You'll see more focus on outpatient treatment of community-acquired pneumonia...based on new guidelines.
Lean away from azithromycin for generally healthy adults in areas with high S. pneumoniae resistance. If needed, check your local hospital lab for a best estimate of resistance rates for your area.
For example, if resistance rates in your area are typically 25% or higher, recommend amoxicillin 1 g TID. This is a big change.
Explain the high dose overcomes resistant S. pneumoniae...and efficacy seems similar to a quinolone for community-acquired pneumonia.
Or consider doxycycline...it also covers common pneumonia bugs.
Keep in mind, amoxicillin/clavulanate isn't needed for generally healthy adults...since S. pneumoniae isn't a beta-lactamase producer.
On the other hand, advise stepping up coverage for patients with comorbidities (COPD, diabetes, etc)...especially for those in poor health. They may be at higher risk for poor outcomes...and antibiotic resistance.
In these cases, suggest a broader-spectrum beta-lactam PLUS either a macrolide or doxycycline. For example, recommend amoxicillin/clavulanate to cover gram-negative bugs...PLUS azithromycin to cover atypicals.
Respiratory quinolones (levofloxacin, etc) are also still an option.
Regardless of comorbidities, check if the patient used an antibiotic from the same class in the last 90 days. If so, recommend alternatives.
For example, for an otherwise healthy adult who recently used amoxicillin, suggest doxycycline. Or if an adult with comorbidities recently used azithromycin, consider a beta-lactam plus doxycycline.
Usually recommend a 5-day antibiotic course for community-acquired pneumonia. Refer patients if symptoms haven't improved within a few days.
- www.canada.ca/en/public-health/services/publications/drugs-health-products/canadian-antimicrobial-resistance-surveillance-system-report-2016.html#a4-2-5 (11-14-19)
- Am J Respir Crit Care Med 2019;200(7):e45-e67
- Breathe (Sheff) 2019;15(3):216-25
- Curr Opin Pulm Med 2019;25(3):249-56