Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Primary options
azithromycin: 500 mg orally once daily on the first day, followed by 250 mg once daily for 4 days; 500 mg intravenously once daily for at least 5 days
OR
clarithromycin: 500 mg orally (immediate-release) twice daily for 14-21 days
OR
erythromycin base: 500 mg orally four times daily for 14-21 days; 1000 mg intravenously four times daily for 14-21 days
Macrolides cover all common atypical pathogens as well as many of the other causes of community-acquired pneumonia. If the patient is unable to take drugs orally, intravenous formulations are available.
Treatment recommended for ALL patients in selected patient group
Patients should be assessed for hydration status, adequacy of gas exchange, and haemodynamic stability. Oxygen and ventilation should be started immediately if needed.
Tracheal intubation animated demonstration
Bag-valve-mask ventilation animated demonstration[
]
Primary options
doxycycline: 100 mg orally twice daily for 14 days
Doxycycline covers common atypical pathogens as well as many of the other causes of community-acquired pneumonia. It is considered to be the first-line treatment for less common zoonotic atypical pathogens, such as Chlamydophila psittaci (psittacosis) and Coxiella burnetii (Q fever).
Treatment recommended for ALL patients in selected patient group
Patients should be assessed for hydration status, adequacy of gas exchange, and haemodynamic stability. Oxygen and ventilation should be started immediately if needed.
Tracheal intubation animated demonstrationBag-valve-mask ventilation animated demonstration[
]
Primary options
levofloxacin: 750 mg orally/intravenously once daily for 5 days
OR
moxifloxacin: 400 mg orally/intravenously once daily for 7-14 days
OR
gemifloxacin: 320 mg orally once daily for 5-7 days
These agents provide coverage for all atypical pathogens, although less evidence exists for Chlamydophila species. They are the drug of choice for patients with comorbidities such as diabetes, alcoholism, chronic heart, lung, liver, or renal disease.
These agents can be given orally or intravenously and they generally provide broader spectrum coverage than is needed for atypical bacterial pneumonia.
Their use may promote emergence of fluoroquinolone resistance, and so widespread use in the community is discouraged.[18]
Consider safety issues before prescribing fluoroquinolones. The US Food and Drug Administration has issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[76][77] The European Medicines Agency 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.[78]
Treatment recommended for ALL patients in selected patient group
Patients should be assessed for hydration status, adequacy of gas exchange, and haemodynamic stability. Oxygen and ventilation should be started immediately if needed.
Tracheal intubation animated demonstrationBag-valve-mask ventilation animated demonstration[
]
severe community-acquired disease
Treatment recommended for ALL patients in selected patient group
In severe community-acquired pneumonia, guidelines recommend empirical treatment with a beta-lactam antibiotic, as well as coverage for atypical pathogens.[18][40] Antibiotic treatment should be directed at the causative organism once aetiology is established. Consult local guidelines for guidance on antibiotic regimen selection and doses.
Treatment recommended for SOME patients in selected patient group
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; 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.[18]
A study from Japan suggests that corticosteroids may not offer any advantage in the treatment of M pneumoniae pneumonia.[75]
Primary options
azithromycin: children ≥3 months of age: 10 mg/kg orally once daily on day 1, followed by 5 mg/kg once daily on days 2-5, maximum 500 mg/day; adults: 500 mg intravenously/orally once daily on day 1, followed by 500 mg intravenously once daily or 250 mg orally once daily on days 2-5
OR
erythromycin lactobionate: children and adults: 20 mg/kg/day intravenously given in divided doses every 6 hours, maximum 4000 mg/day
OR
erythromycin base: children: 40 mg/kg/day orally given in 4 divided doses, maximum 2000 mg/day; adults: 500 mg orally four times daily
OR
clarithromycin: children ≥3 months of age: 7.5 mg/kg orally twice daily, maximum 1000 mg/day; adults: 500 mg orally (immediate-release) twice daily
Macrolides cover all common atypical pathogens as well as many of the other causes of community-acquired pneumonia.
If the patient is unable to take drugs orally, intravenous formulations of erythromycin and azithromycin are available; however, the patient should be switched to oral therapy when possible.
Treatment course: 5 days (azithromycin); 14-21 days (erythromycin, clarithromycin).
Treatment recommended for ALL patients in selected patient group
Patients should be assessed for hydration status, adequacy of gas exchange, and haemodynamic stability. Oxygen and ventilation should be started immediately if needed.
Tracheal intubation animated demonstrationBag-valve-mask ventilation animated demonstration[
]
Primary options
doxycycline: consult specialist for guidance on dose
OR
levofloxacin: consult specialist for guidance on dose
OR
moxifloxacin: consult specialist for guidance on dose
If a patient has a macrolide resistant Mycoplasma pneumoniae infection, doxycycline or a fluoroquinolone may be considered as an alternative treatment.
Doxycycline is generally not recommended in children aged <12 years (<8 years in some countries) due to the ability of tetracycline antibiotics to cause permanent discolouration of developing teeth. Fluoroquinolones are generally not recommended in children due to their adverse effects on joints. However, these drugs may be used with caution in children provided the benefits of using them outweigh the risks, and there are no other appropriate treatment options available.
Doxycycline is not recommended in pregnant women due to its detrimental effect on fetal skeletal development and bone growth. However, it may be used in situations where there is no alternative option and the benefits outweigh the risks. Likewise, fluoroquinolones should not be used in pregnancy unless the potential benefits outweigh the risks.
Consider safety issues before prescribing fluoroquinolones. The US Food and Drug Administration has issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[76][77] The European Medicines Agency 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.[78]
Treatment recommended for ALL patients in selected patient group
Patients should be assessed for hydration status, adequacy of gas exchange, and haemodynamic stability. Oxygen and ventilation should be started immediately if needed.
Tracheal intubation animated demonstrationBag-valve-mask ventilation animated demonstration[
]
severe community-acquired disease
Treatment recommended for ALL patients in selected patient group
In severe community-acquired pneumonia, guidelines recommend empirical treatment with a beta-lactam antibiotic, as well as coverage for atypical pathogens.[18][40] Antibiotic treatment should be directed at the causative organism once etiology is established. Consult local guidelines for guidance on antibiotic regimen selection and doses.
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