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Community acquired pneumonia (CAP)

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Community-Acquired Pneumonia: Empiric Antibiotic Selection for Adults Admitted to General Medical Wards
Definition	Signs/ Symptoms	Management
Definition	Signs/ Symptoms	Initial Empirical Therapy	Comment
Acute infection of the pulmonary parenchyma acquired outside the hospital	Cough (with or without sputum production), fever, dyspnea, pleuritic chest pain, hypoxemia, tachypnea, tachycardia, leucocytosis, infiltrate in chest imaging.	No Pseudomonas or MRSA risk factors Select one of the following antibiotics: Ceftriaxone 1 to 2 g IV once daily Cefotaxime 1 to 2 g IV every 8 hours Ertapenem 1 g IV once daily Plus: Select one of the following: Azithromycin 500 mg IV once daily Clarithromycin 500 mg IV every 12 hours	Doxycycline may be Used for patients have contraindication to macrolides
		Pseudomonas risk factors only Select one of the following antibiotics: Ceftazidime 2 g IV every 8 hours Cefepime 2 g IV every 8 hours Pipracillin/Tazo 4.5 g IV every 6 hours Meropenem 1 g IV every 8 hours Imipenem/Cil 500 mg IV every 6 hours Plus: Select one of the following: Levofloxacin 750 mg IV once daily Ciprofloxacin 400 mg IV every 8 hours	Respiratory Fluoroquinolones (Levofloxacin or Moxifloxacin) monotherapy is alternative regimen
		MRSA Risk factors only Select one of the following antibiotics: Ceftriaxone 1 to 2 g IV once daily Cefotaxime 1 to 2 g IV every 8 hours Ertapenem 1 g IV once daily Plus: Select one of the following: Azithromycin 500 mg IV once daily Clarithromycin 500 mg IV every 12 hours Plus (Anti-MRSA): Select one of the following: Vancomycin 15–20 mg/kg/dose IV every 8 to 12 hours Linezolid 600 mg IV every 12 hours	Anti-MRSA + Respiratory Fluoroquinolones may be used in penicillin allergy
		Pseudomonas AND MRSA risk factors Select one of the following antibiotics: Ceftazidime 2 g IV every 8 hours Cefepime 2 g IV every 8 hours Pipracillin/Tazo 4.5 g IV every 6 hours Meropenem 1 g IV every 8 hours Imipenem/Cil 500 mg IV every 6 hours Plus: Select one of the following: Levofloxacin 750 mg IV once daily Ciprofloxacin 400 mg IV every 8 hours Plus (Anti-MRSA): Select one of the following: Vancomycin 15–20 mg/kg/dose IV every 8 to 12 hours Linezolid 600 mg IV every 12 hours	Levofloxacin + Aztreonam + Aminoglycoside + Anti-MRSA may be used in penicillin allergy.

Duration: 5–7 days in mild to moderate infection

MRSA risk factors

Known MRSA colonization
Prior MRSA infection
Gram-positive cocci in clusters on good quality sputum gram stain
High MRSA prevalence in local antibiogram

Pseudomonas risk factors

Known Pseudomonas colonization
Prior Pseudomonas infection
Gram-negative bacilli seen on good quality sputum gram stain
Hospitalization with receipt of I.V antibiotics in the prior 3 months
High Pseudomonas prevalence in local antibiogram

Community-acquired pneumonia : Empiric antibiotic selection for adults admitted to the intensive care unit
Definition	Signs/ Symptoms	Management
Definition	Signs/ Symptoms	Initial Empirical Therapy	Comment
Acute infection of the pulmonary parenchyma acquired outside the hospital	Cough (with or without sputum production ) , fever, dyspnea , pleuritic chest pain , hypoxemia , tachypnea, tachycardia , leukocytosis , infiltrate in chest imaging.	No Pseudomonas or MRSA risk factors Select one of the following antibiotics: Ceftriaxone 1 to 2 g IV once daily Cefotaxime 1 to 2 g IV every 8 hours Ertapenem 1 g IV once daily Plus: Select one of the following: Azithromycin 500 mg IV once daily Clarithromycin 500 mg IV every 12 hours	β-Lactams + Respiratory Fluoroquinolones (Levofloxacin or Moxifloxacin) (alternative regimen)
		Pseudomonas risk factors only Select one of the following antibiotics: Ceftazidime 2 g IV every 8 hours Cefepime 2 g IV every 8 hours Piperacillin/Tazo 4.5 g IV every 6 hours Meropenem 1 g IV every 8 hours Imipenem/Cil 500 mg IV every 6 hours Plus: Select one of the following: Levofloxacin 750 mg IV once daily Ciprofloxacin 400 mg IV every 8 hours
		MRSA Risk factors only Select one of the following antibiotics: Ceftriaxone 1 to 2 g IV once daily Cefotaxime 1 to 2 g IV every 8 hours Ertapenem 1 g IV once daily Plus: Select one of the following: Azithromycin 500 mg IV once daily Clarithromycin 500 mg IV every 12 hours Plus: Select one of the following: Vancomycin 15 - 20 mg/kg/dose IV every 8 to 12 hours Linezolid 600 mg IV every 12 hours	"β-Lactams + Respiratory Fluoroquinolones + Anti-MRSA (alternative regimen)"
		Pseudomonas And MRSA risk factors Select one of the following antibiotics: Ceftazidime 2 g IV every 8 hours Cefepime 2 g IV every 8 hours Piperacillin/Tazo 4.5 g IV every 6 hours Meropenem 1 g IV every 8 hours Imipenem/Cil 500 mg IV every 6 hours Plus: Select one of the following: Levofloxacin 750 mg IV once daily Ciprofloxacin 400 mg IV every 8 hours Plus: Select one of the following: Vancomycin 15 - 20 mg/kg/dose IV every 8 to 12 hours Linezolid 600 mg IV every 12 hours	"Levofloxacin + Aztreonam + Aminoglycoside + Anti-MRSA may be used in penicillin allergy"

Duration: 7 - 10 days in severe infection

MRSA risk factors

Septic Shock
Respiratory failure require mechanical ventilation
Known MRSA colonization
Prior MRSA infection
Gram-positive cocci in clusters on good quality sputum gram stain
Hospitalization with receipt of I.V antibiotics in the prior 3 months
Recent influenzas like illness
Necrotizing or cavitary pneumonia
Presence of empyema

Pseudomonas risk factors

Known Pseudomonas colonization
Prior Pseudomonas infection
Gram-negative bacilli seen on good quality sputum gram stain
Hospitalization with receipt of I.V antibiotics in the prior 3 months
Structural lung abnormalities (eg, bronchiectasis)
Frequent COPD exacerbation requiring frequent glucocorticoid or antibiotic use

References:

ATS/IDSA Guidelines for Diagnosis and Treatment of Adults with Community-acquired Pneumonia 2019