Duration: 5 days
Amoxicillin PO* 1g every 8 hours
Or Clarithromycin PO* 250-500 mg twice daily
Or Doxycycline PO 200mg on day 1 then 100mg daily
* Use IV route if oral route compromised.
In pregnant patients, doxycycline is contraindicated.
Clarithromycin should not be prescribed concurrently with ciclosporin, sirolimus and tacrolimus.
Duration: review total (IV plus PO) duration after 5 days
Amoxicillin 1000mg IV every 8 hours
plus Clarithromycin 500mg PO/IV* every 12 hours
Clarithromycin 500mg PO/IV* every 12 hours
* Only use IV if PO route compromised.
Clarithromycin should not be prescribed concurrently with ciclosporin, sirolimus and tacrolimus.
Duration: review total (IV plus PO) duration after 5 days
First line
Amoxicillin 1000mg IV every 6 hours
plus Clarithromycin 500mg PO/IV* every 12 hours
Penicillin allergy
Levofloxacin 500mg PO/IV* every 12 hoursIn pregnant patients, levofloxacin is contraindicated - discuss appropriate empirical choices with an infection specialist.
*Consider using the PO formulations of Clarithromycin or Levofloxacin unless the oral route is compromised.
Clarithromycin should not be prescribed concurrently with ciclosporin, sirolimus and tacrolimus.
Use CRB65 (primary care) or CURB65 (hospitalised) score to assess severity. Give one point each for any of the following:
Primary care, including nursing homes and long-term care facilities: Patients with CRB65 score 0 are suitable for home treatment; scores 1-2 should be referred to hospital for assessment; scores 3 and 4 require urgent hospital admission.
British Thoracic Society pneumonia severity score:
Abnormal vital signs (fever >38°C, tachycardia >100 beats per minute and tachypnoea >20 breaths per minute) or an abnormal physical examination of the chest (crackles, decreased breath sounds, dullness to percussion) can predict radiographic changes of CAP (sensitivity of 95%, negative predictive value 92%). In elderly patients, classic symptoms and signs of pneumonia are less likely, but non-specific features - especially confusion - are more likely.
Streptococcus pneumoniae is the most common cause of severe CAP, and respiratory tract infections can be treated with amoxicillin even if intermediate susceptibility to penicillin is found on testing. Use of Co-Amoxiclav or piperacillin-tazobactam for pneumococcal CAP offers no additional benefit.
Doxycycline resistance rates in Haemophilus influenzae are lower than those to Co-Amoxiclav.
Levofloxacin provides cover for atypical pneumonia and should not be administered with clarithromycin as both drugs prolong the QTc. Quinolones like levofloxacin should not be used for treatment of mild or moderate infections – MHRA warning (2019).
