This protocol covers community-acquired pneumonia (CAP) due to Streptococcus pneumoniae in adults treated in the outpatient setting who carry one or more of the comorbidities listed below. The presence of these conditions shapes the antibiotic strategy.
The protocol applies when the patient has at least one of the following:
Management involves either combination antibiotic therapy or monotherapy with a respiratory fluoroquinolone. The complete protocol specifies the individual agents, their selection criteria, and duration guidance.
The target is achievement of clinical stability — resolution of vital sign abnormalities (heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature), ability to eat, and normal mentation — generally within the first 48 to 72 hours and by 5 days.
DOI: 10.1164/rccm.201908-1581ST
For outpatient adults with comorbidities such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia we recommend (in no particular order of preference) (Table 3):
Comorbidities include chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia.
Combination therapy: amoxicillin/clavulanate 500 mg/125 mg three times daily, or amoxicillin/clavulanate 875 mg/125 mg twice daily, or 2,000 mg/125 mg twice daily, or a cephalosporin (cefpodoxime 200 mg twice daily or cefuroxime 500 mg twice daily); AND macrolide (azithromycin 500 mg on first day then 250 mg daily, clarithromycin [500 mg twice daily or extended release 1,000 mg once daily]) (strong recommendation, moderate quality of evidence for combination therapy), or doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence for combination therapy); OR Monotherapy: respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily, or gemifloxacin 320 mg daily) (strong recommendation, moderate quality of evidence).
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