Use Amoxicillin More Often for Outpatients With Community-Acquired Pneumonia

You'll see shifts in the outpatient treatment of community-acquired pneumonia...based on new guidelines.

Lean away from azithromycin for generally healthy adults...since S. pneumoniae resistance is typically 25% or higher across the U.S.

Instead, choose amoxicillin 1 g TID. This is a big change.

The high dose overcomes resistant S. pneumoniae...and efficacy seems similar to a quinolone for community-acquired pneumonia.

Or consider doxycycline...it also covers common pneumonia bugs.

Keep in mind, amoxicillin/clavulanate isn't needed for generally healthy adults...since S. pneumoniae isn't a beta-lactamase producer.

On the other hand, step up coverage for patients with comorbidities (COPD, diabetes, etc)...especially for those in poor health. They may be at higher risk for poor outcomes...and antibiotic resistance.

In these cases, use a broader-spectrum beta-lactam PLUS either a macrolide or doxycycline. For example, choose amoxicillin/clavulanate for additional gram-negative coverage...PLUS azithromycin to cover atypicals.

Respiratory quinolones (levofloxacin, etc) are also still an option, including Baxdela (delafloxacin)...which is now approved for pneumonia.

But due to mounting quinolone risks, save them for when other antibiotics aren't appropriate...such as a true beta-lactam allergy.

Regardless of comorbidities, check if the patient used an antibiotic from the same class in the last 90 days. If so, choose alternatives.

For example, for an otherwise healthy adult who recently used amoxicillin, give doxycycline. Or if an adult with comorbidities recently used azithromycin, consider a beta-lactam plus doxycycline.

Don't turn to the newer antibiotics Xenleta (lefamulin) or Nuzyra (omadacycline). They don't offer an advantage and are costly.

Usually give a 5-day antibiotic course for community-acquired pneumonia. Schedule a follow-up visit or phone call in a few days, to ensure symptoms are improving.

Find med regimens and doses in our chart, Treatment of Community-Acquired Pneumonia...and use our toolbox, Preventing and Treating Pneumonia, for vaccination guidance and other considerations.

Key References

  • Am J Respir Crit Care Med 2019;200(7):e45-e67
  • Breathe (Sheff) 2019;15(3):216-25
  • Curr Opin Pulm Med 2019;25(3):249-56
Prescriber's Letter. December 2019, No. 351201



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