Guideline for Antibiotic Use in Adults with Community-acquired Pneumonia

Lee, Mi Suk; Oh, Jee Youn; Kang, Cheol-In; Kim, Eu Suk; Park, Sunghoon; Rhee, Chin Kook; Jung, Ji Ye; Jo, Kyung-Wook; Heo, Eun Young; Park, Dong-Ah; Suh, Gee Young; Kiem, Sungmin

(a) β-lactam + azithromycin or (b) β-lactam + fluoroquinolone combination therapy is performed. The following antibiotics are recommended (in alphabetical order) • β-lactam: ampicillin/sulbactam, cefotaxime, ceftriaxone • Macrolide: azithromycin • Respiratory fluoroquinolone: gemifloxacin, levofloxacin, moxifloxacin (Respiratory fluoroquinolone + aztreonam are recommended if a patient is hypersensitive to penicillin.) In a randomized controlled clinical trial involving patients with community-acquired pneumonia not accompanied by shock, combination therapy had no significant effects; however, the combination therapy showed better outcomes than the fluoroquinolone monotherapy for patients who were on mechanical ventilation [173] . In another retrospective study, the β-lactam + macrolide combination therapy led to higher survival rates than the fluoroquinolone monotherapy for patients with severe pneumonia [175] . Most patients who are admitted to an ICU experience shock, or require mechanical ventilation. Therefore, combination therapy is recommended over the fluoroquinolone monotherapy for these patients. The effectiveness of the fluoroquinolone monotherapy in pneumonia accompanied by meningitis caused by S. pneumoniae is unclear. In a recent noninferiority trial, the β-lactam + macrolide combination therapy produced better outcomes than the β-lactam monotherapy in severe pneumonia or pneumonia caused by atypical bacteria [142] . In a prospective observational study involving patients with S. pneumoniae bacteremia, the combination therapy (β-lactam + macrolide or β-lactam + fluoroquinolone) also led to higher survival rates compared with the β-lactam monotherapy, and this result was observed not in patients with mild pneumonia, but patients with severe pneumonia [176] . Some studies have also reported better treatment outcomes from combination therapy than from monotherapy even in patients treated with effective antibiotics [177] [178] [179] . Therefore, for the empirical antibiotic treatment of patients with severe community-acquired pneumonia requiring ICU admission, combination therapy is recommended over monotherapy.