Pneumonia: antibiotic therapy recommendations

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Pneumonia
Duration of treatment: Community acquired-mild: 7-10days. // Gram negative (usually nosocomial): 3 to 6 weeks. // Staphylococcal: 3 to 4 weeks // Legionella, mycoplasma, chlamydia: 14 to 21 days. // Lung abscess: 4 to 6 weeks.

Possible therapeutic alternatives

Pneumonia: Community acquired. (outpatient therapy) Adult 18-60yo

Common pathogens

Erythromycin 500mg orally four times daily or

Azithromycin 250 to 500mg orally once daily for 7-10 days or

Clarithromycin 500mg orally twice daily or 1gram (XR) orally once daily.

Doxycycline 100mg orally twice daily or

Levofloxacin 500 mg - 750 mg once daily or

Augmentin 875 mg orally twice daily or

Moxifloxacin 400mg po qd x 10days

Community acquired. Adult (any age)

Common pathogens

Hospitalized patient:

*Erythromycin 500mg to 1 gram IV every 6 hours + Cefuroxime 750 mg IV every 8 hours (may substitute Azithromycin 500mg IV once daily for erythromycin) or

*Erythromycin 500mg to 1 gram IV every 6 hours + [Ceftriaxone 1 gram IV q12h or Cefotaxime 2 grams IV every 4 to 8 hours] or

If mild (monotherapy):

Azithromycin 500mg IV once daily x 2-5 days, then 500mg orally once daily or

Levofloxacin 500mg IV once daily.

Outpatient therapy:

Azithromycin 500mg once daily or

Clarithromycin 500mg twice daily or

Levofloxacin 500mg once daily or

Augmentin 875mg orally twice daily

Hospital acquired (nosocomial)

Common pathogens

[Piperacillin 3-4 grams IV every 6 hours + tobramycin] or

[Ceftazidime 1-2 grams IV every 8 hours or Cefepime 1-2 grams q 12h ] + tobramycin or

Ticarcillin-clavulanic acid 3.1g IV every 6 hours + Tobra/gent or

Imipenem 500mg IV every 6 hours.

Special considerations:

Add Erythromycin 500mg to 1 gram IV every 6 hours or Azithromycin 500mg IV once daily if legionella suspected.

Substitute: Aztreonam for piperacillin, timentin or cephalosporin if allergic to penicillin.

[Severe penicillin allergy]:
Levofloxacin 500mg IV qd + aminoglycoside or
Aztreonam + Aminoglycoside

Aspiration pneumonia

Common pathogens

Community acquired:

Clindamycin 600mg ivpb every 6 to 8 hours or

Augmentin 875mg PO bid or 500mg tid x 10 days

Hospital acquired:

Piperacillin-tazobactam 3.375g ivpb q6h or

Ticarcillin-clavulanic acid 3.1g ivpb q6h or

Ampicillin-sulbactam (Unasyn) 1.5-3.0 grams ivpb q6h.

Cefoxitin 2 grams ivpb q6-8h or Cefotetan 1-2 grams IV q12h.

[Cefotaxime 2g ivpb q8h or Ceftriaxone 2 grams ivpb q24h] + Clindamycin 600mg IV q6-8h.

Clindamycin 600mg IV q6-8h + [Ciprofloxacin 400mg IV q12h or Levofloxacin 500mg IV qd. ]

Hospital acquired: (Cover most common pathogens + possibility of aspiration)

Common pathogens

Piperacillin-tazobactam 3.375 grams IV every 6 hours + Ciprofloxacin 400mg IV q12h or

Cefepime 2 grams IV every 12 hours + Clindamycin 600mg IV every 6 hours.

(Elderly, nursing home, other risk factors, pseudomonas not suspected) OR Non-ICU patient:

Common pathogens

[Ceftriaxone 1-2 grams q12-24h or Cefepime 1-2 grams q12h] + Azithromycin 500mg IV qd.
Or
Levofloxacin 500mg IV qd.
Or
Moxifloxacin 400mg IV qd.

Antimicrobial Series
References

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Lipsky BA, Berendt AR.Principles and practice of antibiotic therapy of diabetic foot infections.
Diabetes Metab Res Rev. 2000 Sep-Oct;16 Suppl 1:S42-6.

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Curr Infect Dis Rep. 1999 Apr;1(1):57-64.

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