Community-acquired pneumonia medical therapy

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

Overview

Community acquired pneumonia treatment includes using the appropriate antibiotic and managing complications. An empirical therapy may be started while awaiting culture results. Once culture results are available specific treatment may be started. Empiric therapy is classified according to severity using the Pneumonia severity scale (PSI) and the CURB-65 score. Empirical therapy usually includes coverage for atypical and typical bacteria.

Antibiotic Therapy

Choice of antibiotic therapy

• Infectious diseases society of America and American thoracic society (IDSA-ATS) recommend the following guidelines for patients admitted to hospital.

1. Respiratory fluoroquinolone- Moxifloxacin 400 mg / day or levofloxacin 750 mg / day OR
2. Use a combination of second generation or third generation cephalosporin and a macrolide.
3. Macrolides, Doxycycline, fluoroquinolones are most appropriate for atypical bacteria.
4. In severe community acquired pneumonia start a cephalosporin with either a fluoroquinolone or a macrolide.
5. Hospitalized patients with community acquired pneumonia should be treated with a respiratory fluoroquinolone or a combination of cephalosporin and macrolide should be used.

• Before initiating therapy the patient should be evaluated according to the following criteria:

1. The level of testing needed to find out the etiology
2. Class of antibiotic to be started
3. Site-of-care decisions (outpatient, inpatient, or intensive care unit)

• The proper antibiotic therapy is the one that provides coverage for

1. Streptococcus pneumoniae
2. Atypical bacteria (Mycoplasma, Chlamydophila, Legionella, etc.)

Following are the guidelines to treat community acquired pneumonia.

• For patients treated in the outpatient department coverage for atypical organisms should be added. Young individuals usually gain herd immunity from infants and children who have been vaccinated with pneumococcal vaccination.

• Macrolides have a better outcome than fluoroquinlones which may be due to nonbactericidal effects.

• Empirical therapy with coverage for Pseudomonas aeruginosa and MRSA should be started for patients with risk factors for healthcare-associated pneumonia. The pneumonia specific criteria according to Shindo et al is

1. Hospitalization for >2 days
2. Antibiotic use during previous admission
3. Non-ambulatory status
4. Tube feedings
5. Immunocompromised status
6. Use of gastric acid suppressive agents

• Some useful interventions to decrease mortality and tranfer from floor to ICU include:

1. Aggressive fluid resuscitation
2. Prompt antibiotic initiation
3. Measure arterial blood gas in patients who have borderline hypoxemia or lactate
4. Treat co-existing illness like asthma and COPD with bronchodilators.

Timing and duration of antibiotic therapy

• High priority should be provided in the emergency room and should be immediately admitted to the intensive care unit for patients who present with 3 or more of the minor criteria:

1. Elevated blood urea nitrogen
2. Confusion
3. High respiratory rate

• First antibiotic dose should be administered within 6 hours of admission into the emergency room.

• An increased in deaths were noted when antibiotic were administered after 4 hours of administration.

• Inadvertently use of antibiotic for patients without community-acquired pneumonia who require treatment before 4 hours may increase the risk of Clostridium difficile colitis.

• Shock is an exception where antibiotic should be started within an hour of hypotension. A decrease in 8% of survival rate for each hour of delay is noted.

• Antibiotic therapy for a duration of 5-7 days has been considered as adequate for treatment of community-acquired pneumonia.

Location of treatment

• IDSA-ATS guidelines suggest that if three or more out of the nine minor criteria is present then the patient must be moved to the ICU.

• Other scores have also been developed which help to distinguish moderately ill to severely ill patients.

Empirical Treatment

▸ Click on the following categories to expand treatment regimens.

Community-Acquired Pneumonia   ▸   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 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

Pathogen Based Treatment

▸ Click on the following categories to expand treatment regimens.

Bacteria   ▸  Streptococcus pneumoniae   ▸  Haemophilus influenzae   ▸  Bacillus anthracis (inhalation)   ▸  Enterobacteriaceae   ▸  Pseudomonas aeruginosa   ▸  Staphylococcus aureus   ▸  Bordetella pertussis   ▸  Anaerobe (aspiration)   ▸  Mycobacterium tuberculosis   ▸  Yersinisa pestis

Streptococcus pneumoniae Penicillin nonresistant; MIC < 2 mg / mL Preferred Regimen ▸ Penicillin G 2-3 million units IV q4h OR ▸Amoxicillin 875 mg PO q12h or 500 mg q8h Alternative Regimen ▸ Macrolide OR ▸ Cefpodoxime 200 mg PO q12h for 14 days OR ▸ Cefprozil 500 mg PO q12h for 10 days OR ▸Cefuroxime 750 mg PO/IV q8h OR ▸Cefdinir 300 mg PO q12h for 10 days OR ▸Cefditoren 400 mg PO q12h for 14 day OR ▸Ceftriaxone 1 g IV q24h, 2 g daily for patients at risk OR ▸Cefotaxime 1 g IM/IV q12h OR ▸Clindamycin 150-450 mg PO q6-8h (max: 1800 mg/day) OR ▸Clindamycin 1.2-2.7 g/day IM/IV in 2-4 divided doses (max:4800 mg/day) OR ▸Doxycycline 100 mg PI/IV q12h OR ▸Respiratory fluoroquinolone Penicillin resistant; MIC > 2 mg / mL Preferred Regimen ▸ Agents chosen on the basis of susceptibililty ▸ Cefotaxime 1 g IM/IV q12h OR ▸Ceftriaxone 1 g IV q24h, 2 g daily for patients at risk OR ▸Fluoroquinolone Alternative Regimen ▸ Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days depending on severity OR ▸Linezolid 600 mg PO/IV q12h for 10-14 days OR ▸Amoxicillin 875 mg PO q12h or 500 mg q8h ( 3 g/day with penicillin MIC 4 ≤ microgram / mL) Haemophilus influenzae Non–B-lactamase producing Preferred Regimen ▸ Amoxicillin 875 mg PO q12h or 500 mg q8h Alternative Regimen ▸ Fluoroquinolone OR ▸ Doxycycline 100 mg PO/IV q12h OR ▸ Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR ▸Clarithromycin 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days B-lactamase producing Preferred Regimen ▸ 2nd or 3rd Generation Cephalosporin OR ▸Amoxicillin-clavulanate 2 g q12h Alternative Regimen ▸ Fluoroquinolone OR ▸ Doxycycline 100 mg PO/IV q12h OR ▸ Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR ▸Clarithromycin 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days Bacillus anthracis (inhalation) Preferred Regimen ▸ 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 ▸Doxycycline 100 mg PO/IV q12h Alternate Regimen ▸ Other fluoroquinolones OR ▸B-lactam (if susceptible) OR ▸Rifampin 600 mg PO/IV q24h for 4 days OR ▸Clindamycin 150-450 mg PO q6-8h OR ▸Chloramphenicol 50-100 mg/kg/day IV in divided q6h Enterobacteriaceae Preferred Regimen ▸ 3rd generation cephalosporin OR ▸Carbapenem † (drug of choice if extended-spectrum b-lactamase producer) Alternate Regimen ▸ b-Lactam / b-lactamase inhibitor‡ OR ▸Fluoroquinolone † = Imipenem-cilastatin, meropenem, ertapenem ‡= Piperacillin-tazobactam for gram-negative bacilli, ticarcillin-clavulanate, ampicillin-sulbactam or amoxicillin-clavulanate Pseudomonas aeruginosa Preferred Regimen ▸Ticarcillin 200-300 mg/kg/day in divided doses q4-6h (max: 18 g/day) OR ▸Piperacillin 6-8 g/day IM/IV (100-125 mg/kg daily) divided q6-12h OR ▸Ceftazidime 500 mg to 1 g q8h OR ▸ Cefepime 1-2 g q12h for 10 days OR ▸ Aztreonam 2 g IV q6-8h (max: 8 g/day) OR ▸ Imipenem 500 mg IV q6h OR ▸Meropenem 500 mg IV q8h PLUS ▸ Ciprofloxacin 500-750 mg q12h for 7-14 days OR ▸Levofloxacin 750 mg daily OR ▸Aminoglycoside Alternate Regimen ▸ Aminoglycoside PLUS ▸Ciprofloxacin 500-750 mg q12h for 7-14 days OR ▸Levofloxacin 750 mg daily Staphylococcus aureus Methicillin susceptible Preferred Regimen ▸ Nafcillin 1000-2000 mg q4h OR ▸Oxacillin 2 g IV q4h OR ▸Flucloxacillin 250 mg IM/IV q6h Alternative Regimen ▸ Cefazolin 500 mg IV q12h OR ▸ Clindamycin 150-450 mg PO q6-8h Methicillin resistant Preferred Regimen ▸ Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days OR ▸Linezolid 600 mg PO/IV q12h for 10-14 days Alternative Regimen ▸ TMP-SMX 1-2 double-strength tablets (800/160 mg) q12-24h Bordetella pertussis Preferred Regimen ▸ Macrolide Alternate Regimen ▸ TMP-SMX 1-2 double-strength tablets (800/160 mg) q12-24h Anaerobe (aspiration) Preferred Regimen ▸ Piperacillin-tazobactam 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) OR ▸Ticarcillin clavulanate 200-300 mg/kg/day idivided q4-6h (max: 18 g/day) OR ▸ Ampicillin-sulbactam 1500-3000 mg IV q6h OR ▸ Amoxicillin-clavulanate 250-500 mg PO q8h or 875 mg q12h OR ▸Clindamycin 150-450 mg PO q6-8h (max: 1800 mg/day) Alternate Regimen ▸ Carbapenem Mycobacterium tuberculosis Preferred Regimen ▸ Isoniazid 5 mg/kg/day q24h (usual dose: 300 mg/day) PLUS ▸ Rifampin 10 mg/kg/day (maximum: 600 mg / day) PLUS ▸ Ethambutol 5-25 mg/kg (maximum dose: 1.6 g) PLUS ▸ Pyrazinamide 1000 - 2000 mg / day Alternate Regimen Click here for more treatment regimens Yersinisa pestis Preferred Regimen ▸ Streptomycin 15 mg/kg/day (max 1 g/day) OR ▸Gentamicin 7 mg/kg/day Alternate Regimen ▸ Doxycycline 100 mg PO/IV q12h OR ▸Fluoroquinolone

Atypical Bacteria   ▸  Mycoplasma pneumoniae   ▸  Chlamydophila pneumoniae   ▸  Legionella species   ▸  Chlamydophila psittaci   ▸  Coxiella burnetii   ▸  Francisella tularensis   ▸  Burkholderia pseudomallei   ▸  Acinetobacter species

Mycoplasma pneumoniae Preferred Regimen ▸ Macrolide OR ▸Tetracycline Oral: 250-500 mg q6h Alternate Regimen ▸ Fluoroquinolone Chlamydophila pneumoniae Preferred Regimen ▸ Macrolide OR ▸Tetracycline 250-500 mg PO q6h Alternate Regimen ▸ Fluoroquinolone Legionella species Preferred Regimen ▸ Fluoroquinolone OR ▸Azithromycin 500 mg PO on day 1 followed by 250 mg q24h Alternate Regimen ▸ Doxycycline 100 mg PO/IV q12h Chlamydophila psittaci Preferred Regimen ▸ Tetracycline 250-500 mg PO q6h Alternate Regimen ▸ Macrolide Coxiella burnetii Preferred Regimen ▸ Tetracycline 250-500 mg PO q6h Alternate Regimen ▸ Macrolide Francisella tularensis Preferred Regimen ▸ Doxycycline Alternate Regimen ▸ Gentamicin 7 mg/kg/day OR ▸Streptomycin 15 mg/kg/day (maximum: 1 g) Burkholderia pseudomallei Preferred Regimen ▸ Carbapenem OR ▸Ceftazidime 0.5-1 g q8h Alternate Regimen ▸ Fluoroquinolone OR ▸TMP-SMX 1-2 double-strength tablets (800/160 mg) q12-24h Acinetobacter species Preferred Regimen ▸ Carbapenem Alternate Regimen ▸ Cephalosporin-aminoglycoside OR ▸ Ampicillin-sulbactam OR ▸Colistin 2.5-5 mg/kg/day IM/IV divided q6-12h (max: 5 mg/kg/day)

Virus   ▸  Influenza virus

Influenza virus) Preferred Regimen ▸ Oseltamivir 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) OR ▸Zanamivir Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)

Fungi   ▸  Coccidioides species   ▸  Histoplasmosis   ▸  Blastomycosis

Coccidioides species) Preferred Regimen ▸ Itraconazole 200 mg q12h OR Fluconazole 200-400 mg daily for 3-6 month Alternate Regimen ▸ Amphotericin B 0.5-0.7 mg/kg/day Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection Histoplasmosis) Preferred Regimen ▸ Itraconazole 200 mg q12h Alternate Regimen ▸ Amphotericin B 0.5-0.7 mg/kg/day Blastomycosis) Preferred Regimen ▸ Itraconazole 200 mg q12h Alternate Regimen ▸ Amphotericin B 0.5-0.7 mg/kg/day

Management of Pneumonia with Parapneumonic Effusion

Shown below is an algorithm for the management of parapneumonic effusion in pediatric patients based on the 2011 Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.
Abbreviations:

Confirm pleural effusion with chest X-ray. If not conclusive, order chest ultrasound or CT

Determine the size of the effusion

Small < 25% opacification of the thorax

Moderate Between 25-50% opacification of the thorax

Large > 50% opacification of the thorax

Give antibiotic treatment. Pleural drainage is not recommended. Is the patient improving?

Does the patient has respiratory distress?

Order a ultrasound or CT to assess effusion size and loculation Pleural drainage is indicated to drain fluid and send sample for culture Is the pleural effusion loculated?

Yes

No

Yes

No

Yes

No

Continue antibiotic therapy

Reassess the size of the effusion and follow the algorithm according to the size of effusion.

Follow algorithm for large effusion

Administer IV antibiotics Obtain chest ultrasound Do thoracocentesis to obtain a fluid sample for culture

Management of Non-responding Pneumonia

Definition

A failure to response even after 7 days of antibiotic treatment is categorized into non responding pneumonia. A progressive or deterioration causing respiratory faiure as septic shock within 72 hrs of hospital admission.

Management

The following steps should be taken as soon as the patient doesn't respond to treatment

1. Transfer to a higher centre
2. Order further diagnostic tests
3. Change treatment

After a failure of treatment the following causes should be considered before proceeding further.

• Resistant microorganism
• Uncovered pathogen
• Nosocomial superinfection/Pneumonia
• Complication of pneumonia (e.g., BOOP)
• Misdiagnosis:

1. Pulmonary Embolism
2. CHF
3. Vasculitis

• Inaccurate diagnosis

The following actions are performed to find out the cause of a non responding pneumonia.

Cultures

A repeat blood culture should be performed if the pneumonia deteriorates .Inspite of treatment with prior antibiotic therapy blood cultures might still show high colonies.

Rapid urinary antigens

S. pneumoniae and L. pneumophila may remain positive inspite of starting antibiotic therapy.

Stopping B-Lactam

Stopping B-Lactam component of the combination may be important to rule out drug fever.

Pneumococcal Antigen test

Some host may be have poor immunity and hence a pneumococcal antigen test should be scheduled to rule out that the cause was not incorrect antibiotics.

Obtain cultures from catheters

Extrapulmonary infection in ICU patients should be ruled out by obtaining cultures from intravascular catheter. A culture must also be obtained to rule out urinary, abdominal and skin infections which may be the result of the non response to treatment.

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.

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.