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Community-Acquired Pneumonia

Antibiotic treatment: Special Situations

Home > Treatment > Antibiotic treatment: Special Situations

Initial or empiric antibiotic therapy in CAP should follow the previously outlined recommendations compliant with the IDSA/ATS CAP Guidelines published in 2007 (see Outpatient Antibiotic TreatmentInpatient Antibiotic Treatment). 

However, there are several uncommon "special" situations that may warrant considerations for alternative initial antibiotic therapy, or at least warrant considerations for obtaining more detailed microbiologic data (blood and sputum cultures, bronchoscopy with bronchoalveolar lavage culture).

Patient with risk factors for CAP caused by Pseudomonas aeruginosa:

Patients with structural lung disease, such as cystic fibrosis, bronchiectasis, or severe emphysema, as well as those with COPD and frequent use of oral corticosteroids or antibiotics, are at risk for CAP caused by Pseudomonas aeruginosa.  Also, patients known to have prior colonization or respiratory infection with Pseudomonas should be considered to be at risk.

Antibiotic recommendations pending culture results include:

  • Piperacillin-tazobactam, imipenem, meropenem, or cefepime, plus ciprofloxacin or levofloxacin[750mg], or
  • Piperacillin-tazobactam, imipenem, meropenem, or cefepime, plus ciprofloxacin or levofloxacin[750mg], plus an aminoglycoside, or
  • Piperacillin-tazobactam, imipenem, meropenem, or cefepime, plus azithromycin plus an aminoglycoside, or
  • For penicillin-allergic patients:  substitute aztreonam for the beta-lactam

Risk factors for community-acquired Staphylococcus aureus (including CA-MRSA):

Patients with a history of end-stage renal disease receiving chronic hemodialysis, patients with injection drug use, and patients with cavitary radiographic opacities, are at risk for CAP caused by Staphylococcus aureus.  Also, patients presenting with acute post-influenza pneumonia are at high-risk for CAP from either Streptococcus pneumoniae or Staphylococcus aureus

Antibiotic recommendations include:


Risk factors for gastric aspiration:

Patients with a history of ongoing or recent alcohol abuse, as well as those with seizure disorder, prior stroke, or suspected or confirmed swallowing dysfunction, are at particularly high risk for oral or gastric aspiration.  Some degree of micro- and/or macro-aspiration likely plays a significant role in many patients with CAP.

Antibiotic recommendations:


  • Routine anaerobic coverage is not recommended.  An appropriate antibiotic regimen should be utilized as previously outlined in Outpatient Antibiotic Treatment Section, or Inpatient Antibiotic Treatment Section.  Addition of clindamycin or metronidazole for a recognized aspiration event may be considered, or if there is radiographic evidence for lung abscess, cavitary infiltrate, or empyema, pending culture results.

Positive blood cultures for Streptococcus pneumoniae (ie. bacteremic Pneumococcal pneumonia):

Antibiotic recommendations:


  • 2-drug antibiotic coverage, pending culture and sensitivity results

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