Table 3.
Comparison of recommendations of recently published guidelines for empirical antimicrobial therapy of community-acquired pneumonia in adults (from North America, United Kingdom, and Japan)
| Guideline | Outpatienta | General warda | ICU/Severea |
|---|---|---|---|
| North American Guidelines (synthesis from Canadian, CDC, 2000; ATS, 2001, IDSA, 2003) [31], [33], [34] | If no significant risks for DRSPb: macrolidec or doxycycline | β-Lactam (ceftriaxone, cefotaxime, ampicillin/sulbactam) plus macrolidec (can use doxycycline if macrolide not tolerated) or antipneumococcal fluoroquinoloned alone | β-Lactam (ceftriaxone, cefotaxime, ampicillin/sulbactam, piperacillin/tazobactam) plus macrolidec or fluoroquinoloned (if β-lactam allergy, use fluoroquinoloned plus clindamycin) |
| If risks for DRSPb: antipneumococcal fluoroquinoloned or high-dose amoxicillin (3 g/d) or amoxicillin/clavulanate plus macrolide (if amoxicillin is used and there is a concern for H influenzae, use agent active for β-lactamase producing strainsc) | Modifying factors of structural lung disease: antipseudomonal agent (piperacillin/tazobactam, carbapenem, or cefepime) plus antipseudomonal fluoroquinolone (high-dose ciprofloxacin or levofloxacin) | ||
| Japanese Respiratory Society [36] | (Specified as mild or moderate pneumonia) | (Specified as severe pneumonia) | Not specified |
| When bacterial pneumonia is suspected: a penicillin-type drug (with a β-lactamase inhibitor) orally or penicillin-type drug (injection) or cepham-type drug | For younger patients without underlying illness: injection use or fluoroquinolone | Consider as for inpatients, elderly patients, or patients with underlying illness | |
| When atypical pneumonia is suspected: macrolide or tetracycline | For elderly or underlying illness: Carbapenem plus tetracycline or macrolide or third-generation cepham plus clindamycin plus tetracycline or macrolide | ||
| British Thoracic Society [35] | Amoxicillin 500--1000 mg three times a day (alternative: erythromycin or clarithromycin) | If admitted for nonclinical reasons or previously untreated in the community: amoxicillin (alternative: macrolide) | (Defined as severe) |
| If admitted for pneumonia and oral therapy appropriate: amoxicillin plus erythromycin or clarithromycin (alternative: antipneumococcal fluoroquinolone) | Co-amoxiclav or 2nd/3rd gene ceph plus [iv erythro or clarithro, +/− rifampin] (fluoroquinolone with enhanced pneumococcal activity plus benzylpenicillin as alternative) | ||
| If parenteral appropriate: ampicillin or benzylpenicillin plus erythromycin or clarithromycin (alternative: intravenous levofloxacin) | Second- or third-generation cepham plus intravenous erythromycin or clarithromycin, with or without rifampin |
Abbreviations: ATS, American Thoracic Society; CDC, Centers for Disease Control and Prevention; IDSA, Infectious Diseases Society of America.
Site of care.
β-Lactam therapy within the past 3 months, hospitalization within the past month, alcoholism, immune-suppressive illness (including therapy with corticosteroids), multiple medical comorbidities, exposure to a child in a day care center.
If chronic obstructive pulmonary disease, use a macrolide active against β-lactamase--producing H influenzae (ie, azithromycin, clarithromycin).
Gatifloxacin, levofloxacin, moxifloxacin.