TABLE 5.
Empirical antimicrobial selection for adult patients with community-acquired pneumonia
| Type of pneumonia | Modifying factors and/or pathogens | First choice | Second choice |
|---|---|---|---|
| Outpatient without modifying factors | Macrolide* | Doxycycline | |
| Outpatient with modifying factors | COPD (no recent antibiotics or oral steroids within past 3 months) | Newer macrolides† | Doxycycline |
| COPD (recent antibiotics or oral steroids within past 3 months) - Haemophilus influenzae and enteric Gram-negative rods | 'Respiratory' fluoroquinolone‡ | Amoxicillin-clavulanate + macrolide or second-generation cephalosporin + macrolide | |
| Suspected macroaspiration - oral anaerobes | Amoxicillin-clavulanate ± macrolide, or fourth-generation fluoroquinolone (eg, moxifloxacin) | Third-generation fluoroquinolones‡ (eg, levofloxacin) plus clindamycin or metronidazole | |
| Nursing home residents in nursing home | Streptococcus pneumoniae, enteric Gram-negative rods, H influenzae | 'Respiratory' fluoroquinolone‡ alone or amoxicillin-clavulante + macrolide | Second-generation cephalosporin + macrolide |
| Nursing home residents in hospital | Identical to treatment for other hospitalized patients (see below) | ||
| Hospitalized patient on medical ward | S pneumoniae, Legionella pneumophila, Chlamydia pneumoniae | 'Respiratory' fluoroquinolone‡ | Second-, third- or fourth-generation cephalosporin + macrolide |
| Hospitalized in intensive care unit | Pseudomonas aeruginosa not suspected (S pneumoniae, L pneumophila, C pneumoniae, enteric Gram-negative rods) | IV 'respiratory' fluoroquinolone + cefotaxime, ceftriaxone or betalactam/beta-lactamase inhibitor | IV macrolide + cefotaxime, ceftriaxone or beta-lactam/beta-lactamase inhibitor |
| P aeruginosa suspected | Antipseudomonal fluroquinolone (eg, ciprofloxacin) plus antipseudomonal beta-lactam (eg, ceftazidime, carbapenem, piperacillin-tazobactam, carbapenem) or aminoglycoside (eg, gentamicin, tobramycin, amikacin) | Triple therapy with antipseudomonal beta-lactam plus aminoglycoside plus macrolide |
*
Macrolide- Erythromycin, azithromycin, clarithromycin;
†
Newer macrolide - Azithromycin, clarithromycin;
‡
Respiratory fluoroquinolone - Levofloxacin (third generation), gatifloxacin and moxifloxacin (fourth generation); trovafloxacin (fourth generation) is restricted because of potential severe hepatoxicity.
COPD Chronic obstructive pulmonary disease; IV Intravenous