Having taken antibiotics within the past 3 months significantly increases the risk of resistant S. pneumoniae.
Choose an antibiotic from a different class, regardless of clinical success.
It is important to note that, although Legionella is defined as an “atypical” pathogen, the presentation is similar to “typical” pathogens (i.e. hyperacute and severe presentation).
Azithromycin dosing and duration of therapy depends on the route of administration and its indication for use:
When using 500 mg IV once daily in non-critically ill patients, 3 days of therapy is adequate
When using the PO formulation, or in patients that are critically ill, 5 days of therapy is adequate
In patients with infections caused by Legionella, 7 to 10 days of therapy may be required
Patients at high risk for pneumonia (e.g. age 65 and older, nursing home residents, COPD, etc.) should receive influenza and pneumococcal vaccines if vaccination not up to date.
While MRSA is rarely associated with CAP in New Brunswick, consider adding vancomycin empirically if severe pneumonia (i.e. DS-CRB65 score of 4 or higher) AND presence of one of the following MRSA risk factors:
History of MRSA infection or colonization
Household contact with a MRSA colonized individual
IV drug use
Recent travel to or residing in an MRSA endemic region or community
Recent literature suggests that corticosteroids could be considered in certain patients with a high inflammatory response due to severe CAP. However, it should be noted that preliminary data suggests patients with influenza pneumonia may not benefit, and could be harmed by adding corticosteroids.
Due to potential QTc prolongation, consider baseline ECG if prescribing macrolides or quinolones to certain patients (e.g. other QTc prolonging drugs, electrolyte abnormalities, etc.).