Table 33-9.
Agents for Specific Therapy of Selected Respiratory Pathogens
| Type of Infection | Preferred Agent(s) | Alternative Agent(s) |
|---|---|---|
| COMMUNITY-ACQUIRED PNEUMONIA | ||
| Streptococcus pneumoniae | ||
| PCN-susceptible | Penicillin G, amoxicillin, clindamycin, doxycycline | Cephalosporin, macrolide,* (MIC < 2 g/mL) fluoroquinolone† |
| PCN-resistant | Agents identified using in vitro susceptibility tests, including cefotaxime, ceftriaxone, vancomycin, and fluoroquinolone† | Macrolide, if susceptible |
| Mycoplasma | Doxycycline, macrolide | Fluoroquinolone† |
| Chlamydophila pneumoniae | Doxycycline, macrolide | Fluoroquinolone† |
| Legionella | Azithromycin, fluoroquinolone (including ciprofloxacin),† erythromycin (± rifampin) | Doxycycline ± rifampin |
| Haemophilus influenzae | Second- or third-generation cephalosporin, clarithromycin, doxycycline, β-lactam/β-lactamase inhibitor, trimethoprim-sulfamethoxazole, azithromycin | Fluoroquinolone† |
| Moraxella catarrhalis | Second- or third-generation cephalosporin, trimethoprim-sulfamethoxazole, macrolide doxycycline, β-lactam/β-lactamase inhibitor | Fluoroquinolone† |
| Neisseria meningitidis | Penicillin | Ceftriaxone, cefotaxime, cefuroxime, chloramphenicol, fluoroquinolone† |
| Streptococci (other than S. pneumoniae) | Penicillin, first-generation cephalosporin | Clindamycin (susceptibility should be confirmed), vancomycin |
| Anaerobes | Clindamycin, β-lactam/β-lactamase inhibitor, β-lactam plus metronidazole | Carbapenem |
| Staphylococcus aureus | ||
| Methicillin-susceptible‡ | Oxacillin, nafcillin, cefazolin; all ± rifampin or gentamicin‡ | Cefuroxime, cefotaxime, ceftriaxone, fluoroquinolones,† clindamycin, vancomycin |
| Methicillin-resistant‡ | Vancomycin‡ ± rifampin or gentamicin | Linezolid, quinupristin-dalfopristin; trimethoprim-sulfamethoxazole, fluoroquinolones,† and tetracyclines may also show activity (in vitro testing required) |
| Klebsiella pneumoniae and other Enterobacteriaceae (excluding Enterobacter spp.) | Third-generation cephalosporin or cefepime (all ± aminoglycoside) carbapenem | Aztreonam, β-lactam/β-lactamase inhibitor,§ fluoroquinolone† |
| HOSPITAL-ACQUIRED INFECTIONS | ||
| Enterobacter spp. | Carbapenem, β-lactam/β-lactamase inhibitor, cefepime, fluoroquinolone; all + aminoglycoside in seriously ill patients | Third-generation cephalosporin + aminoglycoside |
| Pseudomonas aeruginosa | Antipseudomonal β-lactam§ + aminoglycoside, carbapenem + aminoglycoside | Ciprofloxacin + aminoglycoside, ciprofloxacin + antipseudomonal β-lactam‖ |
| Acinetobacter | Aminoglycoside + piperacillin or a carbapenem | Doxycycline, ampicillin-sulbactam, colistin |
| LESS COMMON PATHOGENS | ||
| Nocardia | Trimethoprim-sulfamethoxazole | Imipenem ± amikacin, doxycycline or minocycline, sulfonamide ± minocycline or amikacin |
| Coxiella burnetii (Q fever) | Doxycycline | Fluoroquinolone |
| Chlamydophila psittaci (psittacosis) | Doxycycline | Erythromycin, chloramphenicol |
| Eikenella corrodens | Penicillin | Tetracyclines, β-lactam/β–lactamase inhibitor, second- and third-generation cephalosporins, fluoroquinolones |
MIC, minimum inhibitory concentration.
Azithromycin (IV or PO) is the preferred macrolide; clarithromycin (PO) or erythromycin (IV or PO) may also be used.
Levofloxacin (IV or PO), gatifloxacin (IV or PO), moxifloxacin (IV or PO), or gemifloxacin (PO only) are preferred for Streptococcus pneumoniae. Ciprofloxacin has the best in vitro activity against Pseudomonas aeruginosa.
Rifampin and gentamicin should be reserved for cases of bacteremic Staphylococcus aureus pneumonia, empyema formation, or lung abscesses. Activity of rifampin and gentamicin requires laboratory confirmation for methicillin-resistant S. aureus.
Ticarcillin-clavulanate and piperacillin-tazobactam are the preferred β-lactam/β-lactamase inhibitors for the treatment of nosocomial pneumonia due to Enterobacteriaceae. Ampicillin-sulbactam lacks adequate activity against many nosocomial enteric gram-negative bacilli.
Antipseudomonal β-lactams ceftazidime, cefepime, imipenem, meropenem, mezlocillin, piperacillin, or piperacillin-tazobactam.
Modified from Bartlett JG, Dowell SF, Mandell LA, et al: Practice guidelines for the management of community-acquired pneumonia in adults: Infectious Diseases Society of America. Clin Infect Dis 31:347−382, 2000.