The Harrison's Practice Preview allows you to view 5 FREE complete topics or conduct a search that delivers abstracts for more than 450 medical topics. For full access, please subscribe today!

Specific Treatments

Outpatient (dosing for adults with normal renal function)

• Patients with no comorbidities and no risk factors for drug-resistant S. pneumoniae (DSRP) infection
  • Clarithromycin XL (1000 mg PO qd for 7 days) or
  • Azithromycin (500 mg PO once, then 250 mg/d PO for 4 days or 500 mg/d PO for 3 days or 2 g PO once) or
  • Doxycycline (100 mg PO bid for 7–10 days)
• Patients with comorbidities (COPD, diabetes, renal or congestive heart failure, malignancy) and/or risk factors for DRSP infection or a high DRSP prevalence in the community
  • One of the following
    • Quinolone with enhanced activity against S. pneumoniae
      • Levofloxacin (500–750 mg PO qd) or
      • Moxifloxacin (400 mg PO qd) or
      • Gatifloxacin (400 mg PO qd)
    • β-lactam (cefpodoxime, 200 mg PO bid; or cefprozil, 500 mg PO bid; or amoxicillin, 1000 mg PO tid; or amoxicillin/clavulanic acid, 875/175 mg PO tid or 1000/62.5 mg PO tid) plus
      
      • Macrolide (clarithromycin or azithromycin dosed as above) or
      • Doxycycline dosed as above
    • Telithromycin (800 mg q24h for 7–10 days)

Hospital ward (dosing for adults with normal renal function)

• Quinolone with enhanced activity against S. pneumoniae (see above) or
• Azithromycin (1 g IV; then, 24 h later, start 500 mg IV q24h) plus
  • β-lactam
    • Cefuroxime (750 mg IV q8h) or
    • Ceftriaxone (1–2 g IV qd) or
    • Cefotaxime (1–2 g IV q6–8h) or
    • Ampicillin/sulbactam (1.5–3 g IV q6h)
      

ICU (dosing for adults with normal renal function)

• Patients with no risk factors for P. aeruginosa infection
  • β-lactam (ceftriaxone, 1–2 g IV q24h; or cefotaxime, 1–2 g IV q6–8h) plus
    • Quinolone IV (dosed as above) or
    • Azithromycin (1 g IV; then, 24 h later, start 500 mg IV q24h)
• Patients with risk factors for P. aeruginosa (e.g., bronchiectasis, malnutrition, treatment with > 10 mg of prednisone qd, HIV infection, broad-spectrum antibiotic therapy for > 7 days in the past month, prior P. aeruginosa infection)
  
  • Carbapenem or antipseudomonal cephalosporin or piperacillin/tazobactam (doses below) plus
    
    • Quinolone dosed as above or
    • Azithromycin (1 g IV; then, 24 h later, start 500 mg IV q24h)
  • Dosing
    • Carbapenem: imipenem, 500 mg IV q6h; or meropenem, 1g IV q8h
    • Antipseudomonal cephalosporin: cefepime, 2 g IV q8h; or ceftazidime, 2 g IV q8h
    • Piperacillin/tazobactam: 4.5 g IV q6h
• Severely ill patients
  • Consider coverage for methicillin-resistant S. aureus (MRSA) as well (vancomycin, 1 g IV q12h) until microbiology data become available.
• Monotherapy with a quinolone is not recommended for severely ill patients with CAP.
• Note: Quinolone treatment is not recommended for patients with pneumococcal meningitis.
  

Nursing home treatment (dosing for adults with normal renal function)

• As for outpatients with comorbidities or risk factors for DRSP (see above)
• May use ceftriaxone (500–1000 mg/d IM) or cefotaxime (500 mg IM q12h) in place of PO β-lactam
• Patients from a nursing home who are admitted to the hospital with pneumonia should be treated the same as other hospitalized/ICU patients.
  

Aspiration pneumonitis (dosing for adults with normal renal function)

• Aspiration pneumonitis (presumed to be due to effects of gastric acid or other irritants)
  • Wait 24 h.
  • If symptoms persist, give antibiotic therapy delineated below for aspiration pneumonia.
• Aspiration pneumonia; poor dental hygiene or putrid sputum, alcoholism (anaerobic infection suspected)
  • Quinolone, ceftriaxone, or cefotaxime (doses as above) plus anaerobic coverage
    • Clindamycin (450 mg PO qid or 300–900 mg IV q6–12h) or
    • Metronidazole (500 mg q12h PO) or
    • β-lactam (piperacillin/tazobactam, 4.5 g IV q6h; or ampicillin/sulbactam, 1.5–3 g IV q6h) or
    • Imipenem (500 mg IV q6h)
• Aspiration pneumonia, community-acquired
  • Levofloxacin, moxifloxacin, gatifloxacin, ceftriaxone, or cefotaxime
• Concomitant meningitis (suspected pneumococcal)
  • Vancomycin (1 g IV q12h) plus
  • Ceftriaxone (2 g IV q12h)
    

The Harrison's Practice Preview allows you to view 5 FREE complete topics or conduct a search that delivers abstracts for more than 450 medical topics. For full access, please subscribe today!