Selecting a Treatment Regimen
Table 4. Initial Empirical Antibiotic Therapy for Suspected Bacterial CAP
Patient Variable
OUTPATIENT Previously healthy
No recent antibiotic therapy within previous 3 months, and no risk for drug-resistant S. pneumoniae
Comorbidities
COPD, diabetes, chronic heart, liver, lung or renal disease, malignancy, alcoholism, asplenia, immunosuppressing conditions or use of immunosuppressive drugs, use of antimicrobials within last 3 months
For any patient, including those without comorbidities
Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin [750 mg])* OR β-Lactam (high-dose amoxicillin [1 g tid], or amoxicillin- clavulanate [2 g bid using the 1000 mg/62.5 mg extended-release tablet formulation]), plus a macrolide. Alternative β-lactams include ceſtriaxone, cefpodoxime, cefuroxime (500 mg bid)*
In regions with a 25% or higher rate of infection with high-level (MIC ≥16 μg/mL) macrolide-resistant S. pneumoniae
Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin [750 mg]) OR β-Lactam (high-dose amoxicillin [1 g tid] , or amoxicillin- clavulanate [2 g bid using the 1000 mg/62.5 mg extended- release tablet formulation]), plus a macrolide (doxycycline is an alternative to the macrolide)
INPATIENT Medical ward
Respiratory fluoroquinolone OR β-Lactam (cefotaxime, ceſtriaxone, ampicillin, or ertapenem for selected patients) plus a macrolide (doxycycline is an alternative to the macrolide; a respiratory fluoroquinolone should be used for penicillin-allergic patients)
Intensive care unit (ICU) Special Concerns
Pseudomonas infection an issue Antipneumococcal, antipseudomonal β-lactam (cefepime, imipenem, meropenem, piperacillin-tazobactam) + ciprofloxacin or levofloxacin (750 mg dose) OR Above β-lactam + an aminoglycoside and azithromycin (for penicillin allergy, substitute aztreonam for β-lactam) OR Above β-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin allergy, substitute aztreonam for β-lactam)
CA-MRSA is a consideration Add linezolid or vancomycin * If patient received a macrolide in previous 3 months, use a fluoroquinolone and vice versa.
β-Lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) + either azithromycin or a respiratory fluoroquinolone (for penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam)
Macrolide OR doxycycline Treatment Option (See Table 5 for dosage)
