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Community Acquired Pneumonia

The following is a summary of the 2019 American Thoracic Society and Infectious Diseases Society of America Guidelines1. (Full Text) The guidelines recommend abandoning the “health care associated pneumonia” categorization of patients and instead recommend the following.

Antibiotic Selection


Outpatient adult with no comorbidities:

  • Amoxicillin 1 g TID (strong recommendation, moderate quality of evidence), or
  • Doxycycline 100 mg BID (conditional recommendation, low quality of evidence), or
  • Macrolide – only in areas with pneumococcal resistance to macrolides <25% (conditional recommendation, moderate quality of evidence). Note: Most areas in the US have already exceeded this threshold.
    • azithromycin 500 mg on first day then 250 mg daily or
    • clarithromycin 500 mg BID or clarithromycin extended release 1,000 mg daily

Outpatient adults with comorbidities such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia:

  • Combination therapy: strong recommendation, moderate quality of evidence
    • Amoxicillin/clavulanate 500 mg/125 mg TID or
    • Amoxicillin/clavulanate 875 mg/125 mg BID or
    • Amoxicillin/clavulanate 2,000 mg/125 mg BID or
    • Cefpodoxime 200 mg BID or
    • Cefuroxime 500 mg BID
  • AND
    • Azithromycin 500 mg day one, then 250 mg daily or
    • Clarithromycin 500 mg BID or
    • Clarithromycin extended release 1,000 mg once daily or
    • Doxycycline 100 mg twice daily (conditional, low quality of evidence)
  • Monotherapy: strong recommendation, moderate quality of evidence
    • Levofloxacin 750 mg daily or
    • Moxifloxacin 400 mg daily or
    • Gemifloxacin 320 mg daily

Adult inpatient without risk factors for MRSA or Pseudomonas

  • Combination Therapy: strong recommendation, high quality of evidence
    • Ampicillin + sulbactam 1.5–3 g every 6 h or
    • Cefotaxime 1–2 g every 8 h or
    • Ceftriaxone 1–2 g daily or
    • Ceftaroline 600 mg every 12 h
  • Plus
    • Azithromycin 500 mg daily or
    • Clarithromycin 500 mg BID

Patient who have contraindications to both macrolides and fluoroquinolones may substitute doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence).

  • Monotherapy: strong recommendation, high quality of evidence
    • Levofloxacin 750 mg orally or IV daily or
    • Moxifloxacin 400 mg orally or IV daily

Adult inpatient with prior history of culture positive MRSA or P. Aeruginosa

Previous MRSA isolation

  • Vancomycin 15 mg/kg every 12 hours, adjust based on levels
  • Linezolid 600 mg every 12 hours

Previous evidence of Pseudomonas aeruginosa

  • Piperacillin-tazobactam 4.5 g every 6 hours
  • Cefepime 2 g every 8 hours
  • Ceftazidime 2 g every 8 hours
  • Imipenem 500 mg every 6 hours
  • Meropenem 1 g every 8 hours
  • Aztreonam 2 g every 8 hours

Disposition

The guidelines recommend use of a risk scoring system to guide decision of disposition. Recommended options include:

Who needs to be admitted?

Admit to inpatient floor or ICU?


Sources:

  1. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST. PMID: 31573350; PMCID: PMC6812437.
  2. Jones BE, Jones J, Bewick T, Lim WS, Aronsky D, Brown SM, et al. CURB-65 pneumonia severity assessment adapted for electronic decision support. Chest 2011;140:156–163. PubMed

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