Antibiotic Treatment for Bronchitis and Pneumonia

Introduction to Antibiotic Treatment

The European guidelines from 2011 strongly recommend adding a macrolide (preferably azithromycin over erythromycin) to beta-lactam therapy to improve coverage of atypical pathogens such as Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella 1, 2, 4.

For hospitalized patients with moderate community-acquired pneumonia, first-line options include aminopenicillin ± macrolide, aminopenicillin/beta-lactamase inhibitor ± macrolide, or third-generation cephalosporin (cefotaxime or ceftriaxone) ± macrolide 1, 2.
Primary choices for ordinary ward patients include ceftriaxone 1-2 g IV every 12 hours + azithromycin 500 mg IV/PO per day, cefotaxime 1-2 g IV every 8 hours + azithromycin 500 mg IV/PO per day, amoxicillin/clavulanate 1.2 g IV every 8-12 hours ± macrolide, levofloxacin 750 mg IV/PO per day in monotherapy, or moxifloxacin 400 mg IV/PO per day in monotherapy 1, 2, 3.

For patients with severe pneumonia requiring intensive care without risk factors for Pseudomonas aeruginosa, use non-antipseudomonal third-generation cephalosporin + macrolide, or respiratory fluoroquinolone (moxifloxacin or levofloxacin) ± cephalosporin 1, 2.
With risk factors for P. aeruginosa: antipseudomonal cephalosporin (ceftazidime, cefepime) or piperacillin-tazobactam 4.5 g IV every 6 hours or carbapenem (meropenem preferred) PLUS ciprofloxacin OR PLUS macrolide + aminoglycoside 1, 2, 5.

The duration of treatment should not generally exceed 8 days in a patient who responds to therapy 1, 2, 4.

In outpatient pneumonia, treatment can be applied orally from the start 1, 2.
In hospitalized patients, sequential treatment should be considered in all patients except the most severely ill 1, 2.

For patients admitted from home, use beta-lactam/beta-lactamase inhibitor (amoxicillin/clavulanate, ampicillin/sulbactam) orally or intravenously, clindamycin, or moxifloxacin 1, 5.
For patients in intensive care or from nursing homes: clindamycin + cephalosporin, or cephalosporin + metronidazole 1, 5.

For Legionella spp.: levofloxacin 750 mg/day or moxifloxacin 400 mg/day, or macrolide (azithromycin preferred) ± rifampicin 1, 2, 4.
For Mycoplasma pneumoniae and Chlamydophila pneumoniae: doxycycline 100 mg every 12 hours, macrolide (azithromycin 500 mg on day 1, then 250 mg/day for 4 days), levofloxacin 750 mg/day, or moxifloxacin 400 mg/day 1, 2, 3, 4.

Start antibiotic therapy immediately after diagnosis of community-acquired pneumonia 2, 4.
Avoid using azithromycin as monotherapy in patients with pneumonia who require hospitalization, as it has been shown to be effective only in combination with beta-lactams or as an alternative to respiratory fluoroquinolones 1, 2.