What is the treatment for severe Community-Acquired Pneumonia (CAP)?

From the Guidelines

For severe community-acquired pneumonia (CAP), the recommended treatment is typically parenteral antibiotics in an inpatient setting, with a regimen consisting of a beta-lactam plus a macrolide or a beta-lactam plus a respiratory fluoroquinolone, as recommended by the 2019 American Thoracic Society and Infectious Diseases Society of America guidelines 1.

Key Considerations

• The choice of antibiotic regimen should be based on the severity of the pneumonia, the patient's risk factors for drug-resistant pathogens, and local antimicrobial resistance patterns.
• For patients with severe CAP, coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa should be considered if locally validated risk factors are present, as recommended by the 2019 guidelines 1.
• The use of fluoroquinolones, such as levofloxacin or moxifloxacin, may be appropriate for patients with severe CAP, especially if atypical pathogens are suspected or the patient has comorbidities.

Treatment Options

• Beta-lactam plus macrolide: ampicillin-sulbactam 1.5-3 g every 6 hours plus azithromycin 500 mg daily, or cefotaxime 1-2 g every 8 hours plus azithromycin 500 mg daily.
• Beta-lactam plus respiratory fluoroquinolone: ceftriaxone 1-2 g daily plus levofloxacin 750 mg daily, or ceftaroline 600 mg every 12 hours plus moxifloxacin 400 mg daily.

Patient Management

• Patients with severe CAP should be closely monitored for clinical improvement, with reevaluation necessary if symptoms worsen or do not improve within 48-72 hours of starting antibiotics.
• Antipyretics, such as acetaminophen, and hydration should be encouraged to manage symptoms and support recovery.
• The treatment regimen should be tailored to the individual patient's needs, with consideration of underlying comorbidities, allergies, and potential drug interactions.

From the FDA Drug Label

The recommended dose of Azithromycin for Injection for the treatment of adult patients with community-acquired pneumonia due to the indicated organisms is: 500 mg as a single daily dose by the intravenous route for at least two days Intravenous therapy should be followed by azithromycin by the oral route at a single, daily dose of 500 mg, administered as two 250 mg tablets to complete a 7 to 10 day course of therapy.

The treatment for severe community-acquired pneumonia (CAP) with azithromycin (IV) is 500 mg as a single daily dose by the intravenous route for at least two days, followed by oral therapy to complete a 7 to 10 day course of therapy 2.

• The dosage is the same for severe CAP, as the label does not provide different dosing recommendations based on the severity of CAP.
• Intravenous therapy should be used for at least the first two days, and then switched to oral therapy at the discretion of the physician and in accordance with clinical response.

From the Research

Treatment for Severe Community-Acquired Pneumonia (CAP)

• The treatment of severe CAP (sCAP) is a complex process that requires careful consideration of various factors, including the patient's risk factors, national and local antimicrobial susceptibility data, and the characteristics of the patient 3.
• Empirical antibiotic therapy for sCAP should be chosen based on these factors, and current guidelines recommend the use of combination therapies, such as a beta-lactam and a macrolide, or an antipneumococcal fluoroquinolone alone 4, 5.
• The use of fluoroquinolones, such as levofloxacin, has been shown to be effective in the treatment of CAP, including cases caused by macrolide-resistant Streptococcus pneumoniae 4.
• New antibiotics, such as delafloxacin, omadacycline, lefamulin, solithromycin, nemonoxacin, and ceftaroline, have been approved or are in development for the treatment of CAP, and offer enhanced activity against antibiotic-resistant bacterial pathogens, including methicillin-resistant Staphylococcus aureus and macrolide-resistant Streptococcus pneumoniae 6.
• The implementation of effective policies for de-escalation of antibiotic therapy is crucial to avoid antibiotic resistance and reduce the risk of subsequent infections 5.
• Severity scores and biomarkers can be useful in guiding the treatment of sCAP and avoiding unnecessary broad-spectrum antibiotic use 5, 7.