Community-acquired pneumonia medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Antibiotic Therapy

Community-Acquired Pneumonia   ▸  Outpatient Therapy   ▸  Inpatient Therapy   ▸  Special Concerns

Outpatient Therapy Preferred Regimen Previously healthy and no use of antimicrobials within the previous 3 months ▸ Azithromycin OR ▸ Clarithromycin OR ▸ Erythromycin OR ▸DoxycyclineWeak recommendation Comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; or use of antimicrobials within the previous 3 months style="fontsize:90%padding:05pxbackground:#DCDCDC;"align=left▸Levofloxacin OR ▸Moxifloxacin OR ▸Gemifloxacin OR ▸ β-Lactam PLUS ▸ Macrolide Regions with a high rate (>25%) of infection with high-level (MIC>=16mg/mL) macrolide-resistant Streptococcus pneumoniae ▸ Levofloxacin OR ▸Moxifloxacin OR ▸Gemifloxacin OR ▸ β-Lactam PLUS ▸ Macrolide|} Inpatient Therapy Preferred Regimen Non-ICU Treatment ▸ Respiratory Fluoroquinolone ' OR ▸β-Lactam PLUS ▸ Macrolide ICU Treatment ▸ Cefotaxime OR ▸Ceftriaxone OR ▸Ampicillin-sulbactam PLUS ▸ Azithromycin OR ▸ Respiratory Fluoroquinolone OR ▸ Respiratory Fluoroquinolone PLUS ▸ Aztreonam Special Concerns Preferred Regimen If Pseudomonas is a considered ▸ Piperacillin-tazobactam OR ▸Cefepime OR Imipenem OR Meropenem PLUS ▸ Aminoglycoside PLUS ▸Azithromycin OR ▸Piperacillin-tazobactam OR ▸[[Cefepime] OR Imipenem OR Meropenem PLUS ▸ Aminoglycoside PLUS ▸ Antipneumococcal Fluoroquinolone OR ▸ Aztreonamsubstitute aztreonam for above b-lactam for penicillin-allergic patients ▸ Piperacillin-tazobactam OR ▸[[Cefepime] OR Imipenem OR Meropenem ''If MRSA is considered then ADD ▸ Vancomycin OR ▸Linezolid Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Empiric Antibiotic Treatment of Community-acquired Pneumonia in Adults (DO NOT EDIT) “ Previously Healthy and No Risk Factors for Drug Resistant Streptococcus Pneumoniae A macrolide (azithromycin, clarithromycin, or erythromycin (Strong recommendation; level I evidence) Doxycycline (Weak recommendation; level III evidence) Presence of Comorbidities or Other Risks for Drug Resistant Streptococcus Pneumoniae Presence of comorbidities, such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected); or other risks for DRSP infection: A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) (Strong recommendation; level I evidence) A beta-lactam plus a macrolide (Strong recommendation; level I evidence) (High-dose amoxicillin [e.g., 1 g 3 times daily] or amoxicillin-clavulanate [2 g 2 times daily] is preferred; alternatives include ceftriaxone, cefpodoxime, and cefuroxime [500 mg 2 times daily]; doxycycline (level II evidence) is an alternative to the macrolide.) In Regions With a High Rate (>25%) of Infection In regions with a high rate (>25%) of infection with high-level (minimal inhibitory concentration [MIC], >16 micrograms/mL) macrolide-resistant S. pneumoniae, consider the use of alternative agents for any patient, including those without comorbidities. (Moderate recommendation; level III evidence) Inpatient, Non-ICU Treatment The following regimens are recommended for hospital ward treatment. A respiratory fluoroquinolone (Strong recommendation; level I evidence) A beta-lactam plus a macrolide (Strong recommendation; level I evidence) (Preferred beta-lactam agents include cefotaxime, ceftriaxone, and ampicillin; ertapenem for selected patients; with doxycycline (level III evidence) as an alternative to the macrolide. A respiratory fluoroquinolone should be used for penicillin-allergic patients.) Inpatient, ICU Treatment The following regimen is the minimal recommended treatment for patients admitted to the ICU. A beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin (level II evidence) or a fluoroquinolone (Strong recommendation; level I evidence) (For penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are recommended.) For Pseudomonas infection, use an antipneumococcal, antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750-mg dose) or the above beta-lactam plus an aminoglycoside and azithromycin or the above beta-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin-allergic patients, substitute aztreonam for the above beta-lactam). (Moderate recommendation; level III evidence) For community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) infection, add vancomycin or linezolid. (Moderate recommendation; level III evidence) ” For Level of evidence classification click here. Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Pandemic Influenza Community-acquired pneumonia in Adults (DO NOT EDIT) “ Pathogen Directed Therapy Once the etiology of CAP has been identified on the basis of reliable microbiological methods, antimicrobial therapy should be directed at that pathogen (Moderate recommendation; level III evidence) Early treatment (within 48 h of the onset of symptoms) with oseltamivir or zanamivir is recommended for influenza A. (Strong recommendation; level I evidence) Use of oseltamivir and zanamivir is not recommended for patients with uncomplicated influenza with symptoms for >48 h (level I evidence), but these drugs may be used to reduce viral shedding in hospitalized patients or for influenza pneumonia. (Moderate recommendation; level III evidence) Pandemic Influenza Patients with an illness compatible with influenza and with known exposure to poultry in areas with previous H5N1 infection should be tested for H5N1 infection. (Moderate recommendation; level III evidence) In patients with suspected H5N1 infection, droplet precautions and careful routine infection control measures should be used until an H5N1 infection is ruled out. (Moderate recommendation; level III evidence) Patients with suspected H5N1 infection should be treated with oseltamivir (level II evidence) and antibacterial agents targeting S. pneumoniae and S. aureus, the most common causes of secondary bacterial pneumonia in patients with influenza. (Moderate recommendation; level III evidence) ” For Level of evidence classification click here. Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Time, Route, and Duration of Community-acquired pneumonia in Adults (DO NOT EDIT) “ Time to First Antibiotic Dose For patients admitted through the emergency department (ED), the first antibiotic dose should be administered while still in the ED. (Moderate recommendation; level III evidence) Switch from Intravenous to Oral Therapy Patients should be switched from intravenous to oral therapy when they are hemodynamically stable and improving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract. (Strong recommendation; level II evidence). Patients should be discharged as soon as they are clinically stable, have no other active medical problems, and have a safe environment for continued care. Inpatient observation while receiving oral therapy is not necessary. (Moderate recommendation; level II evidence) Duration of Antibiotic Therapy Patients with CAP should be treated for a minimum of 5 days (level I evidence), should be afebrile for 48 to 72 h, and should have no more than 1 CAP-associated sign of clinical instability before discontinuation of therapy. (level II evidence) (Moderate recommendation) A longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infection, such as meningitis or endocarditis. (Weak recommendation; level III evidence) ” For Level of evidence and classes click here. Other Treatments Consideration Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Other Treatments Considerations for Acquired Pneumonia in Adults (DO NOT EDIT) “ This recommendation has been removed due to the market withdrawal of drotrecogin alfa. Hypotensive, fluid-resuscitated patients with severe CAP should be screened for occult adrenal insufficiency. (Moderate recommendation; level II evidence) Patients with hypoxemia or respiratory distress should receive a cautious trial of noninvasive ventilation (NIV) unless they require immediate intubation because of severe hypoxemia (arterial oxygen pressure/fraction of inspired oxygen [PaO2/FiO2] ratio <150) and bilateral alveolar infiltrates. (Moderate recommendation; level I evidence) Low-tidal-volume ventilation (6 cm3/kg of ideal body weight) should be used for patients undergoing ventilation who have diffuse bilateral pneumonia or acute respiratory distress syndrome. (Strong recommendation; level I evidence) ” For Level of evidence and classes click here. Management of Non-responding Pneumonia Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Non Responding Acquired Pneumonia in Adults (DO NOT EDIT) “ Because of the limitations of diagnostic testing, the majority of CAP is still treated empirically. Critical to empirical therapy is an understanding of the management of patients who do not follow the normal response pattern. ” For Level of evidence and classes click here. References