What is the assessment and plan for community-acquired pneumonia (CAP)?

From the Guidelines

For pneumonia, I recommend a comprehensive assessment and treatment approach that prioritizes patient outcomes in terms of morbidity, mortality, and quality of life, with a focus on severity and setting, as outlined in the most recent guidelines 1. The assessment should include vital signs, oxygen saturation, respiratory examination, and chest imaging (X-ray or CT scan), as well as laboratory tests such as complete blood count, blood cultures, and sputum culture.

• Treatment depends on the severity of the pneumonia and the setting, with outpatient community-acquired pneumonia in otherwise healthy adults typically managed with oral antibiotics such as amoxicillin or a respiratory fluoroquinolone, while hospitalized patients require intravenous antibiotics such as ceftriaxone plus azithromycin, as recommended by the Infectious Diseases Society of America 2.
• For patients with severe pneumonia, broader antibiotic coverage may be necessary, and supportive care measures such as oxygen therapy, hydration, and antipyretics are crucial to maintain oxygenation and facilitate recovery.
• The American Thoracic Society recommends nucleic acid-based testing for noninfluenza viral pathogens in adults with suspected community-acquired pneumonia, which can aid in the identification of the causative pathogen and guide treatment decisions 1.
• Reassessment within 48-72 hours is essential to ensure clinical improvement and adjust the treatment plan as needed, with a focus on preventing complications and improving patient outcomes.
• Prevention through pneumococcal and influenza vaccination is also important for high-risk individuals, as it can reduce the risk of developing pneumonia and its associated morbidity and mortality. The choice of antibiotic should be guided by the most recent and highest-quality evidence, with consideration of the patient's comorbidities, risk factors, and potential resistance patterns, as well as the need for cost-effective, least toxic, and narrow-spectrum agents 2.

From the FDA Drug Label

Community-acquired pneumonia (mild severity) 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5 The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with community-acquired pneumonia is 10 mg/kg as a single dose on the first day followed by 5 mg/kg on Days 2 through 5.

The assessment and plan for pneumonia using azithromycin is as follows:

• For adults with mild severity community-acquired pneumonia, the recommended dose is 500 mg on Day 1, followed by 250 mg once daily on Days 2 through 5.
• For pediatric patients, the recommended dose is 10 mg/kg on Day 1, followed by 5 mg/kg on Days 2 through 5. Key considerations include:
• Renal insufficiency: Caution should be exercised when administering azithromycin to patients with severe renal impairment.
• Hepatic insufficiency: No dose adjustment recommendations can be made for patients with impaired hepatic function. 3

From the Research

Assessment of Pneumonia

• Pneumonia is a common cause of respiratory infection, accounting for more than 800,000 hospitalizations in the United States annually 4.
• Presenting symptoms of pneumonia are typically cough, pleuritic chest pain, fever, fatigue, and loss of appetite, although children and the elderly may have different presenting features 4.
• Knowledge of local bacterial pathogens and their antibiotic susceptibility and resistance profiles is key for effective pharmacologic selection and treatment of pneumonia 4.

Treatment Plan for Pneumonia

• Azithromycin has been shown to be effective in the treatment of community-acquired pneumonia, including patients with macrolide-resistant Streptococcus pneumoniae infection 5.
• A study comparing levofloxacin with ceftriaxone and azithromycin combination in the treatment of community-acquired pneumonia in hospitalized patients found that monotherapy with oral levofloxacin was as effective as treatment with ceftriaxone plus azithromycin combination 6.
• Azithromycin may be the first-choice macrolide for treatment of community-acquired pneumonia, with a shorter treatment course resulting in better compliance with therapy 7.
• Vaccinations for influenza and pneumococcal infections are becoming widely available for vulnerable groups of people, which will help to reduce the incidence of pneumonia 8.

Considerations for Treatment

• The choice of antibiotic should be based on the severity of the pneumonia, the patient's age and underlying health conditions, and the local antibiotic resistance patterns 4, 5, 6, 7.
• Combination treatment with a beta-lactam plus a macrolide may improve the outcome for elderly patients with community-acquired pneumonia 7.
• The length of hospital stay and mortality rate may be lower with azithromycin compared to other macrolides 7.