Initial treatment for any patient with pneumonia is guided by the severity of the disease and presence of co-morbidities, prior hospitalisations, and resistant bacteria in the community.[17]

Patients should be assessed for hydration status, adequacy of gas exchange, and haemodynamic stability. Oxygen and ventilation should be started immediately if needed. [ Cochrane Clinical Answers logo ]

Antibiotic therapy

Atypical bacterial pneumonia pathogens generally do not respond to beta-lactam antibiotics and require treatment with a macrolide, tetracycline, or fluoroquinolone. The current pneumonia treatment guidelines recommend considering empirical use of a macrolide or doxycycline for uncomplicated community-acquired pneumonia to ensure coverage of atypical organisms.[17][38][39][40] [ Cochrane Clinical Answers logo ] Coverage of atypical organisms is also recommended in more severe disease and patients with comorbidities.[17][38][41] The recommendation to cover atypical pathogens in the empirical antibiotic regimen is debated;[42][43][44] however, the recommendation is supported by current data.[45][46]

Tetracyclines and fluoroquinolones are generally not recommended in children or pregnant women; however, their use may be considered in these patients when the benefits of using these drugs outweigh the risks, and there are no other suitable treatment options available, especially in cases of macrolide resistance.

When a specific aetiology for the pneumonia is found using a reliable method, antimicrobial therapy should be directed at that pathogen.[17] However, in the last few years an increasing frequency (up to 80%) of macrolide-resistant Mycoplasma pneumoniae cases have been reported in Asia,[47] whereas rates are lower in the Middle East (30%),[48] Europe (10%),[49][50][51] and the US (10%).[52] This is likely due to overuse of macrolides for the treatment of community-acquired pneumonia. Tetracyclines and fluoroquinolones are highly effective for macrolide-resistant strains of M pneumoniae.[53][54] When Legionella pneumophila is diagnosed, either macrolides or fluoroquinolones should be used without preference to any of the agents.[55]

The use of procalcitonin (a biomarker) to guide initiation and duration of antibiotic treatment has been found to result in a lower risk of mortality, lower antibiotic consumption, and lower risk of side effects in patients with acute respiratory infections.[56][57] However, one review found no difference in short-term mortality in critically ill patients specifically, while another study found that procalcitonin-guided therapy did not result in decreased use of antibiotics in patients with suspected lower respiratory tract infection.[58][59]

Outpatient care of hospitalisation

Scoring the severity of illness can help to determine whether the patient can be treated as an outpatient or requires hospitalisation or intensive care. It is most commonly determined using the Pneumonia Severity Index (PSI).[60][ Community-acquired pneumonia severity index (PSI) for adults ] The PSI, also referred to as the Pneumonia Patient Outcomes Research Team Model, has been re-purposed as an on-line tool. Twenty factors are assessed, including age, respiratory rate, pulse, blood pressure, and temperature, and total points are added together. CURB-65 is another severity scoring system developed by the British Thoracic Society.[38][ CURB-65 pneumonia severity score ]

New scoring systems might have some advantage on the PSI and the CURB-65, in identifying patients who need intensive care and hospital admission.[61][62][63][64] Two studies suggest that saturation below 92% is associated with adverse effects and more severe disease, thus requiring admission.[63][65]

Role of corticosteroids

The use of corticosteroids in patients with severe community-acquired pneumonia has been a long-debated issue. Current guidelines generally recommend against the use of corticosteroids in patients with non-severe or severe community-acquired pneumonia; although, the Surviving Sepsis Campaign guidelines acknowledge that they may be considered in patients with refractory septic shock and can be used as clinically appropriate for comorbid conditions (e.g., COPD, asthma, autoimmune diseases). This recommendation is based on the fact that there are no data suggesting benefit in patients with non-severe community-acquired pneumonia with respect to mortality or organ failure, and only limited data to support their use in patients with severe community-acquired pneumonia.[17]

Meta-analyses of studies of hospitalised adults with community-acquired pneumonia found that the use of corticosteroids was associated with reduced need for mechanical ventilation, reduced hospital stay, lower clinical failure rates, fewer complications (including septic shock), decreased C-reactive protein (CRP) levels, and reduced all-cause mortality. However, it appears that the reduction in mortality applies only to patients with severe community-acquired pneumonia. In patients with non-severe disease, adjunctive corticosteroids reduce morbidity, but not mortality.[66][67][68][69][70][71][72] A study from Japan suggests that corticosteroids may not offer any advantage in the treatment of M pneumoniae pneumonia.[73]

Patients treated with corticosteroids have an increased risk for hyperglycaemia.[68][69] Other adverse effects include super infection and upper gastrointestinal bleeding.

Adjunctive corticosteroid therapy has not been studied in pregnant or paediatric populations and cannot currently be recommended.

Safety of fluoroquinolone antibiotics

Consider safety issues before prescribing fluoroquinolones. The US Food and Drug Administration (FDA) has issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[74][75]

The European Medicines Agency (EMA) completed a review of serious, disabling, and potentially irreversible adverse effects associated with fluoroquinolones in 2018. These adverse effects included tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects. Patients who are older, have renal impairment, or have had a solid organ transplant, and those being treated with a corticosteroid are at a higher risk of tendon damage. Co-administration of a fluoroquinolone and a corticosteroid should be avoided if possible. This review resulted in prescribing restrictions in Europe, limiting the use of fluoroquinolones to severe infections only.[76]

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