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ED: Initial Empiric Antimicrobials for Management of Community-acquired Pneumonia (CAP) and
Healthcare-associated Pneumonia (HAP)
Condition
Preferred treatment options
Comments
Outpatient- Being Discharged from ED
Previously healthy
AND
No antibiotic therapy within the
past 3 months
Levofloxacin 750 mg orally every
24 hours for 5 days (dose adjust
for renal insufficiency)
**(If the patient has Medicaid,
insurance covers moxifloxacin
400 mg orally every 24 hours,
not levofloxacin. The treatment
duration is the same)**
OR
Azithromycin 500 mg orally once
on day 1 then 250 mg once daily
on days 2 through 5
Macrolides are active against 70
– 80% of Streptococcus
pneumoniae but resistance is
increasing. They also have
activity against atypical bacteria.
During influenza season, would
consider addition of an antiviral
agent like oseltamivir or
zanamivir depending on the
susceptibilities of circulating
virus if patient is at risk for
severe disease or influenza
related complications (e.g.,
asthma).
Doxycycline is active against 85%
- 90%of strains of S. pneumoniae
and also has activity against H.
influenzae and atypical bacteria.
It is also inexpensive.
Antibiotic therapy within the
past 3 months
OR
Comorbid conditions
(COPD, DM, Renal Insufficiency,
Cirrhosis, CHF)
Amoxicillin-Clavulanate 500/125
mg (1 tablet) orally every 6-8
hours for 5-7 days
OR
Cefpodoxime 200 mg orally
every 12 hours for 5-7 days
AND
Azithromycin 500 mg orally
every 24 hours on day 1 then
250 mg every 24 hours on days 2
through 5
OR
Levofloxacin 750 mg orally every
11/17/10
If patient has received a
fluoroquinolone recently, should
strongly consider using a nonfluoroquinolone based regimen,
and vice versa.
During influenza season, would
consider addition of an antiviral
agent like oseltamivir or
zanamivir depending on the
susceptibilities of circulating
virus.
24 hours for 5 days
**(If the patient has Medicaid,
insurance covers moxifloxacin
400 mg orally every 24 hours,
not levofloxacin. The duration of
therapy is the same)**
If severe B-lactam allergy:
Levofloxacin 750 mg orally every
24 hours for 5 days
**(If the patient has Medicaid,
insurance covers moxifloxacin
400 mg orally every 24 hours,
not levofloxacin. The duration of
therapy is the same)**
Patient being admitted to a non-ICU setting with suspected CAP
No recent hospitalization
Ceftriaxone 1-2 g IV every 24
hours
AND
Azithromycin 500 mg orally or IV
every 24 hours
In patients > 80 kg, use
ceftriaxone 2g every 24 hours.
Please send 2 sets of blood
cultures, a sputum culture if
possible, and a urinary Legionella
antigen.
OR
If severe B-lactam allergy:
Levofloxacin750 mg orally or IV
every 24 hours
Pseudomonal Risk
Please document “pseudomonal
risk”
Includes patients with history of
structural lung disease (e.g.,
bronchiectasis, interstitial lung
disease, chronic bronchitis,
COPD, emphysema, pulmonary
fibrosis, restrictive lung disease)
AND frequent antibiotic use or
chronic steroid use
11/17/10
Cefepime 1-2 g IV every 12 hours
AND
Azithromycin 500 mg orally or IV
every 24 hours
OR
If severe B-lactam allergy:
Levofloxacin 750 mg orally or IV
every 24 hours once daily
Addition of Vancomycin should
Recent antibiotics: antibiotic for
treatment of any infection within
the past 3 months.
If recent use of a
fluoroquinolone, should strongly
consider selection of a nonfluoroquinolone based regimen,
and vice versa.
Ceftriaxone and levofloxacin are
active against >95% of S.
pneumoniae strains.
PLEASE DOCUMENT SUSPICION
be based on patient’s acuity of
illness and patient’s previous
colonization status. If patient is
Please send 2 sets of blood
known to have a history of
cultures, a sputum culture if
MRSA, please add Vancomycin
possible, and a urinary Legionella 15 mg/kg IV every 12 hours
antigen.
(rounded to nearest 250 mg).
FOR PSEUDOMONAS
Patient with severe CAP (being admitted to an ICU with CAP)
Not recently hospitalized
Ceftriaxone 2 g IV every 24 hours
AND
Azithromycin 500 mg IV every 24
hours
Please send 2 sets of blood
cultures, a sputum culture if
possible, and a urinary Legionella If severe B-lactam allergy:
antigen.
Levofloxacin 750 mg IV every 24
hours
For patients with CAP in the ICU,
always cover S. pneumoniae and
Legionella. Consider coverage
for Staphylococcus aureus in the
appropriate clinical situation.
Addition of Vancomycin (15
mg/kg IV every 12 hours
(rounded to nearest 250 mg)
should be based on patient’s
acuity of illness . Pneumonia
post influenza or viral syndrome
and/or a chest X-ray with
necrotizing features should raise
the suspicion for Staphylococcus
aureus (MSSA or MRSA).
Healthcare-associated pneumonia (HAP)
Cefepime 1 - 2 g IV every 12
hours
AND
Azithromycin 500 mg orally or IV
every 24 hours
AND
Vancomycin 15 mg/kg IV every
Please send 2 sets of blood
12 hours (rounded to closest 250
cultures, a sputum culture if
possible, and a urinary Legionella mg)
antigen.
Recently hospitalized or resident
of a skilled nursing facility,
chronic dialysis,
immunocompromised
If severe B-lactam allergy:
11/17/10
Antimicrobials should be
modified based on previous
culture data.
Aztreonam 1-2 g IV every 8 hours
AND
Azithromycin 500 mg orally or IV
every 24 hours
AND
Vancomycin 15 mg/kg IV every
12 hours (rounded to closest 250
mg)
1. Clin Infect Dis: 2007; 44: S27-S72.
2. Am J Respir Crit Care Med 2005; 171:388-416.
11/17/10