Treatment Options for Pneumonia
Guidelines for the treatment of diseases are published by the related societies in the respective nations. These are based on prior evidence of clinical benefit from specific therapies. The evidence is graded to provide a clear understanding.
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Level I — High level of evidence. Evidence from well-conducted, randomized controlled trials.
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Level II — Moderate level of evidence. Evidence from well-designed, controlled trials without randomization. (Randomization is a process where research participants are assigned to either the investigational group or the control group randomly (by chance not by choice). The goal of randomization is to produce comparable groups in terms of general participant characteristics, such as age or gender, and other key factors that affect the probable course the disease would take. A randomized, controlled trial is considered the most reliable and impartial method of determining what medical interventions work the best).
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Level III – Low level of evidence. Evidence from case studies and expert opinion. In some instances, therapy recommendations come from antibiotic susceptibility data without clinical observations.
In USA, two of the most widely referenced guidelines for the treatment of CAP are those of the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS).4 In response to confusion regarding differences between their respective guidelines, the IDSA and the ATS convened a joint committee to develop a unified CAP guideline document. The guidelines can be adapted to suit local regulations and practices.
Outpatient Treatment
1. Previously healthy and no use of antimicrobials within the previous 3 months
2. Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; or use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected)
3. In regions with a high rate (125%) of infection with high-level macrolide-resistant Streptococcus pneumoniae, consider the use of alternative agents listed above in (2) for patients without comorbidities (moderate recommendation; level III evidence).
Inpatients and Non-ICU Treatment
A β-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin (level II evidence) or a respiratory fluoroquinolone (level I evidence) (strong recommendation) (for penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are recommended)
Special Concerns
If community acquired-methicillin resistant Staphylococcus aureus (CA-MRSA) is a consideration, add vancomycin or linezolid (moderate recommendation; level III evidence).