What are the treatment guidelines for Streptococcal (Strep) pneumonia (PNA)?

From the Guidelines

For adults with community-acquired pneumococcal pneumonia, a respiratory fluoroquinolone (such as moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) or a b-lactam plus a macrolide (such as high-dose amoxicillin [e.g., 1 g 3 times daily] or amoxicillin-clavulanate [2 g 2 times daily] plus a macrolide) is recommended as first-line treatment 1. The choice of antibiotic should be guided by the presence of comorbidities, such as chronic heart, lung, liver, or renal disease, and other risks for drug-resistant Streptococcus pneumoniae (DRSP) infection. Some key points to consider when selecting therapy include:

• The effectiveness of penicillins against Streptococcus pneumoniae is due to their ability to inhibit cell wall synthesis in the bacteria, though resistance patterns should be considered when selecting therapy, as regional variations in antibiotic resistance exist.
• For penicillin-allergic patients, alternatives include doxycycline 100 mg twice daily, a macrolide such as azithromycin 500 mg on day 1 followed by 250 mg daily for 4 more days, or a respiratory fluoroquinolone like levofloxacin 750 mg daily for 5 days.
• Treatment duration is generally 5-7 days for uncomplicated cases, but may be extended for complicated infections.
• Supportive care including adequate hydration, rest, and antipyretics for fever is also important, and oxygen therapy may be necessary for patients with hypoxemia. It is essential to note that the most recent and highest quality study, published in 2007, provides level I evidence for the recommended treatment options 1. In contrast, the 2000 study, although providing valuable information on antibiotic resistance patterns, is less relevant for current treatment guidelines due to its older publication date and lower level of evidence compared to the 2007 study 1. Therefore, the 2007 study should be prioritized when making treatment decisions for community-acquired pneumococcal pneumonia.

From the FDA Drug Label

1 INDICATIONS AND USAGE Adults and Pediatric Patients Upper Respiratory Tract Infections of the Ear, Nose, and Throat:Amoxicillin for oral suspension is indicated in the treatment of infections due to susceptible (ONLY β-lactamase–negative) isolates of Streptococcusspecies. (α-and β-hemolytic isolates only), Streptococcus pneumoniae, Staphylococcusspp., or Haemophilus influenzae.

• Treatment guidelines for strep pneumonia: Amoxicillin is indicated for the treatment of infections due to susceptible isolates of Streptococcus pneumoniae.
• The drug should be used to treat infections that are proven or strongly suspected to be caused by bacteria.
• Usage: To reduce the development of drug-resistant bacteria and maintain the effectiveness of amoxicillin and other antibacterial drugs, amoxicillin should be used only to treat infections that are proven or strongly suspected to be caused by bacteria 2

From the Research

Treatment Guidelines for Strep Pneumonia

• The treatment of Streptococcus pneumoniae infections, including pneumonia, depends on the site of infection and the level of resistance 3.
• For non-life-threatening infections, such as otitis media, amoxicillin, amoxicillin-clavulanate potassium, or a third-generation cephalosporin may still be effective 3.
• For pneumococcal pneumonia in otherwise healthy patients requiring hospitalization, recommended initial treatment includes cefuroxime, ceftriaxone, or cefotaxime 3.
• Penicillin has largely been abandoned as the initial treatment for pneumococcal meningitis in favor of cefotaxime or ceftriaxone 3.
• The use of beta-lactam antibiotics, such as penicillin, amoxicillin, and ceftriaxone, is still recommended for the treatment of non-meningeal pneumococcal infections, despite increasing resistance 4, 5.
• Vaccination remains an important strategy in preventing pneumococcal infections, particularly in at-risk populations 3.

Antibiotic Resistance and Treatment

• The emergence of penicillin-resistant Streptococcus pneumoniae has made treatment more challenging 3, 5.
• Studies have shown that the use of beta-lactam antibiotics can still be effective in treating pneumococcal infections, even in cases of resistance 4, 5.
• The antimicrobial resistance profile of S. pneumoniae isolates can vary by region, with some areas reporting high levels of resistance to penicillin and other antibiotics 6.
• Multidrug resistance is a concern, with some studies reporting high rates of resistance to multiple antibiotics 6.

Duration of Antibiotic Treatment

• The optimal duration of antibiotic treatment for Streptococcus pneumoniae bacteremia is not well established, but shorter courses (5-10 days) may be effective in some cases 7.
• A study comparing short and long antibiotic durations found no significant difference in clinical failure rates between the two groups 7.