Pneumonia, Community-Acquired — Treatment Failure— Clinical Pathway: All Settings

Community Acquired Pneumonia Clinical Pathway — All Settings

CAP Treatment Failure

Treatment failure is defined as increasing respiratory distress, increasing respiratory support requirement, or worsening fever curve in a patient who received at least > 48 hrs of adequately dosed preferred first line therapy.

  • Consider testing and treatment for atypical organisms (e.g., Mycoplasma, Legionella) per recommendations for Initial Treatment
Initial Empirical
Antibiotic Treatment		 Mild/Moderate Pneumonia
Transition to:		 Severe Pneumonia
Transition to:
High-Dose Amoxicillin
or
Ampicillin
  • Ampicillin-Sulbactam
    • 75 mg/kg/dose IV q6hr
    • Max: 2 g/dose
      • Rationale: ampicillin-sulbactam adds coverage for MSSA (now more common than MRSA at CHOP – see CHOP antibiogram) and respiratory gram-negatives (including beta-lactamase producing non-typeable H. influenzae)
  • or
  • Clindamycin
    • 14 mg/kg/dose IV q8hr
    • Max: 900 mg/dose
      • If History of MRSA or high concern for MRSA pneumonia (e.g., severe lobar pneumonia, ill appearance); severe penicillin allergy
        • Rationale: clindamycin adds coverage for ~ 80% of CA-MRSA at CHOP (see CHOP antibiogram) and no coverage for respiratory gram-negatives. Review prior susceptibilities and consider alternatives for patients with a history of clindamycin resistant MRSA
  • Vancomycin (IV)
    • ≤ 50 kg: 15 mg/kg/dose IV q6hr
    • Max: 750 mg/dose
    • > 50 kg and/or > 18 yrs: 15 mg/kg/dose IV q8hr
    • Max: 1,000 mg/dose
  • and
  • Ceftriaxone
    • 100 mg/kg/day IV, q24hr
    • Max: 2 g/dose
Clindamycin
  • Ceftriaxone
    • 100 mg/kg/dose IV q24hr
    • Max: 2 g/dose
Clindamycin + Ceftriaxone
or
Vancomycin + Ceftriaxone
or
Ceftriaxone		 Consult Infectious Diseases Consult Infectious Diseases