What antibiotic is suitable for a patient with glucose-6-phosphate dehydrogenase (G6PD) deficiency and pneumonia?

Antibiotic Selection for Pneumonia in G6PD-Deficient Patients

For patients with G6PD deficiency and pneumonia, use standard pneumonia antibiotics such as beta-lactams (amoxicillin-clavulanate, ceftriaxone, cefotaxime), macrolides (azithromycin), or respiratory fluoroquinolones (levofloxacin, moxifloxacin), as these are safe and effective in this population. 1, 2

Community-Acquired Pneumonia Treatment Options

For hospitalized patients with community-acquired pneumonia not requiring ICU admission, the following regimens are appropriate and safe in G6PD deficiency: 1

• Aminopenicillin ± macrolide (e.g., amoxicillin with or without azithromycin) 1
• Aminopenicillin/β-lactamase inhibitor ± macrolide (e.g., amoxicillin-clavulanate with or without azithromycin) 1
• Non-antipseudomonal cephalosporin ± macrolide (cefotaxime or ceftriaxone with or without azithromycin) 1
• Respiratory fluoroquinolone monotherapy (levofloxacin 750mg or moxifloxacin 400mg) 1

Azithromycin is specifically indicated for community-acquired pneumonia due to Chlamydophila pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, or Streptococcus pneumoniae in patients appropriate for oral therapy. 2

Hospital-Acquired Pneumonia Considerations

For hospital-acquired pneumonia, treatment should be stratified based on mortality risk and multidrug-resistant pathogen risk factors: 1

• Low-risk patients: Monotherapy with appropriate coverage 1
• High-risk patients (requiring ventilatory support or in septic shock): Dual antipseudomonal coverage 1
• MRSA risk factors present: Add vancomycin 15-20 mg/kg IV q8-12h or linezolid 600mg IV q12h 1

Critical Medications to AVOID in G6PD Deficiency

The following medications are absolutely contraindicated due to hemolytic risk: 3, 4

• Dapsone - causes severe hemolysis and methemoglobinemia in G6PD-deficient patients 3, 4
• Primaquine - contraindicated beyond 5 days in populations with severe G6PD deficiency 3, 4
• Nitrofurantoin - documented to cause hemolysis 4
• Rasburicase - absolutely contraindicated in G6PD deficiency 3

Special Context: Pneumocystis Pneumonia

While this question asks about general pneumonia, it's worth noting that if Pneumocystis jirovecii pneumonia is suspected (typically in immunocompromised patients), the situation becomes more complex: 5, 6

• Trimethoprim-sulfamethoxazole (TMP-SMX) remains first-line but carries theoretical hemolytic risk 7, 6
• Recent evidence suggests TMP-SMX may be used cautiously in certain G6PD-deficient populations (particularly Southeast Asian variants) with close monitoring 7, 8
• Atovaquone is the preferred alternative for G6PD-deficient patients when TMP-SMX, dapsone, or primaquine cannot be used 6
• Pentamidine is another alternative when documented allergy or intolerance to TMP-SMX exists 6

Medications with Reassuring Safety Data

Real-world evidence demonstrates that the following medications, previously suspected of causing hemolysis, have been prescribed safely to thousands of G6PD-deficient patients: 8

• Ciprofloxacin and ofloxacin (fluoroquinolones) 8
• Sulfamethoxazole/cotrimoxazole (with appropriate monitoring) 8
• Sulfasalazine 8

Duration of Treatment

• Community-acquired pneumonia: 5-7 days 1
• Aspiration pneumonia: 7-14 days 1

Key Clinical Pitfall

The most common error is unnecessarily restricting safe antibiotics in G6PD-deficient patients based on outdated or unsubstantiated concerns. 4, 8 Many compounds have been wrongly cited as causing hemolysis because they were administered during infection-related hemolytic episodes, not because the drug itself caused hemolysis. 4 Standard beta-lactams, macrolides, and fluoroquinolones used for pneumonia treatment are safe and should not be withheld. 1, 2, 8