From the Guidelines
Doxycycline-resistant pneumonia can be treated with alternative antibiotics such as amoxicillin, a macrolide, or a respiratory fluoroquinolone.
Outpatient Therapy Options
- For healthy outpatient adults without comorbidities, amoxicillin 1 g three times daily or a macrolide (azithromycin 500 mg on first day then 250 mg daily or clarithromycin 500 mg twice daily) can be used as first-line therapy 1.
- For outpatient adults with comorbidities, combination therapy with a beta-lactam (amoxicillin-clavulanate 500 mg/125 mg three times daily) and a macrolide (azithromycin 500 mg on first day then 250 mg daily) or a respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily, or gemifloxacin 320 mg daily) is recommended 1.
Rationale
The choice of antibiotic therapy depends on the patient's underlying health status, recent antibiotic use, and local resistance patterns. Doxycycline is not recommended as a first-line therapy due to potential resistance, but amoxicillin and macrolides are effective against most common pathogens, including Streptococcus pneumoniae 1. Respiratory fluoroquinolones are also effective, but their use is generally reserved for patients with comorbidities or recent antibiotic exposure due to concerns about resistance development 1.
Key Considerations
- Local resistance patterns should be taken into account when selecting antibiotic therapy 1.
- Recent antibiotic use can increase the risk of resistant infections, and alternative agents should be chosen 1.
- Patient comorbidities, such as chronic heart, lung, liver, or renal disease, can increase the risk of complications and require more aggressive therapy 1.
From the Research
Appropriate Outpatient Therapy for Pneumonia Resistant to Doxycycline
- For outpatient treatment of community-acquired pneumonia, suitable empirical oral antimicrobial agents include a macrolide (eg, erythromycin, clarithromycin, azithromycin), or an oral beta-lactam with good activity against pneumococci (eg, cefuroxime axetil, amoxicillin, or a combination of amoxicillin and clavulanate potassium) 2.
- New fluoroquinolones with improved activity against S pneumoniae can also be used to treat adults with community-acquired pneumonia, but their use should be limited to adults for whom one of the above regimens has already failed, who are allergic to alternative agents, or who have a documented infection with highly drug-resistant pneumococci (eg, penicillin MIC > or =4 microg/mL) 2.
- Amoxicillin-clavulanate and ceftriaxone are equally safe and effective for the empirical treatment of acute bacterial pneumonia, including penicillin and cephalosporin-resistant pneumococcal pneumonia 3.
- The use of ceftriaxone plus doxycycline as an initial empiric therapy for patients hospitalized with CAP appears safe and effective, but its potential superiority should be evaluated prospectively 4.
Considerations for Antibiotic Management
- Successful treatment of community-acquired pneumonia hinges on expedient delivery of appropriate antibiotic therapy tailored to both the likely offending pathogens and the severity of disease 5.
- Macrolides play an antimicrobial and anti-inflammatory role in CAP, and specific information is available for managing individual CAP pathogens such as community-acquired methicillin-resistant Staphylococcus aureus and drug-resistant Streptococcus pneumoniae 5.
- The transition of hospitalized patients from intravenous antibiotics to oral therapy should be guided by evidence-based best practices 5.