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

From the Guidelines

Community acquired pneumonia (CAP) treatment should typically involve empiric antibiotic therapy based on severity and patient factors, with the most recent guidelines recommending a fluoroquinolone alone or an extended-spectrum cephalosporin plus a macrolide for hospitalized patients, as stated in the 2020 study 1.

Key Considerations

• The choice of antibiotic therapy should be based on the severity of illness, pathogen probabilities, resistance patterns of S. pneumoniae, and comorbid conditions, as outlined in the 2000 study 1.
• For outpatient treatment of healthy adults without risk factors, alternatives include doxycycline 100mg twice daily or azithromycin 500mg on day 1, then 250mg daily for 4 more days, as suggested in the 2002 study 1.
• Hospitalized non-ICU patients should receive a beta-lactam (such as ampicillin-sulbactam 3g IV every 6 hours or ceftriaxone 1-2g IV daily) plus a macrolide, as recommended in the 2011 study 1.
• Severely ill patients requiring ICU admission need broader coverage with a beta-lactam plus either a respiratory fluoroquinolone or azithromycin.

Treatment Duration and Supportive Care

• Treatment duration is typically 5 days for uncomplicated cases, but should be extended if the patient remains febrile after 72 hours or has complications, as noted in the 2000 study 1.
• Supportive care including adequate hydration, fever control, and oxygen supplementation as needed is essential, with antibiotics targeting the most common pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms like Mycoplasma pneumoniae.

Pathogen-Specific Treatment

• The 2011 study 1 provides guidance on pathogen-specific treatment, including doxycycline, macrolides, levofloxacin, and moxifloxacin for Chlamydophila pneumoniae, Legionella spp., and Coxiella burnetii.
• The choice of antibiotic therapy should be based on local resistance patterns and the severity of illness, with consideration of the most recent guidelines and studies, such as the 2020 study 1.

From the FDA Drug Label

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)]. Clinical success rates (cure plus improvement) with levofloxacin at 5 to 7 days posttherapy, the primary efficacy variable in this study, was superior (95%) to the control group (83%). For both studies, the clinical success rate in patients with atypical pneumonia due to Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila were 96%, 96%, and 70%, respectively.

Community-acquired pneumonia treatment with levofloxacin is effective against various pathogens, including:

• Streptococcus pneumoniae (including multi-drug-resistant isolates)
• Haemophilus influenzae
• Chlamydophila pneumoniae
• Mycoplasma pneumoniae
• Legionella pneumophila

The clinical success rates for levofloxacin in the treatment of community-acquired pneumonia are:

• 95% at 5 to 7 days posttherapy in one study
• 93% in another study
• 96% for Chlamydophila pneumoniae and Mycoplasma pneumoniae
• 70% for Legionella pneumophila

Levofloxacin is indicated for the treatment of community-acquired pneumonia due to the above-mentioned pathogens 2, 2.

From the Research

Community Acquired Pneumonia Treatment

• Community-acquired pneumonia (CAP) is a common condition that causes a significant disease burden for the community, particularly in children younger than five years, the elderly, and immunocompromised people 3.
• Antibiotics are the standard treatment for CAP, but increasing antibiotic use is associated with the development of bacterial resistance and side effects for the patient 3.
• Several studies have been published regarding optimal antibiotic treatment for CAP, but many of these data address treatments in hospitalized patients 3.

Antibiotic Options

• Levofloxacin is a fluoroquinolone that has a broad spectrum of activity against several causative bacterial pathogens of CAP, and can be used as a monotherapy in patients with CAP 4.
• 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, acute bacterial sinusitis, acute pyelonephritis, and complicated urinary tract infections 4.
• Levofloxacin combination therapy with anti-pseudomonal beta-lactam (or aminoglycoside) should be considered if Pseudomonas aeruginosa is the causative pathogen of the respiratory infection 4.
• Other antibiotic options for CAP include amoxicillin/clavulanate, clarithromycin, and ceftriaxone, among others 5, 6, 7.

Efficacy and Safety

• The efficacy and tolerability of levofloxacin 500 mg once daily for 10 days in patients with CAP are well established 4.
• A study comparing levofloxacin and amoxicillin/clavulanate plus clarithromycin for the treatment of hospitalized patients with CAP found that levofloxacin had a higher microbiological response rate overall, and for Gram-negative and non-pseudomonas Gram-negative pathogens than the combination therapy, but the difference was not statistically significant 5.
• A network meta-analysis found that ceftaroline and piperacillin have the highest probability of being the best in terms of cure rate, while ceftriaxone plus levofloxacin, ertapenem, and amikacin plus clarithromycin have the highest probability of being the best in terms of mortality rate 7.
• The certainty of evidence for each result is moderate, and it seems necessary to conduct an RCT that compares treatments with the highest probability of being the best for each event (cure or mortality) 7.