Community-Acquired Pneumonia Treatment Guidelines

Introduction to Treatment Options

The American Thoracic Society recommends that treatment for community-acquired pneumonia (CAP) should be based on patient risk factors, severity of illness, and setting of care, with empiric antibiotic therapy tailored to cover the most likely pathogens while considering local resistance patterns 1, 2

For healthy adults without comorbidities, the first choice of treatment is Amoxicillin 1 g three times daily (strong recommendation, moderate quality evidence) 1, 2
Alternative options for healthy adults without comorbidities include Doxycycline 100 mg twice daily (conditional recommendation, low quality evidence) 1, 2 and Macrolides (azithromycin 500 mg on first day then 250 mg daily or clarithromycin 500 mg twice daily) only in areas with pneumococcal resistance to macrolides <25% (conditional recommendation) 1, 2
For adults with comorbidities, combination therapy options include Amoxicillin/clavulanate (500/125 mg three times daily, 875/125 mg twice daily, or 2000/125 mg twice daily) OR a cephalosporin (cefpodoxime 200 mg twice daily or cefuroxime 500 mg twice daily) PLUS a macrolide (azithromycin 500 mg on first day then 250 mg daily, clarithromycin 500 mg twice daily) or doxycycline 100 mg twice daily 1, 2

The preferred regimen for inpatient treatment (non-ICU) is β-lactam (ampicillin/sulbactam, cefotaxime, ceftriaxone, or ceftaroline) PLUS a macrolide (azithromycin or clarithromycin) 4, 5
Alternative options for inpatient treatment (non-ICU) include a respiratory fluoroquinolone alone (levofloxacin, moxifloxacin) 4, 5

For patients without risk factors for Pseudomonas aeruginosa, combination therapy includes Non-antipseudomonal β-lactam (ceftriaxone, cefotaxime) PLUS either a macrolide or a respiratory fluoroquinolone 2, 6, 3, 5
For patients with risk factors for Pseudomonas aeruginosa, combination therapy includes Antipseudomonal β-lactam (cefepime, ceftazidime, piperacillin-tazobactam, meropenem) PLUS either Ciprofloxacin OR a macrolide plus aminoglycoside (gentamicin, tobramycin, or amikacin) 2, 6, 3, 5

For patients with MRSA risk factors, add MRSA coverage (vancomycin or linezolid) and obtain cultures/nasal PCR to allow de-escalation 5
The duration of therapy is generally 5-7 days for responding patients 6, 3
Procalcitonin levels may guide shorter treatment duration 6, 3

For suspected or confirmed Legionella, treatment options include Respiratory fluoroquinolone (levofloxacin preferred) or macrolide (azithromycin preferred) ± rifampin 6, 3
For Mycoplasma or Chlamydophila, treatment options include Macrolide, doxycycline, or respiratory fluoroquinolone 6, 3

Delayed antibiotic administration can reduce mortality 6, 3
Overuse of fluoroquinolones should be avoided to prevent development of resistance 1, 2
Inadequate coverage of causative pathogens is associated with worse outcomes 1, 2
Procalcitonin should not be used to withhold initial antibiotic therapy in patients with clinically suspected and radiographically confirmed CAP 5
Validated severity tools (2007 IDSA/ATS criteria) should be used to guide site-of-care decisions and treatment intensity 1, 2