Patient selection: mild community-acquired pneumonia suitable for outpatient care
Factors used to select a patient requiring more aggressive antibiotic therapy:
(1) pre-existing ill-health
(1a) chronic heart disease
(1b) chronic lung disease
(1c) chronic liver disease, including alcoholism
(1d) chronic renal disease
(1e) a current, significant malignancy
(2) diabetes mellitus
(3) immunosuppressive therapy or immunocompromising conditions
(4) asplenia
(5) high rate (> 25%) in the community of high level macrolide resistance in Streptococcus pneumoniae
(6) therapy with an antibiotic in the past 3 months (may select for an antibiotic-resistant strain)
If none of these conditions are present, then the patient can be treated with:
(1) a macrolide (azithromycin, clarithromycin, erythromycin)
(2) doxycycline (secondary choice)
If one or more of these factors is present then consider therapy with:
(1) a respiratory fluoroquinolone (moxifloxacin, levofloxacin, gemifloxacin)
(2) a beta-lactam (high dose amoxicillin, amoxicillin-clavulanate, ceftriaxone, defpodoxime, cefuroxime) plus a macrolide
(3) a beta-lactam plus doxycycline
If the patient has been treated with one of these antibiotics in the past 3 months, then a different class should be selected.
If the patient has a contraindications to a macrolide, beta-lactam antibiotic or fluoroquinolone then an alternative agent should be used.
