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

From the Guidelines

Community acquired pneumonia (CAP) treatment should be guided by the most recent and highest quality evidence, which recommends a minimum of 5 days of antibiotics, with extension of therapy guided by validated measures of clinical stability, as stated in the 2021 study 1.

Overview of CAP Treatment

The treatment of CAP typically involves empiric antibiotic therapy based on severity.

• For outpatient treatment of mild to moderate CAP, amoxicillin 1g three times daily for 5-7 days is recommended as first-line therapy, as seen in the 2003 study 1.
• Alternatives include doxycycline 100mg twice daily or azithromycin 500mg on day one followed by 250mg daily for 4 more days.
• For patients with comorbidities or risk factors for drug-resistant pathogens, a respiratory fluoroquinolone like levofloxacin 750mg daily or a combination of amoxicillin-clavulanate plus a macrolide is appropriate, as suggested in the 2019 study 1.

Hospitalized Patients

Severe CAP requiring hospitalization should be treated with combination therapy of a beta-lactam (ceftriaxone 1-2g daily or ampicillin-sulbactam 1.5-3g every 6 hours) plus a macrolide or respiratory fluoroquinolone, as recommended in the 2011 study 1.

• Treatment should be reassessed after 48-72 hours based on clinical response and culture results.

Supportive Care

Supportive care including adequate hydration, oxygen supplementation if needed, and antipyretics for fever is essential, as stated in the 2021 study 1.

• These recommendations target the most common CAP pathogens including Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms like Mycoplasma pneumoniae, ensuring broad coverage until a specific pathogen is identified.

Key Considerations

• The 2019 study 1 highlights the importance of selecting agents effective against the major treatable bacterial causes of CAP.
• The 2021 study 1 emphasizes the need for validated measures of clinical stability to guide extension of therapy.
• The 2003 study 1 provides a comprehensive overview of the initial empiric therapy for suspected bacterial community-acquired pneumonia in immunocompetent adults.

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 1.3 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

Levofloxacin is indicated for the treatment of community-acquired pneumonia due to various susceptible microorganisms.

• The 7 to 14 day treatment regimen is used for pneumonia due to methicillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae (including multi-drug-resistant Streptococcus pneumoniae [MDRSP]), and other microorganisms.
• The 5 day treatment regimen is used for pneumonia due to Streptococcus pneumoniae (excluding multi-drug-resistant isolates [MDRSP]), Haemophilus influenzae, Haemophilus parainfluenzae, Mycoplasma pneumoniae, or Chlamydophila pneumoniae. The clinical success rates for levofloxacin in the treatment of community-acquired pneumonia are:
• 93% for the 7 to 14 day treatment regimen 2
• 90.9% for the 5 day treatment regimen 2

From the Research

Community Acquired Pneumonia Treatment

• The treatment of community-acquired pneumonia (CAP) has been studied in various clinical trials, with a focus on comparing the efficacy and tolerability of different antibiotic regimens 3, 4, 5, 6, 7.
• One study compared levofloxacin monotherapy with a combination of azithromycin and ceftriaxone in hospitalized adults with moderate to severe CAP, and found that levofloxacin was at least as effective as the combination regimen 3.
• Another study found that levofloxacin was effective in treating CAP, with a high-dose, short-course regimen maximizing its concentration-dependent antibacterial activity and decreasing the potential for drug resistance 4.
• A prospective randomized trial compared oral levofloxacin with a combination of parenteral ceftriaxone and oral azithromycin in CAP patients, and found that monotherapy with oral levofloxacin was as effective as the combination regimen 5.
• A retrospective nationwide database analysis compared azithromycin plus β-lactam with levofloxacin plus β-lactam for severe CAP, and found no significant differences in 28-day mortality and in-hospital mortality between the two groups 6.
• A randomized clinical trial compared levofloxacin with a combination of ceftriaxone and azithromycin for treating mild to moderate CAP, and found that levofloxacin improved patients' signs and symptoms and reduced hospitalization length, with a similar rate of side effects 7.

Antibiotic Regimens

• Levofloxacin monotherapy has been shown to be effective in treating CAP, with a high-dose, short-course regimen being a viable option 4, 5, 7.
• Combination regimens, such as azithromycin and ceftriaxone, or azithromycin and β-lactam, have also been studied, with mixed results 3, 6.
• The choice of antibiotic regimen may depend on various factors, including the severity of the disease, the presence of comorbidities, and the potential for drug resistance 4, 6.

Efficacy and Tolerability

• Levofloxacin has been shown to be well tolerated, with a low incidence of drug-related adverse events 3, 4, 7.
• The efficacy of levofloxacin in treating CAP has been demonstrated in several studies, with high clinical success rates and microbiologic eradication rates 3, 4, 5, 7.
• Combination regimens have also been shown to be effective, but may be associated with a higher incidence of side effects 3, 6.