Community-acquired pneumonia in adults (non Covid-19)
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
outpatient
oral amoxicillin, doxycycline, or a macrolide
Use a validated clinical prediction rule for prognosis, preferably the Pneumonia Severity Index (PSI) over CURB-65, in addition to clinical judgment, to determine whether the patient should be treated as an outpatient.[81]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com Outpatient treatment is recommended in patients with PSI risk class I or II with a PSI score ≤70 (low risk), or a CURB-65 score of 0-1 (low severity).[90]Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243-50. http://www.nejm.org/doi/full/10.1056/NEJM199701233360402#t=article http://www.ncbi.nlm.nih.gov/pubmed/8995086?tool=bestpractice.com [91]Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003 May;58(5):377-82. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746657 http://www.ncbi.nlm.nih.gov/pubmed/12728155?tool=bestpractice.com PSI is preferred over CURB-65.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [81]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com
Be aware of the limitations of severity scores and consider other factors when assessing a patient's suitability for outpatient management (e.g., contraindications to outpatient therapy such as inability to maintain oral intake, history of substance abuse, severe comorbid illnesses, cognitive impairment, and impaired functional status, or availability of outpatient support resources). Do not routinely use biomarkers to increase the performance of clinical decision rules when assessing whether to treat the patient as an outpatient.[81]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com
Empiric oral antibiotics are recommended: amoxicillin, doxycycline, or a macrolide (e.g., azithromycin or clarithromycin). Only use a macrolide in areas with pneumococcal resistance to macrolides <25% and when there are contraindications to alternative therapies.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Treat for a minimum of 5 days. Duration of treatment should be guided by a validated measure of clinical stability (e.g., resolution of vital sign abnormalities, normal cognitive function, ability to eat).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [118]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com [119]Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Ann Intern Med. 2021 Jun;174(6):822-7. https://www.doi.org/10.7326/M20-7355 http://www.ncbi.nlm.nih.gov/pubmed/33819054?tool=bestpractice.com Consider discontinuing treatment when the patient has been afebrile for 48-72 hours and there are no signs of complications (endocarditis, meningitis).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [118]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Reassess patients at 48 hours. Symptoms should improve within this time with appropriate treatment. Consider hospital admission in patients who fail to improve within 48 hours.
Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.
Primary options
amoxicillin: 1000 mg orally three times daily
OR
doxycycline: 100 mg orally twice daily
Secondary options
azithromycin: 500 mg orally once daily on the first day, followed by 250 mg once daily thereafter
OR
clarithromycin: 500 mg orally (immediate-release) twice daily; 1000 mg orally (extended-release) once daily
These drug options and doses relate to a patient with no comorbidities.
Primary options
amoxicillin: 1000 mg orally three times daily
OR
doxycycline: 100 mg orally twice daily
Secondary options
azithromycin: 500 mg orally once daily on the first day, followed by 250 mg once daily thereafter
OR
clarithromycin: 500 mg orally (immediate-release) twice daily; 1000 mg orally (extended-release) once daily
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
amoxicillin
OR
doxycycline
Secondary options
azithromycin
OR
clarithromycin
supportive care
Treatment recommended for ALL patients in selected patient group
Advise patients not to smoke, to rest, and to stay well hydrated.
influenza antiviral cover
Treatment recommended for SOME patients in selected patient group
Consider antiviral therapy (e.g., oseltamivir) in outpatients who test positive for influenza virus.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
These drug options and doses relate to a patient with no comorbidities.
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
oseltamivir
1st line – oral combination antibiotic therapy or fluoroquinolone monotherapy
oral combination antibiotic therapy or fluoroquinolone monotherapy
Use a validated clinical prediction rule for prognosis, preferably the Pneumonia Severity Index (PSI) over CURB-65, in addition to clinical judgment, to determine whether the patient should be treated as an outpatient.[81]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com Outpatient treatment is recommended in patients with PSI risk class I or II with a PSI score ≤70 (low risk), or a CURB-65 score of 0-1 (low severity).[90]Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243-50. http://www.nejm.org/doi/full/10.1056/NEJM199701233360402#t=article http://www.ncbi.nlm.nih.gov/pubmed/8995086?tool=bestpractice.com [91]Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003 May;58(5):377-82. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746657 http://www.ncbi.nlm.nih.gov/pubmed/12728155?tool=bestpractice.com PSI is preferred over CURB-65.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [81]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com
Be aware of the limitations of severity scores and consider other factors when assessing a patient's suitability for outpatient management (e.g., contraindications to outpatient therapy such as inability to maintain oral intake, history of substance abuse, severe comorbid illnesses, cognitive impairment, and impaired functional status, or availability of outpatient support resources). Do not routinely use biomarkers to increase the performance of clinical decision rules when assessing whether to treat the patient as an outpatient.[81]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com
Broader-spectrum antibiotic regimens are required in patients with comorbidities such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcohol abuse; malignancy; or asplenia. Many of these patients have risk factors for drug-resistant pathogens (e.g., recent hospitalization and administration of parenteral antibiotics in the past 90 days), and they are more vulnerable to poor outcomes if the empiric regimen is inadequate.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Empiric oral antibiotics are recommended: combination therapy with amoxicillin/clavulanate or a cephalosporin (e.g., cefpodoxime, cefuroxime) plus a macrolide or doxycycline; or monotherapy with a respiratory fluoroquinolone (e.g., levofloxacin, moxifloxacin). These regimens should effectively cover drug-resistant pathogens.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[116]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.doi.org/10.3390/pharmaceutics15030804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Despite these concerns, American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines still recommend fluoroquinolones as an option in patients with low-severity CAP who have comorbidities and are managed in the outpatient setting.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Treat for a minimum of 5 days. Duration of treatment should be guided by a validated measure of clinical stability (e.g., resolution of vital sign abnormalities, normal cognitive function, ability to eat).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [118]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com [119]Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Ann Intern Med. 2021 Jun;174(6):822-7. https://www.doi.org/10.7326/M20-7355 http://www.ncbi.nlm.nih.gov/pubmed/33819054?tool=bestpractice.com Consider discontinuing treatment when the patient has been afebrile for 48-72 hours and there are no signs of complications (endocarditis, meningitis).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [118]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Reassess patients at 48 hours. Symptoms should improve within this time with appropriate treatment. Consider hospital admission in patients who fail to improve within 48 hours.
Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.
Primary options
amoxicillin/clavulanate: 500 mg orally (immediate-release) three times daily; 875 mg orally (immediate-release) twice daily; 2000 mg orally (extended-release) twice daily
More amoxicillin/clavulanateDose refers to amoxicillin component.
or
cefpodoxime proxetil: 200 mg orally twice daily
or
cefuroxime axetil: 500 mg orally twice daily
-- AND --
azithromycin: 500 mg orally once daily on the first day, followed by 250 mg once daily thereafter
or
clarithromycin: 500 mg orally (immediate-release) twice daily; 1000 mg orally (extended-release) once daily
or
doxycycline: 100 mg orally twice daily
OR
levofloxacin: 750 mg orally once daily
OR
moxifloxacin: 400 mg orally once daily
These drug options and doses relate to a patient with no comorbidities.
Primary options
amoxicillin/clavulanate: 500 mg orally (immediate-release) three times daily; 875 mg orally (immediate-release) twice daily; 2000 mg orally (extended-release) twice daily
More amoxicillin/clavulanateDose refers to amoxicillin component.
or
cefpodoxime proxetil: 200 mg orally twice daily
or
cefuroxime axetil: 500 mg orally twice daily
-- AND --
azithromycin: 500 mg orally once daily on the first day, followed by 250 mg once daily thereafter
or
clarithromycin: 500 mg orally (immediate-release) twice daily; 1000 mg orally (extended-release) once daily
or
doxycycline: 100 mg orally twice daily
OR
levofloxacin: 750 mg orally once daily
OR
moxifloxacin: 400 mg orally once daily
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
amoxicillin/clavulanate
or
cefpodoxime proxetil
or
cefuroxime axetil
-- AND --
azithromycin
or
clarithromycin
or
doxycycline
OR
levofloxacin
OR
moxifloxacin
supportive care
Treatment recommended for ALL patients in selected patient group
Advise patients not to smoke, to rest, and to stay well hydrated.
influenza antiviral cover
Treatment recommended for SOME patients in selected patient group
Consider antiviral therapy (e.g., oseltamivir) in outpatients who test positive for influenza virus.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
These drug options and doses relate to a patient with no comorbidities.
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
oseltamivir
inpatient
1st line – intravenous combination antibiotic therapy or fluoroquinolone monotherapy
intravenous combination antibiotic therapy or fluoroquinolone monotherapy
Use a validated clinical prediction rule for prognosis, preferably the Pneumonia Severity Index (PSI) over CURB-65, in addition to clinical judgment to determine whether the patient should be treated as an inpatient. Hospital admission is recommended in patients with a PSI risk class III (these patients may benefit from a brief period of hospitalization), PSI risk class IV or V, or a CURB-65 score of 3.[90]Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243-50. http://www.nejm.org/doi/full/10.1056/NEJM199701233360402#t=article http://www.ncbi.nlm.nih.gov/pubmed/8995086?tool=bestpractice.com [91]Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003 May;58(5):377-82. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746657 http://www.ncbi.nlm.nih.gov/pubmed/12728155?tool=bestpractice.com PSI is preferred over CURB-65.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [81]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com
Empiric intravenous antibiotics are recommended: combination therapy with a beta-lactam (e.g., ampicillin/sulbactam, cefotaxime, ceftriaxone, ceftaroline) plus a macrolide (e.g., azithromycin, clarithromycin); or monotherapy with a respiratory fluoroquinolone (e.g., levofloxacin, moxifloxacin). Consider combination therapy with a beta-lactam plus doxycycline in patients who have contraindications to both macrolides and fluoroquinolones. Note that clarithromycin is only available as an oral formulation in the US, and so can only be used if the oral route is feasible.
Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[116]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.doi.org/10.3390/pharmaceutics15030804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Treat for a minimum of 5 days. Duration of treatment should be guided by a validated measure of clinical stability (e.g., resolution of vital sign abnormalities, normal cognitive function, ability to eat).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [118]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com [119]Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Ann Intern Med. 2021 Jun;174(6):822-7. https://www.doi.org/10.7326/M20-7355 http://www.ncbi.nlm.nih.gov/pubmed/33819054?tool=bestpractice.com Consider discontinuing treatment when the patient has been afebrile for 48-72 hours and there are no signs of complications (endocarditis, meningitis).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [118]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Evaluate whether the patient can be switched to oral therapy on a daily basis; the switch should be made as soon as possible. Switch to an oral formulation of the same drug or an oral formulation of a drug within the same drug class.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.
Primary options
ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours
More ampicillin/sulbactamDose consists of 1 g of ampicillin plus 0.5 g sulbactam (1.5 g) or 2 g of ampicillin plus 1 g sulbactam (3 g).
or
cefotaxime: 1-2 g intravenously every 8 hours
or
ceftriaxone: 1-2 g intravenously every 24 hours
or
ceftaroline fosamil: 600 mg intravenously every 12 hours
-- AND --
azithromycin: 500 mg intravenously every 24 hours
or
clarithromycin: 500 mg orally (immediate-release) twice daily
OR
levofloxacin: 750 mg intravenously every 24 hours
OR
moxifloxacin: 400 mg intravenously every 24 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours
More ampicillin/sulbactamDose consists of 1 g of ampicillin plus 0.5 g sulbactam (1.5 g) or 2 g of ampicillin plus 1 g sulbactam (3 g).
or
cefotaxime: 1-2 g intravenously every 8 hours
or
ceftriaxone: 1-2 g intravenously every 24 hours
or
ceftaroline fosamil: 600 mg intravenously every 12 hours
-- AND --
azithromycin: 500 mg intravenously every 24 hours
or
clarithromycin: 500 mg orally (immediate-release) twice daily
OR
levofloxacin: 750 mg intravenously every 24 hours
OR
moxifloxacin: 400 mg intravenously every 24 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ampicillin/sulbactam
or
cefotaxime
or
ceftriaxone
or
ceftaroline fosamil
-- AND --
azithromycin
or
clarithromycin
OR
levofloxacin
OR
moxifloxacin
MRSA antibiotic cover
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for methicillin-resistant Staphylococcus aureus (MRSA) if locally validated risk factors are present.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
If the patient has a prior history of respiratory isolation of MRSA: add vancomycin or linezolid and obtain cultures (or nasal polymerase chain reaction [PCR] if available) to guide de-escalation or to confirm the need to continue additional cover.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
If the patient has had a recent hospitalization and parenteral antibiotics in the past 90 days, and has been locally validated for risk factors for MRSA: obtain cultures and nasal PCR. If PCR or cultures are negative, withhold additional cover. If PCR or cultures are positive, start additional cover.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course of 7 days is recommended in patients with MRSA.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours; adjust dose based on serum vancomycin levels
OR
linezolid: 600 mg intravenously every 12 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours; adjust dose based on serum vancomycin levels
OR
linezolid: 600 mg intravenously every 12 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
vancomycin
OR
linezolid
Pseudomonas antibiotic cover
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for Pseudomonas aeruginosa if locally validated risk factors are present.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
If the patient has a prior history of respiratory isolation of P aeruginosa: add piperacillin/tazobactam, cefepime, ceftazidime, aztreonam, meropenem, or imipenem/cilastatin, and obtain cultures to guide de-escalation or to confirm the need to continue additional cover.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
If the patient has had a recent hospitalization and parenteral antibiotics in the past 90 days, and has been locally validated for risk factors for P aeruginosa: obtain cultures but only initiate cover for P aeruginosa if cultures are positive.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course of 7 days is recommended in patients with P aeruginosa.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Take the initial empiric regimen into account adding Pseudomonas cover so that two antibiotics from the same class are not used together.
Primary options
piperacillin/tazobactam: 4.5 g intravenously every 6 hours
More piperacillin/tazobactamDose consists of 4 g of piperacillin plus 0.5 g tazobactam.
OR
cefepime: 2 g intravenously every 8 hours
OR
ceftazidime sodium: 2 g intravenously every 8 hours
OR
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component.
OR
meropenem: 1 g intravenously every 8 hours
OR
aztreonam: 2 g intravenously every 8 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
piperacillin/tazobactam: 4.5 g intravenously every 6 hours
More piperacillin/tazobactamDose consists of 4 g of piperacillin plus 0.5 g tazobactam.
OR
cefepime: 2 g intravenously every 8 hours
OR
ceftazidime sodium: 2 g intravenously every 8 hours
OR
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component.
OR
meropenem: 1 g intravenously every 8 hours
OR
aztreonam: 2 g intravenously every 8 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
piperacillin/tazobactam
OR
cefepime
OR
ceftazidime sodium
OR
imipenem/cilastatin
OR
meropenem
OR
aztreonam
Enterobacteriaceae antibiotic cover
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for extended-spectrum beta-lactamase-producing Enterobacteriaceae. Consult an infectious disease specialist for guidance on an appropriate antibiotic regimen.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course is recommended in patients in cases of pneumonia due to less common pathogens.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
influenza antiviral cover
Treatment recommended for SOME patients in selected patient group
Add antiviral treatment (e.g., oseltamivir) to antimicrobial treatment in patients with CAP who test positive for influenza in the inpatient setting, independent of duration of illness before diagnosis.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
These drug options and doses relate to a patient with no comorbidities.
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
oseltamivir
supportive care
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary.
[ 
]
What are the effects of noninvasive positive pressure ventilation with supplemental oxygen, when compared with Venturi mask oxygen delivery, in adults with pneumonia?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.73/fullShow me the answer Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO₂ above 92%. High concentrations of oxygen can safely be given in uncomplicated pneumonia. Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation. Oxygen therapy for patients with COPD complicated by ventilatory failure is guided by repeated arterial blood gas measurements.[110]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017;4(1):e000170.
https://www.doi.org/10.1136/bmjresp-2016-000170
http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com
Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids as needed, and give nutritional support in prolonged illness.
Monitor temperature, respiratory rate, pulse, blood pressure, and mental status at least twice daily and more frequently in those with severe pneumonia or requiring regular oxygen therapy.
Monitor C-reactive protein (CRP) levels regularly as they are a sensitive marker of progress in pneumonia. Repeat chest x-rays in patients who are not progressing satisfactorily. Routine follow-up chest imaging is not recommended if symptoms resolve within 5-7 days.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
intravenous combination antibiotic therapy
Admit patients with hypotension requiring vasopressor therapy or respiratory failure requiring mechanical ventilation to the intensive care unit (ICU). In patients who do not require vasopressor therapy or mechanical ventilation, use the American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) criteria for defining severe CAP (see Diagnostic criteria) and clinical judgment to guide the need for higher levels of treatment intensity.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [81]Smith MD, Fee C, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with community-acquired pneumonia. Ann Emerg Med. 2021 Jan;77(1):e1-e57. http://www.ncbi.nlm.nih.gov/pubmed/33349374?tool=bestpractice.com Admit patients with severe CAP (defined as one major criterion or three or more minor criteria) to the ICU.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Start antibiotic therapy promptly as a delay in administration has been associated with an increased risk in mortality.[117]Garnacho-Montero J, Barrero-García I, Gómez-Prieto MG, et al. Severe community-acquired pneumonia: current management and future therapeutic alternatives. Expert Rev Anti Infect Ther. 2018 Sep;16(9):667-77. http://www.ncbi.nlm.nih.gov/pubmed/30118377?tool=bestpractice.com
Empiric intravenous antibiotics are recommended: combination therapy with a beta-lactam (e.g., ampicillin/sulbactam, cefotaxime, ceftriaxone, ceftaroline) plus a macrolide (e.g., azithromycin, clarithromycin); or combination therapy with a beta-lactam plus a respiratory fluoroquinolone (e.g., levofloxacin, moxifloxacin). There is stronger evidence for beta-lactam plus macrolide combination.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com Although ATS/IDSA recommend clarithromycin in these patients, it is only available as an oral formulation in the US so is unlikely to be useful in this setting.
Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[116]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.doi.org/10.3390/pharmaceutics15030804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Treat for a minimum of 5 days. Duration of treatment should be guided by a validated measure of clinical stability (e.g., resolution of vital sign abnormalities, normal cognitive function, ability to eat).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [118]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com [119]Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. Ann Intern Med. 2021 Jun;174(6):822-7. https://www.doi.org/10.7326/M20-7355 http://www.ncbi.nlm.nih.gov/pubmed/33819054?tool=bestpractice.com Consider discontinuing treatment when the patient has been afebrile for 48-72 hours and there are no signs of complications (endocarditis, meningitis).[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [118]Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016 Sep 1;176(9):1257-65. http://www.ncbi.nlm.nih.gov/pubmed/27455166?tool=bestpractice.com
Evaluate whether the patient can be switched to oral therapy on a daily basis; the switch should be made as soon as possible. Switch to an oral formulation of the same drug or an oral formulation of a drug within the same drug class.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider switching patients to an organism-specific antimicrobial therapy guided by antibiotic sensitivity in patients in whom laboratory tests have revealed a causative organism.
Primary options
ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours
More ampicillin/sulbactamDose consists of 1 g of ampicillin plus 0.5 g sulbactam (1.5 g) or 2 g of ampicillin plus 1 g sulbactam (3 g).
or
cefotaxime: 1-2 g intravenously every 8 hours
or
ceftriaxone: 1-2 g intravenously every 24 hours
or
ceftaroline fosamil: 600 mg intravenously every 12 hours
-- AND --
azithromycin: 500 mg intravenously every 24 hours
Secondary options
ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours
More ampicillin/sulbactamDose consists of 1 g of ampicillin plus 0.5 g sulbactam (1.5 g) or 2 g of ampicillin plus 1 g sulbactam (3 g).
or
cefotaxime: 1-2 g intravenously every 8 hours
or
ceftriaxone: 1-2 g intravenously every 24 hours
or
ceftaroline fosamil: 600 mg intravenously every 12 hours
-- AND --
levofloxacin: 750 mg intravenously every 24 hours
or
moxifloxacin: 400 mg intravenously every 24 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours
More ampicillin/sulbactamDose consists of 1 g of ampicillin plus 0.5 g sulbactam (1.5 g) or 2 g of ampicillin plus 1 g sulbactam (3 g).
or
cefotaxime: 1-2 g intravenously every 8 hours
or
ceftriaxone: 1-2 g intravenously every 24 hours
or
ceftaroline fosamil: 600 mg intravenously every 12 hours
-- AND --
azithromycin: 500 mg intravenously every 24 hours
Secondary options
ampicillin/sulbactam: 1.5 to 3 g intravenously every 6 hours
More ampicillin/sulbactamDose consists of 1 g of ampicillin plus 0.5 g sulbactam (1.5 g) or 2 g of ampicillin plus 1 g sulbactam (3 g).
or
cefotaxime: 1-2 g intravenously every 8 hours
or
ceftriaxone: 1-2 g intravenously every 24 hours
or
ceftaroline fosamil: 600 mg intravenously every 12 hours
-- AND --
levofloxacin: 750 mg intravenously every 24 hours
or
moxifloxacin: 400 mg intravenously every 24 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ampicillin/sulbactam
or
cefotaxime
or
ceftriaxone
or
ceftaroline fosamil
-- AND --
azithromycin
Secondary options
ampicillin/sulbactam
or
cefotaxime
or
ceftriaxone
or
ceftaroline fosamil
-- AND --
levofloxacin
or
moxifloxacin
MRSA antibiotic cover
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for methicillin-resistant Staphylococcus aureus (MRSA) if locally validated risk factors are present.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Add appropriate additional antibiotic cover and obtain cultures (or nasal polymerase chain reaction if available) to guide de-escalation of therapy or confirm the need to continue therapy.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course of 7 days is recommended in patients with MRSA.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours; adjust dose based on serum vancomycin levels
OR
linezolid: 600 mg intravenously every 12 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours; adjust dose based on serum vancomycin levels
OR
linezolid: 600 mg intravenously every 12 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
vancomycin
OR
linezolid
Pseudomonas antibiotic cover
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for Pseudomonas aeruginosa if locally validated risk factors are present.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Add appropriate additional antibiotic cover and obtain cultures to guide de-escalation of therapy or confirm the need to continue therapy.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Consider de-escalation to standard antibiotic therapy at 48 hours provided cultures do not reveal a drug-resistant pathogen and the patient is clinically improving.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course of 7 days is recommended in patients with P aeruginosa.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Take the initial empiric regimen into account adding Pseudomonas cover so that two antibiotics from the same class are not used together.
Primary options
piperacillin/tazobactam: 4.5 g intravenously every 6 hours
More piperacillin/tazobactamDose consists of 4 g of piperacillin plus 0.5 g tazobactam.
OR
cefepime: 2 g intravenously every 8 hours
OR
ceftazidime sodium: 2 g intravenously every 8 hours
OR
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component.
OR
meropenem: 1 g intravenously every 8 hours
OR
aztreonam: 2 g intravenously every 8 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
piperacillin/tazobactam: 4.5 g intravenously every 6 hours
More piperacillin/tazobactamDose consists of 4 g of piperacillin plus 0.5 g tazobactam.
OR
cefepime: 2 g intravenously every 8 hours
OR
ceftazidime sodium: 2 g intravenously every 8 hours
OR
imipenem/cilastatin: 500 mg intravenously every 6 hours
More imipenem/cilastatinDose refers to imipenem component.
OR
meropenem: 1 g intravenously every 8 hours
OR
aztreonam: 2 g intravenously every 8 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
piperacillin/tazobactam
OR
cefepime
OR
ceftazidime sodium
OR
imipenem/cilastatin
OR
meropenem
OR
aztreonam
Enterobacteriaceae antibiotic cover
Treatment recommended for SOME patients in selected patient group
Additional empiric antibiotic cover is required in patients with risk factors for extended-spectrum beta-lactamase-producing Enterobacteriaceae. Consult an infectious disease specialist for guidance on an appropriate antibiotic regimen.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
A longer treatment course is recommended in patients in cases of pneumonia due to less common pathogens.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
influenza antiviral cover
Treatment recommended for SOME patients in selected patient group
Add antiviral treatment (e.g., oseltamivir) to antimicrobial treatment in patients with CAP who test positive for influenza in the inpatient setting, independent of duration of illness before diagnosis.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
These drug options and doses relate to a patient with no comorbidities.
Primary options
oseltamivir: 75 mg orally twice daily for 5 days
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
oseltamivir
corticosteroid
Treatment recommended for SOME patients in selected patient group
The use of corticosteroids in patients with severe CAP has been a long-debated issue.
Current American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines generally recommend against the use of corticosteroids in patients with nonsevere or severe CAP, although acknowledge that they may be considered in patients with refractory septic shock according to Surviving Sepsis Campaign guidelines, and can be used as clinically appropriate for comorbid conditions (e.g., COPD, asthma, autoimmune diseases). This recommendation is based on the fact that there are no data suggesting benefit in patients with nonsevere CAP with respect to mortality or organ failure, and only limited data to support their use in patients with severe CAP.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
supportive care
Treatment recommended for ALL patients in selected patient group
Administer oxygen therapy as necessary.
[ ]
What are the effects of noninvasive positive pressure ventilation with supplemental oxygen, when compared with Venturi mask oxygen delivery, in adults with pneumonia?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.73/fullShow me the answer Monitor oxygen saturation and inspired oxygen concentration with the aim of maintaining SaO₂ above 92%. High concentrations of oxygen can safely be given in uncomplicated pneumonia. Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation. Oxygen therapy for patients with COPD complicated by ventilatory failure is guided by repeated arterial blood gas measurements.[110]O'Driscoll BR, Howard LS, Earis J, et al. British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respir Res. 2017;4(1):e000170.
https://www.doi.org/10.1136/bmjresp-2016-000170
http://www.ncbi.nlm.nih.gov/pubmed/28883921?tool=bestpractice.com
Assess volume status, paying particular attention to signs of volume depletion. Administer intravenous fluids as needed, and give nutritional support in prolonged illness.
Monitor temperature, respiratory rate, pulse, blood pressure, and mental status at least twice daily and more frequently in those with severe pneumonia or requiring regular oxygen therapy.
Monitor C-reactive protein (CRP) levels regularly as they are a sensitive marker of progress in pneumonia. Repeat chest x-rays in patients who are not progressing satisfactorily. Routine follow-up chest imaging is not recommended if symptoms resolve within 5-7 days.[18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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