Empirical therapy for high-severity CAP in adults

For management considerations, including adjustments to empirical therapy (eg in tropical regions of Australia¹), see Management of high-severity CAP in adults.

For adults with high-severity CAP, as a 2-drug regimen, useAllgaier, 2021 Falcone, 2021 Jasper, 2021 Kato, 2022 Polgreen, 2018 Zhang, 2018:

ceftriaxone 2 g intravenously, daily; for patients with septic shock or requiring intensive care support, use ceftriaxone 1 g intravenously, 12-hourly. See advice on patient review, intravenous to oral switch and duration of therapy ceftriaxone ceftriaxone ceftriaxone

PLUS

azithromycin 500 mg intravenously, daily; see advice on patient review, intravenous to oral switch and duration of therapy. azithromycin azithromycin azithromycin

Pharmacokinetics may be altered in adults who are critically ill (eg because of enhanced kidney clearance or changes in volume of distribution). To ensure adequate drug exposure in adults with high-severity CAP who have septic shock or require intensive care support, modified dosages of ceftriaxone are recommended. Once the critical illness has resolved, consider switching to the standard dosage.

For adults with high-severity CAP who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use ceftriaxone plus azithromycin at the dosage above.

For adults with high-severity CAP who have had a severe immediate² hypersensitivity reaction to a penicillin, ceftriaxone (at the dosage above) can be considered 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 high-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, 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

Consider the need for additional or replacement therapy for patients:

with suspected viral high-severity CAP
who require adjunctive corticosteroid therapy
with suspected staphylococcal high-severity CAP
with suspected pseudomonal high-severity CAP.

¹ Tropical regions of Australia refer to regions north of 20°S latitude. This includes areas of Queensland north of Mackay, the Northern Territory north of Tennant Creek, and Western Australia north of Port Hedland.Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

³ Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return