Intravenous plus enteral therapy for moderate-severity CAP in adults
For management considerations, including adjustments to empirical therapy (eg in tropical regions of Australia1), see Management of moderate-severity CAP in adults.
For adults with moderate-severity CAP who can tolerate and absorb oral therapy and have appropriate clinical review, oral therapy can be used. Use intravenous plus enteral therapy for patients who are unable to tolerate or absorb oral therapy (see Choosing a suitable route of administration for antimicrobials for detailed advice).
For adults with moderate-severity CAP who are not suitable for oral therapy, as a 2-drug regimen, useAl-Salloum, 2021Aldhahri, 2022Choi, 2022Hill, 2020Patel, 2020Polgreen, 2018:
benzylpenicillin 1.2 g intravenously, 6-hourly; see advice on patient review, intravenous to oral switch and duration of therapy benzylpenicillin benzylpenicillin benzylpenicillin
PLUS one of the following
1doxycycline 100 mg enterally, 12-hourly; see advice on patient review and duration of therapy doxycycline doxycycline doxycycline
OR
2azithromycin 500 mg enterally, daily; see advice on patient review and duration of therapy azithromycin azithromycin azithromycin
OR
2clarithromycin 500 mg enterally, 12-hourly. For dosage adjustment in adults with kidney impairment, see clarithromycin dosage adjustment. See advice on patient review and duration of therapy. clarithromycin clarithromycin clarithromycin
If enteral therapy is not possible, use intravenous azithromycin; for dosages, see High-severity CAP.
For adults with moderate-severity CAP who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, replace benzylpenicillin in the above regimen with:
ceftriaxone 2 g intravenously, daily; see advice on patient review, intravenous to oral switch and duration of therapy. ceftriaxone ceftriaxone ceftriaxone
For adults with moderate-severity CAP who have had a severe immediate2 hypersensitivity reaction to a penicillin, consider replacing benzylpenicillin in the regimen above with ceftriaxone (at the dosage above) if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).
For adults with moderate-severity CAP who have had a severe immediate2 hypersensitivity reaction to a penicillin in whom ceftriaxone is not used, or for patients who have had a severe delayed3 hypersensitivity reaction to a penicillin, as monotherapy, use:
moxifloxacin 400 mg intravenously or enterally, daily. For dosage adjustment in adults with kidney impairment, see moxifloxacin dosage adjustment. See advice on patient review, intravenous to oral switch and duration of therapy. moxifloxacin moxifloxacin moxifloxacin