Bacterial pneumonia medical therapy: Difference between revisions

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Latest revision as of 13:15, 12 May 2022

Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Philip Marcus, M.D., M.P.H.[2]

Overview

Antimicrobial therapy is the mainstay of treatment for bacterial pneumonia. Patients with severe disease, co-morbidities, and/or complications usually require hospitalization and multidrug therapy.

Medical Therapy

Antimicrobials are the treatment of choice for bacterial pneumonia. The choice of antibiotic depends on the nature of the pneumonia, the microorganisms most commonly causing pneumonia in the geographical region, and the immune status and underlying health of the individual. In the United Kingdom, Amoxicillin is used as first-line therapy in the vast majority of patients who acquire pneumonia in the community, sometimes with added Clarithromycin.

In North America, macrolides are recommended as monotherapy for outpatient treatment of pneumonia in previously healthy patients. However, macrolide resistance is increasing among Streptococcus pneumonia. A macrolide + beta-lactam (amoxicillin-clavulonate, cefpodoxime) should be considered if macrolide resistance is > 25% (which is true in most areas of the US). Macrolide + beta-lactam should be used if the patient is not otherwise healthy.^[1] The macrolide + beta-lactam combination is also recommended for patients who require inpatient treatment for community acquired pneumonia.

If Staphylococcus aureus (rare cause of community-acquired pneumonia, but common in healthcare-associated pneumonia) is suspected based on history or chest x-ray, vancomycin should be added to the treatment. If Pseudomonas aeruginosa is suspected (likewise rare in the community, but common in healthcare settings), a beta-lactam antibiotic with activity against Pseudomonas should be chosen. Piperacillin-tazobactam and cefepime are commonly used for this purpose.

Respiratory fluoroquinolones (levofloxacin, moxifloxacin) are also options for treating community acquired pneumonia on an inpatient or outpatient basis ^[1]. However, in light of recent FDA warnings about fluoroquinolone use ^[2] given concerns about emerging resistance, fluoroquinolones are a less ideal treatment option.

Local patterns of antibiotic-resistance should always be considered when initiating pharmacotherapy. In critically ill patients or those with immune deficiencies, local guidelines determine the selection of antibiotics. These antibiotics are typically given intravenously.

Treatment of gram-positive organisms

Treatment of gram-negative organisms

Haemophilus influenzae (typical community-acquired organism) - amoxicillin-clavulonate or 3rd generation cephalosporin
Moraxella catarrhalis (typical community-acquired organism) - amoxicillin-clavulonate or 3rd generation cephalosporin
Klebsiella pneumoniae (typical hospital-acquired organism) - depends on resistance pattern, highly resistant strains (including ESBLs) can be seen. May require carbapenems in some cases.
Escherichia coli (typical hospital-acquired organism) - depends on resistance pattern, highly resistant strains (including ESBLs) can be seen. May require carbapenems in some cases.
Pseudomonas aeruginosa (typical hospital-acquired organism) - 4th generation cephalosporins, anti-pseudomonal penicillins, or fluoroquiolones

Treatment of atypical organisms

Most atypical causes of pneumonia require treatment for 14-21 days.

Chlamydophila pneumoniae (typical community-acquired organism) - Macrolide or doxycycline
Chlamydophila psittaci (less common community-acquired organism) - Macrolide or doxycycline
Mycoplasma pneumoniae (typical community-acquired organism) - Macrolide or doxycycline
Legionella pneumophila (less common community-acquired organism) - Macrolide or doxycycline

People who have difficulty breathing due to pneumonia may require extra oxygen. An extremely sick individual may require artificial ventilation and intensive care as life-saving measures while his or her immune system fights off the infectious cause with the help of antibiotics and other drugs.

References

↑ ^1.0 ^1.1 IDSA 2007 guidelines on pneumonia
↑ http://www.fda.gov/Drugs/DrugSafety/ucm500143.htm

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[:0-1] 1.0 ^1.1 IDSA 2007 guidelines on pneumonia

[2] ttp://www.fda.gov/Drugs/DrugSafety/ucm500143.htm

[1]

[2]

@@ Line 3: / Line 3: @@
 '''Editor(s)-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com] Phone:617-632-7753; [[Philip Marcus, M.D., M.P.H.]][mailto:pmarcus192@aol.com]
 ==Overview==
+Antimicrobial therapy is the mainstay of treatment for bacterial pneumonia.  Patients with severe disease, co-morbidities, and/or complications usually require hospitalization and multidrug therapy.
+==Medical Therapy==
+[[Antimicrobial]]s are the treatment of choice for bacterial pneumonia. The choice of antibiotic depends on the nature of the pneumonia, the microorganisms most commonly causing pneumonia in the geographical region, and the immune status and underlying health of the individual. In the [[United Kingdom]], [[Amoxicillin]] is used as first-line therapy in the vast majority of patients who acquire pneumonia in the community, sometimes with added [[Clarithromycin]].
+In North America, macrolides are recommended as monotherapy for outpatient treatment of pneumonia in previously healthy patients.  However, macrolide resistance is increasing among ''[[Streptococcus pneumonia]]''.  A [[macrolide]] + [[beta-lactam]] ([[amoxicillin-clavulonate]], [[cefpodoxime]]) should be considered if [[macrolide resistance]] is > 25% (which is true in most areas of the US).  [[Macrolide + beta-lactam]] should be used if the patient is not otherwise healthy.<ref name=":0">IDSA 2007 guidelines on pneumonia</ref> The [[macrolide]] + [[beta-lactam]] combination is also recommended for patients who require inpatient treatment for community acquired pneumonia.
-[[Antibiotic]]s are the treatment of choice for bacterial pneumonia. The antibiotic choice depends on the nature of the pneumonia, the microorganisms most commonly causing pneumonia in the geographical region, and the immune status and underlying health of the individual. In the [[United Kingdom]], [[amoxicillin]] is used as first-line therapy in the vast majority of patients who acquire pneumonia in the community, sometimes with added [[clarithromycin]]. In North America, where the "atypical" forms of community-acquired pneumonia are becoming more common, [[clarithromycin]], [[azithromycin]], or [[fluoroquinolones]] as single therapy, have displaced the amoxicillin as first-line therapy. Local patterns of antibiotic-resistance should always be considered when initiating pharmacotherapy. In hospitalized individuals or those with immune deficiencies, local guidelines determine the selection of antibiotics. These antibiotics are typically given through an [[intravenous]] line.
+If ''Staphylococcus aureus'' (rare cause of community-acquired pneumonia, but common in healthcare-associated pneumonia) is suspected based on history or [[chest x-ray]], [[vancomycin]] should be added to the treatment.  If ''Pseudomonas aeruginosa'' is suspected (likewise rare in the community, but common in healthcare settings), a beta-lactam antibiotic with activity against ''Pseudomonas'' should be chosen.  [[Piperacillin-tazobactam]] and [[cefepime]] are commonly used for this purpose.
-==Medical Therapy==
+Respiratory fluoroquinolones ([[Levofloxacin (oral)|levofloxacin]], [[moxifloxacin]]) are also options for treating community acquired pneumonia on an inpatient or outpatient basis <ref name=":0" />.  However, in light of recent FDA warnings about [[fluoroquinolone]] use <ref>http://www.fda.gov/Drugs/DrugSafety/ucm500143.htm</ref> given concerns about emerging resistance, fluoroquinolones are a less ideal treatment option.
+Local patterns of antibiotic-resistance should always be considered when initiating pharmacotherapy. In critically ill patients or those with immune deficiencies, local guidelines determine the selection of antibiotics. These antibiotics are typically given intravenously.
 ===Treatment of gram-positive organisms===
-*Streptococcus pneumoniae - [[amoxicillin]] (or erythromycin in patients allergic to penicillin); cefuroxime and erythromycin in severe cases.
+*[[Streptococcus pneumoniae]] ([[Community-acquired pneumonia|typical community-acquired organism]]) - [[Amoxicillin]], [[cephalosporins]], [[macrolides]]
-*Staphylococcus aureus - [[flucloxacillin]] (to counteract the organism's β-lactamase)
+*[[Staphylococcus aureus]] ([[Hospital-acquired pneumonia|typical hospital-acquired organism]]) - [[Vancomycin]]
 ===Treatment of gram-negative organisms===
-*[[Haemophilus influenzae]]
+*[[Haemophilus influenzae]] (typical community-acquired organism) - amoxicillin-clavulonate or 3rd generation cephalosporin
-*[[Klebsiella pneumoniae]]
+*[[Moraxella catarrhalis]] (typical community-acquired organism) - amoxicillin-clavulonate or 3rd generation cephalosporin
-*[[Escherichia coli]]
+*[[Klebsiella pneumoniae]] (typical hospital-acquired organism) - depends on resistance pattern, highly resistant strains (including [[ESBL|ESBLs]]) can be seen.  May require [[carbapenems]] in some cases.
-*[[Pseudomonas aeruginosa]]
+*[[Escherichia coli]] (typical hospital-acquired organism) - depends on resistance pattern, highly resistant strains (including ESBLs) can be seen.  May require carbapenems in some cases.
-*[[Moraxella catarrhalis]]
+*[[Pseudomonas aeruginosa]] (typical hospital-acquired organism) - [[Cefepime|4th generation cephalosporins]], [[Piperacillin sodium and tazobactam sodium|anti-pseudomonal penicillins]], or [[Ciprofloxacin|fluoroquiolones]]
 ===Treatment of atypical organisms===
 Most atypical causes of pneumonia require treatment for 14-21 days.
-*Chlamydophila pneumoniae - [[doxycycline]]
+*Chlamydophila pneumoniae (typical community-acquired organism) - Macrolide or doxycycline
-*[[Chlamydophila psittaci]] - [[erythromycin]]
+*[[Chlamydophila psittaci]] (less common community-acquired organism) - Macrolide or doxycycline
-*Mycoplasma pneumoniae - [[erythromycin]]
+*Mycoplasma pneumoniae (typical community-acquired organism) - Macrolide or doxycycline
-*Coxiella burnetti - [[erythromycin]]
+*[[Legionella pneumophila]] (less common community-acquired organism) - Macrolide or doxycycline
-*[[Legionella pneumophila]]- [[erythromycin]], with [[rifampicin]] sometimes added.
-People who have difficulty breathing due to pneumonia may require extra [[oxygen]]. An extremely sick individual may require[[artificial ventilation]] and [[intensive care medicine|intensive care]] as life-saving measures while his or her immune system fights off the infectious cause with the help of antibiotics and other drugs.
+People who have difficulty breathing due to pneumonia may require extra [[oxygen]]. An extremely sick individual may require [[artificial ventilation]] and [[intensive care medicine|intensive care]] as life-saving measures while his or her immune system fights off the infectious cause with the help of antibiotics and other drugs.
 ==References==
 {{reflist|2}}
-[[Category:Diseaase]]
+[[Category:Disease]]
 [[Category:Pulmonology]]
 [[Category:Bacterial diseases]]
 [[Category:Pneumonia|Pneumonia]]
 [[Category:Emergency medicine]]
+[[Category:Up to Date]]
 {{WH}}
 {{WS}}