azithromycin (as per FDA dosing) 1
- 7-14 days for other macrolides and beta-lactams 4
- Continue until afebrile for 48 hours and clinically stable 4
Critical Clinical Pitfalls
Common errors to avoid:
- Do not delay antibiotics while awaiting culture results in pregnant women with pneumonia 5
- Erythromycin monotherapy was adequate in 99% of cases; avoid unnecessary broad-spectrum coverage 2
- 10% of pregnant women admitted with suspected pneumonia had misdiagnosis at admission—confirm diagnosis before prolonged therapy 2
- Monitor for preterm labor and low birth weight, which are associated with pneumonia in pregnancy 5, 6
Maternal risk factors requiring closer monitoring: