University of Pennsylvania Medical Center Guidelines for Antibiotic Use

PULMONARY INFECTIONS

Clinical Setting	Empiric Treatment	Likely Pathogens	Definitive Treatment	Dosage Regimen	Duration
Community Acquired Pneumonia
Single lobe involvement, without comorbidities¹	azithromycin + penicillin G²	S. pneumoniae	penicillin G³	3.0 mu IV q 4 hr	7-14 days⁴
		Mycoplasma spp. or Legionella spp.⁷	azithromycin	500 mg qd x 3 days	3 days⁴
		Chlamydia pneumoniae	doxycycline	100 mg q 12 hr	10-14 days⁴
With comorbidity¹, multilobar involvement, or gram negative bacilli on sputum Gram stain	levofloxacin⁵ 500 mg q 24 hr -OR- 750 mg q 24h x 5 d	as above	as above	as above	as above
		H. influenzae	TMP/SMX	8-10mg/kg/d TMP in 3-4 divided doses	10-14 days⁴
		Legionella spp.⁷	azithromycin	500 mg qd x3 days	3 days⁴
Transplant recipient (on cyclosporin A or tacrolimus)	levofloxacin⁵ -OR- 750 mg q 24h x 5d	S. pneumoniae	penicillin G^2,3	3.0 mu IV q 4 hr	14-21 days⁴
		H. influenzae	levofloxacin	500 mg q 24 hr	10-14 days⁴
		Mycoplasma spp.
		Chlamydia pneumoniae
		^Legionella^spp.⁷
Long term care facility	see Nosocomial pneumonia below
Intensive Care Unit	azithromycin or levofloxacin⁶ +penicillin G²	S. pneumoniae	penicillin G³	3.0 mu IV q 4 hr	7-14 days⁴
		H. influenzae	TMP/SMX	8-10mg/kg/d TMP in 3-4 divided doses	10-14 days⁴
		Mycoplasma spp. or Legionella spp.⁷	azithromycin	500 mg qd x 3 days	3 days⁴
		Chlamydia pneumoniae	doxycycline	100 mg q 12 hr	10-14 days⁴

¹Comorbidities: COPD, ESRD, liver disease, RR>30/min, SBP<90mmHg, DBP<60mmHg, PaO2<60mmHg or PaCO2>50mmHg

²If beta-lactam allergy: use ceftriaxone 1g IV q 24 hr for rash, vancomycin for hives and more severe reactions

³Review susceptibilities-S. pneumoniae resistance is about 2-5% (NCCLS and CDC criteria)

⁴Should switch to oral therapy once clinical improvement occurs: for penicillin G, switch patient to amoxicillin 1 gm po tid.

⁵If P. aeruginosa a consideration (ANC<500/mcg/l), add tobramycin

⁶If gram negative pneumonia suspected, use levofloxacin

⁷ If patient has Legionnaires' disease and is immunosuppressed, give azithromycin 500 mg qd for 7 to 10 days

PULMONARY INFECTIONS

Clinical Setting	Empiric Treatment	Likely Pathogens	Definitive Treatment	Dosage Regimen	Duration
Aspiration Pneumonia
Outpatient acquired	penicillin G¹ + metronidazole	oral flora	penicillin G + metronidazole	3.0 mu IV q 4 hr 500mg IV/PO q 12 hr	10-14 days³
Nosocomial (includes nursing home²)	cefepime OR piperacillin/tazobactam⁴	oral flora	cefepime	1 gm IV q 12 hr	10-14 days³
		Enterobacteriaceae	TMP/SMX + metronidazole	8-10mg/kg/d TMP in 3-4 divided doses 500mg IV/PO q 12 hr
		P. aeruginosa	review susceptibility data
		S. aureus	nafcillin⁵ or cefazolin⁵	2gm IV q 4-6 hr 500mg IV q 8 hr
		A. baumanii	review susceptibility data
Tracheobronchitis
Acute	TMP/SMX	S. pneumoniae	amoxicillin⁶	1gm PO q 12 hr	10-14 days
		H. influenzae M. catarrhalis	TMP/SMX	160mg/800mg (1 double strength tablet) PO BID
		Mycoplasma spp.	erythromycin base	500mg PO q 6 hr
		Chlamydia pneumoniae	doxycycline OR erythromycin base	100mg PO q 12 hr 500mg PO q 6 hr
		viral	no treatment
Intubation/Tracheostomy	TMP/SMX⁷	S. aureus	nafcillin⁵ OR cefazolin⁵	2 gm IV q 4-6 hr 500mg IV q 8 hr	14 days
		Enterobacteriaceae	TMP/SMX	8-10mg/kg/d TMP IV in 3-4 divided doses
		P. aeruginosa	cefepime⁸	2gm IV q 12 hr
		A. baumanii	review susceptibility data⁸

¹If penicillin allergy use clindamycin

²If community-acquired pneumonia is a possibility add azithromycin to regimen

³Can switch to oral therapy once clinical improvement occurs: for penicillin G - use amoxicillin 1 gm poTID

⁴For piperacillin/tazobactam dosing, please refer to the renal dosing guidelines for recommendations.

⁵If penicillin allergy use clindamycin or trimethoprim/sulfamethoxazole; if MRSA-use vancomycin

⁶Review susceptibilities-S. pneumoniae resistance ranges from 4-7% (NCCLS criteria)

⁷Substitute levofloxacin if gram negative bacilli are seen on Gram stain or if P. aeruginosa suspected.

⁸If multiresistant microorganism, consider aerosolized tobramycin

updated 9/28/04 by Lori LaRosa

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Community Acquired Pneumonia