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Table 132-1

Empirical Antibiotic Treatment of Community-Acquired Pneumonia

Outpatients
  1. Previously healthy and no antibiotics in past 3 months
  2. Comorbidities or antibiotics in past 3 months: select an alternative from a different class
  3. In regions with a high rate of “high-level” pneumococcal macrolide resistance,b consider alternatives listed above for pts with comorbidities.
Inpatients, Non-ICU
  • A respiratory fluoroquinolone (e.g., moxifloxacin [400 mg PO or IV qd] or levofloxacin [750 mg PO or IV qd])
  • A β-lactamc (e.g., ceftriaxone [1-2 g IV qd], ampicillin [1-2 g IV q4-6h], cefotaxime [1-2 g IV q8h], ertapenem [1 g IV qd]) plus a macrolided (e.g., oral clarithromycin or azithromycin [as listed above] or IV azithromycin [1 g once, then 500 mg qd])
Inpatients, ICU
  • A β-lactame (e.g., ceftriaxone [2 g IV qd], ampicillin-sulbactam [2 g IV q8h], or cefotaxime [1-2 g IV q8h]) plus either azithromycin or a fluoroquinolone (as listed above for inpatients, non-ICU)
Special Concerns

IfPseudomonasis a consideration:

  • An antipseudomonal β-lactam (e.g., piperacillin/tazobactam [4. 5 g IV q6h], cefepime [1-2 g IV q12h], imipenem [500 mg IV q6h], meropenem [1 g IV q8h]) plus either ciprofloxacin (400 mg IV q12h) or levofloxacin (750 mg IV qd)
  • The above β-lactams plus an aminoglycoside (amikacin [15 mg/kg qd] or tobramycin [1. 7 mg/kg qd]) plus azithromycin
  • The above β-lactamsf plus an aminoglycoside plus an antipneumococcal fluoroquinolone

If CA-MRSA is a consideration:

aDoxycycline (100 mg PO bid) is an alternative to the macrolide.

bMICs of >16 µg/mL in 25% of isolates.

cA respiratory fluoroquinolone should be used for penicillin-allergic pts.

dDoxycycline (100 mg IV q12h) is an alternative to the macrolide.

eFor penicillin-allergic pts, use a respiratory fluoroquinolone and aztreonam (2 g IV q8h).

fFor penicillin-allergic pts, substitute aztreonam.

Abbreviations: CA-MRSA, community-acquired methicillin-resistant Staphylococcus aureus.