Pneumonia

Pathogens

 Community-Acquired Pneumonia  HAP/VAP/HCAP
Streptococcus pneumoniae
Haemophilus influenzae
Gram-negative bacilli (E. Coli, Klebsiella pneumoniae)
Staphylococcus aureus
Moraxella catarrhalis
Legionella pneumophilia
Chlamydophila pneumoniae
Mycoplasma pneumoniae
Viral (Influenza, parainfluenza, respiratory syncytial virus, metapneumovirus,  adenovirus)
these, plus:
pseudomonas aeruginosa
resistant strep pneumoniae
MRSA

Risk for drug-resistant Strep pneumo:

Age < 2 or > 65 years
β-lactam therapy within the previous 3 months
Alcoholism
Medical comorbidities (COPD, CHF, renal or hepatic failure, etc.)
Immunosupressive illness or therapy
Exposure to a child in a daycare center

Risk for Pseudomonas:

Structural lung disease (e.g. bronchiectasis)
Repeated exacerbations of COPD/asthma leading to frequent steroid/abx use
Prior antibiotic therapy

Risk for MRSA:

End-stage renal disease
Injection drug abuse
Prior influenza infection
Prior antibiotic therapy

Treatment

IDSA/ATS guidelines: Recommended empiric antibiotics for community-acquired pneumonia in adults
Outpatient treatment
1. Previously healthy and no use of antimicrobials within the previous 3 months:

A macrolide (azithromycin, clarithromycin, or erythromycin)

OR

Doxycyline*

2. 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 a different class should be selected):

A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])

OR

A beta-lactam (first-line agents: high-dose amoxicillin, amoxicillin-clavulanate; alternative agents: ceftriaxone, cefpodoxime, or cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)*

3. In regions with a high rate (>25 percent) of infection with high-level (MIC ≥16 µg/mL) macrolide-resistant Streptococcus pneumoniae, consider use of alternative agents listed in (2) above.
Inpatients, non-ICU treatment

A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])

OR

An antipneumococcal beta-lactam (preferred agents: cefotaxime, ceftriaxone, or ampicillin-sulbactam; ertapenem for selected patients) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)*

Inpatients, ICU treatment

An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS azithromycin

OR

An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])

OR

For penicillin-allergic patients, a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) PLUS aztreonam

Special concerns
If Pseudomonas is a consideration:

An antipneumococcal, antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) PLUS either ciprofloxacin or levofloxacin (750 mg)

OR

The above beta-lactam PLUS an aminoglycoside PLUS azithromycin

OR

The above beta-lactam PLUS an aminoglycoside PLUS a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]); for penicillin-allergic patients, substitute aztreonam for above beta-lactam

If CA-MRSA is a consideration:
Add vancomycin or linezolid
This table provides the 2007 recommendations of the Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS) for reference purposes. Please see the UpToDate text for information about choosing between the different guidelines and about the preferred doses and durations of the individual antibiotics.
CA-MRSA: community-acquired methicillin-resistent Staphylococcus aureus; ICU: intensive care unit.
* Doxycycline may be used as an alternative to a macrolide, but there is stronger evidence to support the use of a macrolide than doxycycline for CAP.
Modified with permission from: Mandell, LA, Wunderink, RG, Anzueto, A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27. Copyright © 2007 University of Chicago Press.


HAP/VAP

Kalil et al. Clin Inf Dis 2016
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