eTable 33-4.

Guidelines for Empirical Parenteral Inpatient Treatment of Immunocompetent Adults with Community-Acquired Pneumonia

MILD TO MODERATE DISEASE

British Thoracic Society Primary: ampicillin or penicillin plus a macrolide Alternative: fluoroquinolone* American Thoracic Society No modifying factors†: azithromycin alone, doxycycline, β-lactam, or fluoroquinolone* alone With modifying factors‡: cefotaxime or ceftriaxone or ampicillin-sulbactam or high-dose ampicillin; macrolide or doxycycline; or fluoroquinolone* alone Infectious Diseases Society of America Primary§: cefotaxime, ceftriaxone, ertapenem, or ampicillin/sulbactam plus advanced macrolide†; or fluoroquinolone* alone Suspected aspiration: fluoroquinolone* ± antianaerobic agent‖ Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group Primary: cefuroxime, cefotaxime, ceftriaxone, or ampicillin-sulbactam; macrolide Alternative: fluoroquinolone* Canadian Infectious Diseases Society and Canadian Thoracic Society Fluoroquinolone* or cephalosporin,¶ macrolide**

SEVERE DISEASE

British Thoracic Society Primary: cefuroxime, cefotaxime, or ceftriaxone; macrolide, rifampin Alternative: fluoroquinolone* ± penicillin IV American Thoracic Society Standard: cefotaxime or ceftriaxone; azithromycin or fluoroquinolone* At risk for Pseudomonas aeruginosa ††: antipseudomonal β-lactam‡‡ ciprofloxacin or antipseudomonal β-lactam aminoglycoside plus azithromycin or fluoroquinolone* Infectious Diseases Society of America Primary: cefotaxime, ceftriaxone, ertapenem, or ampicillin/sulbactam; advanced macrolide† or fluoroquinolone* β-Lactam allergy: fluoroquinolone* ± clindamycin Pseudomonas risks††: antipseudomonal β-lactam‡‡ ciprofloxacin or antipseudomonal β-lactam‡‡ aminoglycoside; fluoroquinolone* or a macrolide Pseudomonas risks†† and β-lactam allergy: aztreonam levofloxacin or aztreonam; moxifloxacin or gatifloxacin ± an aminoglycoside Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group Primary: ceftriaxone or cefotaxime, macrolide; or ceftriaxone or cefotaxime, fluoroquinolone* Alternative (with caution): fluoroquinolone* Canadian Infectious Diseases Society and Canadian Thoracic Society Standard: cefotaxime, ceftriaxone or β-lactam/β-lactamase inhibitor; fluoroquinolone* or macrolide** Pseudomonas risks††: ciprofloxacin, antipseudomonal β-lactam‡‡ or aminoglycoside or antipseudomonal β-lactam‡‡ aminoglycoside macrolide**

^*Antipneumococcal fluoroquinolones include levofloxacin, gatifloxacin, and moxifloxacin.

^†Advanced macrolides are azithromycin and clarithromycin.

^‡Modifying factors include those considered to increase the risk of infection by a penicillin-resistant pneumococcus (age older than 65 years, exposure to a β-lactam antimicrobial within the prior 3 months, alcoholism, prior immunosuppressive therapy, multiple medical comorbidities, exposure to a child in a daycare center or to infection by an enteric gram-negative bacillus (residence in a nursing home, underlying cardiopulmonary disease, multiple comorbidities, or recent antimicrobial therapy).

^§Preferred regimen may be determined by whether the patient has received antibiotics within the prior 3 months.

^‖Antianaerobic agents include clindamycin, metronidazole, and β-lactam/β-lactamase inhibitor combinations.

^¶Acceptable cephalosporins include second-generation agents (e.g., cefuroxime, cefamandole), third-generation agents (cefotaxime or ceftriaxone), or fourth-generation agents (cefepime or cefpirome, neither of which is available in the United States).

^**Second-choice agent.

^††American Thoracic Society risk factors for Pseudomonas aeruginosa are structural lung disease (i.e., bronchiectasis, cystic fibrosis), corticosteroid use (>10 mg prednisone/day), broad-spectrum antibiotic therapy for more than 7 days in the past month, or malnutrition. The Infectious Diseases Society of American risk factors for P. aeruginosa include only structural lung disease or recent completion of a course of antibiotics or steroids. The Canadian risk factors include only structural lung disease, recent antibiotic therapy, or recent hospitalization in an intensive care unit.

^‡‡Antipseudomonal β-lactams include ceftazidime, cefepime, imipenem, meropenem, mezlocillin, piperacillin, and piperacillin-tazobactam.