Pneumonia medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]; Priyamvada Singh, M.D. [3]

Overview

The treatment of pneumonia involves three critical decisions: firstly whether the patient truly has pneumonia, secondly what is the severity of the pneumonia, and lastly whether hospitalization is required for adequate management. Most cases of pneumonia can be treated without hospitalization. Typically, oral antibiotics, rest, fluids, and home care are sufficient for complete resolution. However, people with pneumonia who are having trouble breathing, comorbidities, and the elderly may need more advanced treatment. If the symptoms get worse, the pneumonia does not improve with home treatment, or complications occur, the person will often have to be hospitalized.

Medical Therapy

Community-acquired Pneumonia Empirical Therapy

▸ Click on the following categories to expand treatment regimens.

Empirical Regimens   ▸   Neonates, Age < 1 month   ▸   Outpatient Therapy   ▸   Inpatient Therapy, NON-ICU   ▸   Inpatient Therapy, ICU   ▸   Adult Special Concerns

Neonates, Age < 1 month Preferred Regimen ▸ Ampicillin 500 mg/day for 7-14 days or 750 mg/day for 5 days OR ▸Gentamicin 400 mg/day PO/IV for 7-14 days With or without ▸ Cefotaxime 320 mg PO q24h for 5 or 7 days If MRSA is suspected, add the following ▸ Vancomycin 10 mg/kg q8h If C. trachomatis is suspected, add the following ▸ Erythromycin 12.5 mg/kg PO or IV qid x 14 days OR ▸ Azithromycin 10 mg/kg PO/IV on day one then 5 mg/kg PO/IV q24h for 4 days. Alternate Regimen If MRSA is suspected ▸ Vancomycin 10 mg/kg q8h OR ▸Linezolid 10 mg/kg q8h Children (> 3 months) Outpatient Therapy Preferred Regimen ▸Amoxicillin 90 mg/kg/day q12h x 5 days OR ▸Azithromycin 10 mg/kg PO x 1 dose (max 500 mg), then 5 mg/kg (max 250 mg) PO x 4 days Alternate Regimen ▸ Amoxicillin-clavulanate 90 mg/kg/day OR ▸ Clarithromycin 15 mg/kg/day q12h x 7-14 days Adult Outpatient Therapy Category I † Preferred Regimen ▸Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR ▸Azithromycin 500 mg IV as a single dose OR ▸ Clarithromycin 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days OR ▸Erythromycin 250-500 mg q6-12h (max: 4 g/day) Alternative Regimen ▸Doxycycline 100 mg PO/IV q12h (Weak recommendation) Category II †† Preferred Regimen 1 ▸ Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR ▸ Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR ▸ Gemifloxacin 320 mg PO q24h for 5 or 7 days Preferred Regimen 2 ▸Amoxicillin 875 mg PO q12h or 500 mg q8h q8h OR ▸ Amoxicillin-clavulanate 2 g q12h OR ▸ Ceftriaxone 1 g IV q24h, (2 g q24h for patients at risk) OR ▸ Cefpodoxime 200 mg PO q12h for 14 days OR ▸Cefuroxime 750 mg IM/IV q8h PLUS ▸ Macrolide OR ▸Doxycycline 100 mg PO/IV q12h Category III ††† Preferred Regimen ▸ Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR ▸ Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR ▸ Gemifloxacin 320 mg PO q24h for 5 or 7 days OR ▸Amoxicillin 1 g q8h OR ▸ Amoxicillin-clavulanate 2 g q12h Alternative Regimen ▸Ceftriaxone 1 g IV q24h, (2 g q24h for patients at risk) OR ▸ Cefpodoxime 200 mg PO q12h for 14 days OR ▸Cefuroxime 750 mg IM/IV q8h † Previously healthy and no use of antimicrobials within the previous 3 months †† Presence of 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 (in which case an alternative from adifferent class should be selected) ††† In regions with a high rate (25%) of infection with high-level (MIC ≥16mg/mL) macrolide-resistant Streptococcus pneumoniae. Children (> 3 months) Inpatient Therapy, NON ICU Preferred Regimen ▸Ampicillin 150-200 mg/kg/day IV q6h OR ▸ Cefotaxime 150 mg/kg/day IV divided q8h If atypical, add the following ▸ Azithromycin 10 mg/kg (max 500 mg/day) IV day 1 then 5 mg/kg (max 250 mg) If community-associated MRSA is a concern, add the following ▸Vancomycin 40-60 mg/kg/day IV divided q6-8h OR ▸Clindamycin 40 mg/kg/day divided q6-8h Alternate Regimen ▸ Cefotaxime 150 mg/kg/day IV divided q8h Adults Inpatient Therapy, NON ICU Preferred Regimen 1 ▸ Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR ▸Moxifloxacin Oral, I.V.: 400 mg q24h for 7-14 days OR ▸ Gemifloxacin Oral: 320 mg q24h for 5 or 7 days Preferred Regimen 2 ▸Cefotaxime 1 g IM/IV q12h OR ▸Ceftriaxone 1 g IV q24h, (2 g/day for patients at risk) OR ▸ Ampicillin 250-500 mg PO q6h OR ▸ Ampicillin 1-2 g IM/IV q4-6h or 50-250 mg/kg/day in divided doses OR ▸ Ertapenem 1 g IM/IV q24h (For Selected patients) PLUS ▸ Macrolide OR ▸Doxycycline 100 mg PO/IV q12h Alternate Regimen (if penicillin allergy) ▸ Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR ▸ Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR ▸ Gemifloxacin 320 mg PO q24h for 5 or 7 days Adult Inpatient Therapy, ICU Preferred Regimen ▸ Cefotaxime I.M., I.V.: 1 g q12h OR ▸Ceftriaxone 1 g IV q24h, 2 g/day for patients at risk OR ▸Ampicillin-sulbactam 1.5-3 g IV q6h PLUS ▸ Azithromycin 500 mg/day PO once, followed by 250 mg q24h for 4 days OR ▸ Ciprofloxacin 500-750 mg q12h for 7-14 days OR ▸ Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR ▸Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR ▸Gemifloxacin Oral: 320 mg q24h for 5 or 7 days Alternative Regimen (For penicillin allergy) ▸ Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 day OR ▸Moxifloxacin 400 mg q24h PO/IV for 7-14 days OR ▸Gemifloxacin 320 mg PO q24h for 5 or 7 days PLUS ▸ Aztreonam I.V.: 2 g q6-8h (max: 8 g/day) Adult Special Concerns - Pseudomona Preferred Regimen 1 * ▸ Piperacillin-tazobactam 3.375 g IV q6h for 7-10 days OR ▸Cefepime 1-2 g q12h for 10 days OR ▸Imipenem 500 mg IV q6h OR ▸Meropenem 500 mg IV q8h PLUS ▸ Ciprofloxacin 500-750 mg q12h for 7-14 days OR ▸ Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 day Preferred Regimen 2 * ▸ Piperacillin-tazobactam 3.375 g IV q6h for 7-10 days OR ▸Cefepime 1-2 g q12h for 10 days OR ▸Imipenem 500 mg IV q6h OR ▸Meropenem 500 mg IV q8h PLUS ▸ Aminoglycoside PLUS ▸Azithromycin Oral: 500 mg on day 1 followed by 250 mg q24h on days 2-5 OR ▸ Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR ▸ Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR ▸ Gemifloxacin 320 mg PO q24h for 5 or 7 days *For penicillin-allergic patients, substitute the B-lactam for Aztreonam 2 g IV q6-8h (max 8 g/day) Adult Special Concerns - MRSA Add the following to the selected regimen ▸ Vancomycin 45-60 mg/kg/day divided q8-12h OR ▸Linezolid 600 mg PO/IV q12h for 10-14 days

Click here for community-acquired pneumonia additional treatment regimens

Hospital-acquired Pneumonia

Empirical Regimens   ▸   No Risk Factors for MDR   ▸  Presence of Risk Factors for MDR

No Risk Factors for MDR Preferred Regimen ▸ Ceftriaxone 1-2 g q24h IV or IM (max: 4 g/day) OR ▸ Levofloxacin 750 mg q24h for 7-14 days OR ▸Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR ▸Ciprofloxacin 400 mg PO q8h for 10-14 days OR ▸ Ampicillin sulbactam 1-2 g q6-8h IV/IM (max: 8 g/day). OR ▸ Ertapenem 1 g IM/IV q24h for 10-14 days Presence of Risk Factors for MDR Preferred Regimen ▸ Cefepime 1–2 g q8–12h OR ▸ Ceftazidime 2 g q8h OR ▸Imipenem 500 mg q6h or 1g q8h OR ▸Meropenem 1 g q8h OR ▸ Piperacillin-tazobactam 4.5 g q6h PLUS ▸Ciprofloxacin 400 mg q8h OR ▸Levofloxacin 750 mg q24h OR ▸ Amikacin† 20 mg/kg per day OR ▸Gentamycin† 7 mg/kg per day OR ▸Tobramycin† 7 mg/kg per day PLUS ▸ Linezolid 600 mg q12h OR ▸Vancomycin‡ 15 mg/kg q12h † Trough levels for gentamicin and tobramycin should be less than 1 g/ml, and for amikacin they should be less than 4–5 g/ml. ‡ Trough levels for vancomycin should be 15–20 g/ml

Click here for hospital-acquired pneumonia treatment regimens

General Considerations

• The treatment of pneumonia involves three critical decisions: firstly whether the patient truly has pneumonia, secondly what is the severity of the pneumonia, and lastly whether hospitalization is required for adequate management.
• Treatment for pneumonia should ideally be based on the causative microorganism and its known antibiotic sensitivity. However, a specific cause for pneumonia is identified in only 50% of people, even after extensive evaluation.
• Since treatment should generally not be delayed in any person with a serious pneumonia, empiric treatment is usually started well before laboratory reports are available. In both cases, a person's risk factors for different organisms must be remembered when choosing the initial antibiotics (empiric therapy).
• In general, all therapies in older children and adults will include treatment for atypical bacteria. Typically this is a macrolide antibiotic such as azithromycin or clarithromycin although a fluoroquinolone such as levofloxacin can substitute.
• Multiple antibiotics may be administered in combination in an attempt to treat all of the possible causative microorganisms. Antibiotic choices vary from hospital to hospital because of regional differences in the most likely microorganisms and because of differences in the microorganisms' abilities to resist various antibiotic treatments.
• Treatment of viral pneumonia caused by influenza is beneficial only if they are started within 48 hours of the onset of symptoms.
• Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown resistance to rimantadine and amantadine.
• There are no known effective treatments for viral pneumonias caused by the SARS coronavirus, adenovirus, hantavirus, or parainfluenza virus.
• Most newborn infants with CAP are hospitalized and given intravenous ampicillin and gentamicin for at least ten days. This treats the common bacteria streptococcus agalactiae, listeria monocytogenes, and escherichia coli. If herpes simplex virus is the cause, intravenous acyclovir is administered for 21 days.
• Treatment of CAP in children depends on both the age of the child and the severity of his/her illness. Children less than five do not typically receive treatment to cover atypical bacteria. If a child does not need to be hospitalized, amoxicillin for seven days is a common treatment. However, with increasing prevalence of DRSP, other agents such as cefpodoxime will most likely become more popular in the future. Hospitalized children should receive intravenous ampicillin, ceftriaxone, or cefotaxime.
• Fungal pneumonia can be treated with antifungal drugs and sometimes by surgical debridement.
• Antibiotics are used to treat bacterial pneumonia. In contrast, antibiotics are not useful for viral pneumonia, although they sometimes are used to treat or prevent bacterial infections that can occur in the lungs that are damaged by a viral pneumonia. The antibiotic choice depends on:
  • Nature of the pneumonia
  • Microorganisms endemic to a local geographic area
  • Immune status
  • Underlying health of the individual

Infectious Diseases Society of America/American Thoracic Society consensus recommendation on site of care for community-acquired pneumonia in adults. (DO NOT EDIT)

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Hospital Admission Decision Severity-of-illness scores, such as the CURB-65 criteria (confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater), or prognostic models, such as the Pneumonia Severity Index (PSI), can be used to identify patients with CAP who may be candidates for outpatient treatment. (Strong recommendation; level I evidence) Objective criteria or scores should always be supplemented with physician determination of subjective factors, including the ability to safely and reliably take oral medication and the availability of outpatient support resources. (Strong recommendation; level II evidence) For patients with CURB-65 scores >2, more-intensive treatment—that is, hospitalization or, where appropriate and available, intensive in-home health care services—is usually warranted. (Moderate recommendation; level III evidence) Intensive Care Unit (ICU) Admission Decision Direct admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respiratory failure requiring intubation and mechanical ventilation. (Strong recommendation; level II evidence) Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed in the Table below. (Moderate recommendation; level II evidence)

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For Level of evidence classification click here.

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Empiric Antibiotic Treatment of community-acquired pneumonia in adults. (DO NOT EDIT)

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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)

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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)

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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)

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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)

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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)

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For Level of evidence and classes click here.

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on other Treatments Considerations for Acquired Pneumonia in adults. (DO NOT EDIT)

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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)

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For Level of evidence and classes click here.

Infectious Diseases Society of America/American Thoracic Society Consensus Recommendation on Non Responding Acquired Pneumonia in Adults. (DO NOT EDIT)

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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.

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For Level of evidence and classes click here.