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.
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.
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.
- 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