Limit Broad-Spectrum Empiric Antibiotics for Inpatient CAP Treatment

You'll see shifts in inpatient treatment of community-acquired pneumonia (CAP)...based on updated IDSA/Am Thoracic Soc guidelines.

Continue to rely on a beta-lactam, such as ceftriaxone, plus azithromycin for most floor or ICU patients with CAP.

Keep in mind that a respiratory quinolone, such as levofloxacin, is still an option. But try to limit use...due to quinolone risks.

Move away from broadening coverage based on "healthcare-associated pneumonia" (HCAP) criteria...this practice doesn't improve outcomes.

Some criteria...such as chronic dialysis or residing in a skilled nursing facility...don't consistently predict resistant bugs.

Instead, broaden empiric coverage using factors better associated with resistance...such as a prior methicillin-resistant Staph aureus (MRSA) or Pseudomonas culture, especially from the respiratory tract.

Cast a slightly wider net for critically ill patients. Also consider empiric MRSA and Pseudomonas coverage in those hospitalized with antibiotics in the last 90 days.

But narrow antibiotics when possible...such as after 48 hours for a patient who is improving and has negative cultures.

Don't routinely add anaerobic coverage for suspected aspiration pneumonia...anaerobes aren't usually the pathogen in these cases.

Typically use a 5-day course of antibiotics for CAP...or 7 days for MRSA or Pseudomonas pneumonia. This is enough for most patients who stabilize in the first 2 to 3 days.

Expect the use of steroids for CAP treatment to keep stirring up debate. Steroids don't consistently show a reduction in mortality...but they seem to shorten time to clinical stability and length of stay.

Save steroids for CAP patients with a clear indication (COPD exacerbation, etc)...or if benefit may outweigh risk, such as severe CAP.

Use our chart, Treatment of Community-Acquired Pneumonia, for details on antibiotic options...and our toolbox, Preventing and Treating CAP, for resources on vaccinations, reducing readmissions, etc.

Key References

  • Am J Respir Crit Care Med 2019;200(7):e45-e67
  • Breathe (Sheff) 2019;15(3):216-25
  • Clin Infect Dis 2018;66(3):346-54
  • Cochrane Database Syst Rev 2017;12:CD007720
Hospital Prescriber's Letter. December 2019, No. 351201

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