What is the empiric therapy regimen for patients with community-acquired pneumonia (CAP) in the ICU?

Updated: Jul 22, 2021
  • Author: Folusakin O Ayoade, MD; Chief Editor: Thomas E Herchline, MD  more...
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In this setting, empiric regimens are designed to target S pneumoniae, the most common, and atypical, pathogens. Coverage is expanded for outpatients with comorbidities, smoking, and recent antibiotic use to include or better treat beta-lactamase-producing H influenzaeM catarrhalis, and methicillin-susceptible S aureus. For those with structural lung disease, such as cystic fibrosis, coverage is further expanded to include Enterobacteriaceae, such as E coli and Klebsiella spp.

No comorbidities/previously healthy; age < 65 years; no recent antibiotic use; no risk factors for MRSA or Pseudomonas aeruginosa (macrolides should only be used if local pneumococcal resistance is less than 25%):

Comorbidities present (eg, alcoholism, chronic heartlung/liver/renal diseases, malignancy, asplenia, diabetes mellitus) and who have used antibiotics in the last 3 months:

  • Preferred: Combination of a beta-lactam ( amoxicillin-clavulanate 500 mg/125 mg PO tid or  amoxicillin-clavulanate 875 mg/125 mg  PO BID or  amoxicillin-clavulanate 2000 mg/125 mg)  plus  a macrolide (azithromycin  or clarithromycin) or doxycycline (100 mg PO bid)
  • Alternatives to the above regimen:
  • If cephalosporins can be taken, 
    • Cefpodoxime 200 mg PO bid or  cefuroxime 500 mg or cefditoren 400 mg PO bid plus  a macrolide (azithromycin or clarithromycin) or doxycycline (100 mg PO bid)
  • If beta- lactams cannot be taken:
    • Levofloxacin 750 mg PO q24h or
    • Moxifloxacin 400 mg PO q24h or
    • Lefamulin 600 mg PO BID in the absence of hepatic impairment or drug interactions

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