Principles of Antibiotic Management of Community-Acquired Pneumonia

Abstract

Community-acquired pneumonia (CAP) encompasses a broad spectrum of disease severity and may require outpatient, inpatient, or intensive care management. Successful treatment hinges on expedient delivery of appropriate antibiotic therapy tailored to both the likely offending pathogens and the severity of disease. This review summarizes key principles in starting treatment and provides recommended empiric therapy regimens for each site of care. In addition, we discuss the antimicrobial and anti-inflammatory role macrolides play in CAP, as well as specific information for managing individual CAP pathogens such as community-acquired methicillin-resistant and drug-resistant. We also examine several novel antibiotics being developed for CAP and review the evidence guiding duration of therapy and current best practices for the transition of hospitalized patients from intravenous antibiotics to oral therapy.

Diagnostic Value of Bronchoscopy in Critically Ill Ventilated Patients with the Lower Respiratory Tract Infections: Role in Detecting Bronchial Microbial Patterns

“…We used these protocols initially according to the degree of sepsis and clinical suspicion, after that antibiotics escalated depending on the results of the cultures and sensitivity of BAL and sputum. In concordance to our study, most of the guidelines recommend a combination therapy of a beta-lactam and macrolide or fluoroquinolone in those patients requiring ICU admission, and additional options are for possible pseudomonal infection [15], [16], [17], [18]. In our study, we found that BAL can detect up to 90% of pathogens responsible for the infection in the lower respiratory tract, while sputum can detect only 55% of organisms by culture.…”

Appropriate antibiotic management of bacterial lower respiratory tract infections

“…For inpatients with CAP, the IDSA/ATS guideline recommends the use of either a beta-lactam-macrolide combination or fluoroquinolone monotherapy for non-critically ill cases 15 ; the European and South African guidelines have the addition of a macrolide to the beta-lactam as an option 11 , 16 . Most of the guidelines recommend a combination therapy of a beta-lactam and macrolide or fluoroquinolone in those requiring ICU admission, and additional options are for possible pseudomonal infection 11 , 15 , 16 , 20 . The most controversial area has been whether the use of a macrolide antibiotic should be an obligatory component of initial antibiotic treatment 21 .…”

“…Earlier studies of hospitalized patients with moderately severe pneumonia suggested that beta-lactam monotherapy was not inferior to beta-lactam–macrolide combination therapy 22 , 23 . However, as has been indicated by several investigators, those studies had certain limitations that make it difficult to accept their conclusions 20 , 21 . A recent review highlighted all the studies documenting a benefit of combination therapy among inpatients; most of these studies were among CAP patients hospitalized in the ward and not the ICU 17 .…”

“…Furthermore, the systematic review by Lee et al 34 , assessing three aspects of antibiotic therapy in hospitalized patients with CAP, noted that administration of antibiotics within 4 to 8 hours of hospital arrival was associated with a reduction in mortality, although the quality of evidence was assessed as being relatively poor. Thus, while it is clear that patients with severe CAP (especially those with septic shock) should receive antibiotics as soon as possible 20 , the impact of time to antibiotic initiation on outcome in less severely ill cases is not clear 20 . It seems prudent to initiate antibiotics as soon as possible in patients suspected of having CAP; however, it should not be at the expense of an adequate consideration of possible alternative diagnoses, including acute bronchitis, influenza, pulmonary embolism, and heart failure 20 .…”

“…Thus, while it is clear that patients with severe CAP (especially those with septic shock) should receive antibiotics as soon as possible 20 , the impact of time to antibiotic initiation on outcome in less severely ill cases is not clear 20 . It seems prudent to initiate antibiotics as soon as possible in patients suspected of having CAP; however, it should not be at the expense of an adequate consideration of possible alternative diagnoses, including acute bronchitis, influenza, pulmonary embolism, and heart failure 20 . In such patients, administration of an antibiotic would have no benefit, would be associated with potentially serious consequences, and would be contrary to AMS initiatives.…”