TREATMENT OF COMMUNIT-ACQUIRED PNEUMONIA: ANTIBIOTIC SELECTION
Once a diagnosis of community-acquired pneumonia is made, treatment with antibiotics should be initiated promptly. In patients who require admission, intravenous antibiotics should be started after collection of sputum and blood cultures. This should be done without delay. Evidence suggests that appropriately selected, rapidly administered empiric antibiotics are associated with a reduced length of stay.Initial antibiotic selection is empiric and should be based on the patient’s location of therapy (outpatient, inpatient, intensive care unit) and the presence of risk factors for drug-resistant streptococcal pneumonia, and risk factors for gram-negative rod infection. In addition, the presence of underlying cardiopulmonary disease should be considered. Atypical pathogens should be considered in all patients being treated for community-acquired pneumonia.For outpatients without cardiac or pulmonary disease and without risk factors for drug-resistant S. pneumoniae or gram-negative rods, therapy with a macrolide antibiotic (azithromycin or clarithromycin) is recommended. Doxycycline is an alternative if the patient is allergic to macrolides. The general use of fluoroquinolones for otherwise healthy outpatients with community-acquired pneumonia is discouraged because of concerns for the development of fluoroquinolone-resistant S. pneumoniae. For outpatients with cardiopulmonary disease or with risk factors for drug-resistant streptococcal pneumonia, a fluoroquinolone should be used. Alternatively, an oral beta-lactam plus a macrolide can be substituted.For patients admitted to the hospital, treatment with intravenous beta-lactam plus intravenous macrolide, or intravenous fluoroquinolone alone is recommended as empiric therapy. Patients admitted to the intensive care unit should not be treated with a single agent alone. Empiric therapy should consist of a beta-lactam plus either a macrolide or a fluoroquinolone. For patients with risk for Pseudomonas, an anti-pseudomonal beta-lactam plus a fluoroquinolone should be used for empiric therapy.*43/348/5*
