What is the appropriate antibiotic coverage for community-acquired pneumonia (CAP)?

From the Guidelines

For community-acquired pneumonia (CAP), the recommended empiric treatment should be guided by the most recent and highest quality evidence, which suggests that antibiotics should be prescribed for a minimum of 5 days, with extension of therapy guided by validated measures of clinical stability 1. The choice of antibiotic depends on the setting and patient factors, such as comorbidities and recent antibiotic use.

• For outpatient treatment of healthy adults without risk factors, options include amoxicillin, doxycycline, or a macrolide, such as azithromycin 1.
• For outpatients with comorbidities, such as COPD, diabetes, or recent antibiotics, consider using amoxicillin-clavulanate plus azithromycin, or a respiratory fluoroquinolone like levofloxacin 1.
• For hospitalized non-ICU patients, combination therapy with a beta-lactam, such as ceftriaxone, plus a macrolide is recommended 1.
• For ICU patients, a beta-lactam plus either a macrolide or fluoroquinolone is suggested 1. It is essential to adjust therapy based on culture results when available and consider MRSA or Pseudomonas coverage for patients with specific risk factors 1. The most recent guidelines from the American College of Physicians suggest that short-course antibiotics (minimum of 5 days) are effective and may reduce adverse events and mortality compared to longer treatment durations 1.

From the FDA Drug Label

1. 2 Community-Acquired Pneumonia: 7 to 14 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of community-acquired pneumonia due to methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae (including multi-drug-resistant Streptococcus pneumoniae [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae, Legionella pneumophila, or Mycoplasma pneumoniae

2. 3 Community-Acquired Pneumonia: 5 Day Treatment Regimen Levofloxacin tablets are indicated for the treatment of community-acquired pneumonia due to Streptococcus pneumoniae (excluding multi-drug-resistant isolates [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasma pneumoniae, or Chlamydophila pneumoniae

Community-acquired pneumonia coverage for levofloxacin includes:

• Methicillin-susceptible Staphylococcus aureus
• Streptococcus pneumoniae (including multi-drug-resistant Streptococcus pneumoniae [MDRSP])
• Haemophilus influenzae
• Haemophilus parainfluenzae
• Klebsiella pneumoniae
• Moraxella catarrhalis
• Chlamydophila pneumoniae
• Legionella pneumophila
• Mycoplasma pneumoniae

For azithromycin, community-acquired pneumonia coverage is indicated for:

• Mild severity community-acquired pneumonia
• The recommended dose is 500 mg as a single dose on Day 1, followed by 250 mg once daily on Days 2 through 5 2 2 3

From the Research

Community Acquired Pneumonia Coverage

• Community-acquired pneumonia (CAP) is a common infection that significantly contributes to patient morbidity and healthcare costs 4.
• Levofloxacin, a fluoroquinolone, has a broad spectrum of activity against several causative bacterial pathogens of CAP and is effective in treating CAP 5, 6.
• The efficacy and tolerability of levofloxacin 500 mg once daily for 10 days in patients with CAP are well established, and a high-dose (750 mg), short-course (5 days) of once-daily levofloxacin has been approved for use in the USA in the treatment of CAP 5.
• Levofloxacin can be used as a monotherapy in patients with CAP, but combination therapy with anti-pseudomonal beta-lactam (or aminoglycoside) should be considered if Pseudomonas aeruginosa is the causative pathogen of the respiratory infection 5.
• Studies have shown that levofloxacin is at least as effective as amoxicillin/clavulanate plus clarithromycin in clinical and microbiological responses in the treatment of CAP 6.
• Treatment failure rates with levofloxacin were lower compared to azithromycin, particularly in high-risk patients (age ≥65 and/or on Medicaid) 7.

Treatment Options

• Levofloxacin is generally well tolerated, has good tissue penetration, and adequate concentrations can be maintained at the site of infections 5.
• Oral levofloxacin is rapidly absorbed and is bioequivalent to the intravenous formulation, allowing patients to switch between these formulations 5.
• Other treatment options for CAP include amoxicillin/clavulanate, azithromycin, and moxifloxacin, but treatment failure rates may vary depending on the antibiotic used 7.

Diagnostic Methods and Empiric Treatment

• Diagnostic methods and empiric treatment strategies for patients with suspected community-acquired pneumonia are discussed in recent literature and updated guidelines 4.
• Collaborative efforts among researchers and clinical societies provide new information and updated guidelines informing the management of CAP 4.