What is the best course of treatment for a patient with severe bronchopneumonia, non-productive cough, and worsening symptoms, who is not responding to steroid (corticosteroid) treatment and has impaired respiratory function?

Treatment of Bronchopneumonia Not Responding to Steroids

Stop the steroids immediately and initiate empiric antibiotic therapy with levofloxacin (Levaquin) 750 mg once daily, as steroids are not recommended for pneumonia treatment and may worsen outcomes, while this patient requires urgent antimicrobial coverage for bacterial bronchopneumonia. 1

Critical First Step: Discontinue Steroids

• Steroids are explicitly not recommended in the treatment of pneumonia and should be stopped immediately 1
• The worsening severe cough despite steroid treatment strongly suggests bacterial infection requiring antibiotics, not anti-inflammatory therapy 1
• Recent steroid use (>10 mg prednisolone daily in last 2 weeks) is actually a risk factor for Pseudomonas aeruginosa infection, which must be considered in your antibiotic selection 1

Immediate Diagnostic Workup Before Starting Antibiotics

• Obtain chest X-ray, blood cultures, and respiratory cultures (sputum or endotracheal aspirate if intubated) immediately 2
• Do not delay antibiotic initiation waiting for culture results, as delay increases mortality 2
• Measure C-reactive protein, complete blood count, and assess oxygenation status 1

Empiric Antibiotic Selection: Levofloxacin is Appropriate

Levofloxacin 750 mg once daily is an excellent choice for this clinical scenario because:

• It provides broad coverage against both typical and atypical respiratory pathogens, including penicillin-resistant Streptococcus pneumoniae 1
• The 750 mg dose covers Gram-positive bacteria empirically and provides enhanced activity against pneumococci 1
• Recent steroid use creates risk for Pseudomonas, and levofloxacin 750 mg twice daily (or 500 mg twice daily) provides antipseudomonal coverage 1
• It can be given orally from the start if the patient is stable enough for outpatient management, or IV with easy transition to oral 1

Dosing Strategy Based on Severity

For moderate severity (hospitalized but not ICU):

• Levofloxacin 750 mg once daily for 7-14 days 1
• Alternative: Levofloxacin 500 mg twice daily if concerned about Pseudomonas given recent steroid use 1

For severe disease requiring ICU admission:

• Levofloxacin 750 mg once daily (or 500 mg twice daily) PLUS a non-antipseudomonal cephalosporin III 1
• If two or more risk factors for Pseudomonas present (recent hospitalization, frequent antibiotics >4 courses/year, severe disease, oral steroid use), use antipseudomonal beta-lactam PLUS levofloxacin 1

Reassessment at 48-72 Hours

• Monitor temperature, respiratory rate, hemodynamic parameters, and repeat C-reactive protein on days 1 and 3-4 1
• Non-response within first 72 hours suggests antimicrobial resistance, unusually virulent organism, host defense defect, or wrong diagnosis 1
• Non-response after 72 hours usually indicates a complication requiring full reinvestigation 1
• If unstable at 72 hours, perform full microbiological reassessment and consider changing to second empirical regimen with broader coverage 1

Treatment Duration

• Generally 7-8 days for responding patients 1
• Recent evidence supports levofloxacin 750 mg daily for 5 days as equally effective as 500 mg for 10 days in community-acquired pneumonia 3
• Do not exceed 8 days in responding patients 1

Common Pitfalls to Avoid

• Never continue steroids in pneumonia - this is a critical error that worsens outcomes 1
• Do not assume negative Gram stain excludes infection, especially with recent steroid use affecting immune response 2
• Do not delay antibiotics waiting for cultures - start within first hour of presentation 2
• Consider aspiration pneumonia if risk factors present (altered consciousness, dysphagia, nursing home resident) - would require anaerobic coverage with beta-lactam/beta-lactamase inhibitor instead 1