What are the treatment options for community-acquired pneumonia (CAP)?

From the Guidelines

Community-acquired pneumonia should be treated with antibiotics, with the specific regimen depending on the severity of illness and patient factors, and the most recent guidelines from the American Thoracic Society and Infectious Diseases Society of America should be followed 1. The treatment of community-acquired pneumonia (CAP) depends on several factors, including the severity of illness, patient comorbidities, and the likelihood of drug-resistant pathogens.

• For outpatient treatment of previously healthy individuals, a beta-lactam (such as ampicillin or ceftriaxone) plus a macrolide (such as azithromycin) or a respiratory fluoroquinolone (such as levofloxacin) is recommended 1.
• For patients with comorbidities like heart, lung, liver, or kidney disease, a combination of a beta-lactam plus a macrolide or a respiratory fluoroquinolone is recommended 1.
• Hospitalized patients typically receive intravenous antibiotics, often a combination of a beta-lactam (such as ceftriaxone) plus a macrolide (such as azithromycin) or a respiratory fluoroquinolone (such as levofloxacin) 1. Some key points to consider when treating CAP include:
• The need for adequate hydration, rest, fever control with acetaminophen or ibuprofen, and oxygen supplementation if needed.
• The importance of monitoring patients for improvement within 48-72 hours of starting antibiotics, and reassessing if there is no improvement.
• The role of prevention strategies, such as pneumococcal and influenza vaccinations, especially for high-risk individuals. It's worth noting that the antibiotic choices should target the most common causative organisms, including Streptococcus pneumoniae, Haemophilus influenzae, and atypical pathogens like Mycoplasma pneumoniae 1. The guidelines from the American Thoracic Society and Infectious Diseases Society of America provide a comprehensive approach to the diagnosis and treatment of CAP, and should be consulted for specific recommendations on antibiotic regimens and treatment duration 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 [see Dosage and Administration (2.1) and Clinical Studies (14.2)].

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 [see Dosage and Administration (2.1) and Clinical Studies (14.3)].

Levofloxacin is indicated for the treatment of community-acquired pneumonia. The recommended treatment regimens are:

• 7 to 14 days for infections due to methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae (including MDRSP), Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae, Legionella pneumophila, or Mycoplasma pneumoniae.
• 5 days for infections due to Streptococcus pneumoniae (excluding MDRSP), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasma pneumoniae, or Chlamydophila pneumoniae 2.

1. 5 Community-acquired Pneumonia Piperacillin and Tazobactam for Injection is indicated in adults for the treatment of community-acquired pneumonia (moderate severity only) caused by beta-lactamase producing isolates of Haemophilus influenzae.

Piperacillin-tazobactam is also indicated for the treatment of community-acquired pneumonia, but only for moderate severity infections caused by beta-lactamase producing isolates of Haemophilus influenzae 3.

From the Research

Treatment Options for Community-Acquired Pneumonia

• The treatment of community-acquired pneumonia (CAP) depends on the severity of the disease and the likely offending pathogens 4.
• Antibiotic therapy is the mainstay of treatment, with empiric therapy regimens recommended for each site of care 4.
• For outpatient treatment, beta-lactams, macrolides, and fluoroquinolones are commonly used, with fluoroquinolones showing high levels of penetration into the lungs and low levels of resistance 5.
• Short-course regimens using azithromycin, telithromycin, and fluoroquinolones have been shown to be efficacious, safe, and tolerable in patients with CAP 5.

Duration of Antibiotic Treatment

• The usual guidelines for adults with CAP recommend 5-7 days of antibiotic treatment, but some studies suggest that shorter durations may be sufficient 6.
• Several studies and meta-analyses have demonstrated that treatment durations of 7 days or less are effective for CAP, with some trials showing that 3-day treatments can be effective even in hospitalized CAP 6.
• Clinical and biological criteria, such as stability criteria and procalcitonin levels, can be used to customize and shorten the duration of antibiotic treatment 6.

Safety of Antibiotic Regimens

• Broad-spectrum antibiotics have been associated with increased risk of adverse drug events (ADEs) compared to narrow-spectrum regimens 7.
• A study comparing the safety of different antibiotic regimens for outpatient CAP found that broad-spectrum antibiotics were associated with increased risk of ADEs, such as nausea, vomiting, and abdominal pain 7.
• Narrow-spectrum antibiotic regimens, such as macrolide monotherapy, were found to confer similar risk of ADEs 7.

Efficacy of Doxycycline

• Doxycycline has been recommended as a treatment option for non-severe CAP in adults, with a systematic review and meta-analysis showing that it has comparable efficacy to macrolides and fluoroquinolones 8.
• The clinical cure rate was similar between the doxycycline and comparator groups, with a pooled odds ratio of 1.29 (95% CI: 0.73-2.28) 8.
• Adverse event rates were comparable between the doxycycline and comparator groups, suggesting that doxycycline is a viable treatment option for mild-to-moderate CAP 8.