Pulmonary antibiotics

Pneumonia

Outpatient

Coverage targeted at S. pneumoniae, H. influenzae. M. pneumoniae, C. pneumoniae, and Legionella

Healthy

• Clarithromycin XL 1000mg PO QD x7d OR
• Azithromycin 500mg PO day 1, 250mg on days 2-5 OR
• Doxycycline 100mg BID x 10-14d (2nd line choice)

Unhealthy

Chronic heart, lung, liver, or renal disease; DM, alcholism, malignancy.

• Levofloxacin 750mg QD x5d OR
• Moxifloxacin 400mg QD x7-14d OR
• Amoxicillin/Clavulanate 2g BID AND
  • Azithromycin 500mg day 1, 250mg days 2-5 OR
  • Doxycycline 100mg PO BID x 7-10 days OR
  • Clarithromycin 500mg PO BID x 7-10 days

Inpatient

• Monotherapy or combination therapy is acceptable. Combination therapy includes a cephalosporin and macrolide targeting atypicals and Strep Pneumonia
• The use of adjunctive corticosteroids (methylprednisolone 0.5 mg/kg IV BID x 5d) in CAP of moderate-high severity (PSI Score IV or V; CURB-65 ≥ 2) is associated with:
  • ↓ mortality (3%)
  • ↓ need for mechanical ventilation (5%)
  • ↓ length of hospital stay (1d)

Community Acquired (Non-ICU)

Coverage against community acquired organisms plus M. catarrhalis, Klebsiella, S. aureus

• Levofloxacin 750mg IV/PO once daily OR
• Moxifloxacin 400mg IV/PO once daily OR
• Ceftriaxone 1g IV once daily PLUS
  • Azithromycin 500mg IV/PO once daily OR
  • Doxycycline 100mg IV/PO BID

Hospital Acquired or Ventilator Associated Pneumonia

• 3-drug regimen recommended options:
  • Cefepime 1-2gm q8-12h OR ceftazidime 2gm q8h + Levofloxacin 750 mg PO/IV every 24 hours + Vancomycin 15mg/kg q12 OR
  • Imipenem 500mg q6hr + cipro 400mg q8hr + vanco 15mg/kg q12 OR
  • Piperacillin-Tazobactam 4.5gm q6h + cipro 400mg q8h + vanco 15mg/kg q12
• Consider tobramycin in place of fluoroquinolones given FDA 2016 warnings

Ventilator Associated Pneumnoia

• High Risk of MRSA: Use 3-Drug Regimen. Several options are available, but recommendation is to include an antibiotic from each of these categories:
  • 1. MRSA Antibiotic: Vancomycin 15mg/kg q12h OR Linezolid 600 mg IV q12h PLUS
  • 2. Antipseudomonal Antibiotic: Piperacillin-Tazobactam 4.5gm q6h OR Cefepime 2 g IV q8h OR Imipenem 500 mg IV q6h OR Aztreonam 2 g IV q8h PLUS
  • 3. GN Antibiotic With Antipseudomonal Activity: Cipro 400 mg IV q8h

ICU, low risk of pseudomonas

• Ceftriaxone 1gm IV and Azithromycin 500mg IV OR
• Ceftriaxone 1gm IV and (moxifloxacin 400mg IV or levofloxacin 750mg IV)
• Penicillin allergy
  • (Moxifloxacin or levofloxacin) + (aztreonam 1-2gm IV or clindamycin 600mg IV)

ICU, risk of pseudomonas

• Cefipime, Imipenem, OR Piperacillin/Tazobactam + IV cipro/levo
• Cefipime, imipenem, OR piperacillin-tazobactam + gent + azithromycin
• Cefipime, imipenem, OR piperacillin-tazobactam + gent + cipro/levo

Pertussis

• Antibiotics do not help with severity or duration but may decrease infectivity.
• A reasonable guideline is to treat persons aged >1 year within 3 weeks of cough onset and infants aged <1 year and pregnant women (especially near term) within 6 weeks of cough onset.
• TMP--SMZ should not be administered to pregnant women, nursing mothers, or infants aged <2 months.
• The following regemins are for active disease or postexposure prophylaxis. If a patient is has confirmed disease and is likely to be in contact with infants or pregnant women then the patient should be treated as up to 6-8 weeks after the onset of their illness.

< 1 month old

Same antibiotics for active disease and postexposure prophylaxis

• Azithromycin 10mg/kg (max 500mg/day) daily x 5 days

>1 month old

• Azithromycin 10mg/kg (max 500mg/day) daily x 5 days
  • if > 6 months old then day 2-5 of treatment should be reduced to 5mg/kg (250mg/day max)
• TMP/SMX 4mg/kg PO BID daily for 14 days (if > 2 months old)

Adults

andy of the following antibiotics are acceptable although azithromycin is most commonly prescribed

• Azithromycin 500mg PO once daily for day #1 then 250mg PO once daily for days #2-5
• Clarithromycin 500mg BID x7 days
• Erythromycin 500mg QID x7 days

See Also

Antibiotics by diagnosis

• Bone and joint antibiotics
• Cardiovascular antibiotics
• ENT antibiotics
• Eye antibiotics
• GI antibiotics
• GU antibiotics
• Neuro antibiotics
• OB/GYN antibiotics
• Pulmonary antibiotics
• Skin and soft tissue antibiotics
• Bioterrorism antibiotics
• Environmental exposure antibiotics
• Immunocompromised antibiotics
• Post exposure prophylaxis antibiotics
• Pediatric antibiotics
• Sepsis antibiotics
• Arthropod and parasitic antibiotics

For antibiotics by organism see Microbiology (Main)

References

Authors

Ross Donaldson, Daniel Ostermayer