Community Acquired Pneumonia Antibiotic Treatment in the Community (Adults)

Comments from the Expert Advisory Committee

Community acquired pneumonia (CAP) is a pneumonia that is acquired outside hospital.
CAP in the community can been defined as:
- Symptoms of an acute lower respiratory tract illness (cough and at least one other lower respiratory tract symptom)
- New focal chest signs on examination
- At least one systemic feature (either a symptom complex of sweating, fevers, shivers, aches and pains and/or temperature of 38⁰C or more)
Start antibiotics immediately
Review if symptoms are not improving as expected with antibiotics and escalate therapy, or consider hospital referral.
Assess severity using the CRB-65 score.

Screenshot 2021-10-08 102909

The need for hospital referral should be assessed, and at review, re-assessed using the CRB65 criteria.
At convalescence, ensure COVID-19, influenza and pneumococcal vaccinations up to date.

Treatment Table - Community Acquired Pneumonia


Community Acquired Pneumonia (Adults): Antibiotic Treatment Table
Assess using the CRB-65 score (each symptom or sign scores one point) (Confusion, Respiratory rate ≥ 30/min, BP ≤ 90/60 mmHg, Age ≥ 65)
CRB 65 Score Zero (0) Suitable for home treatment Review if symptoms are not improving as expected with antibiotics and escalate therapy, or consider hospital referral.
Amoxicillin	500mg every 8 hours	5 days	Avoid in penicillin allergy. If no response after 48 hours on Amoxicillin monotherapy, consider addition of Clarithromycin or change to Doxycycline
OR Doxycycline	200mg every 24 hours*	5 days	Avoid in pregnancy. Advise to take with a glass of water and sit upright for 30 minutes after taking. Can take with food or milk if gastritis is an issue. Absorption of doxycycline significantly impaired by antacids, iron/calcium/magnesium/zinc-containing products.
OR Clarithromycin (Second line in penicillin allergy)	500mg every 12 hours	5 days	Macrolides should be used with caution in pregnancy. Clarithromycin suitable only in 2nd and 3rd trimester in pregnancy. Alternative macrolide for all trimesters of pregnancy: Azithromycin 500mg stat then 250mg every 24 hours from Day 2 to Day 5.
CRB 65 Score 1-2 and assessed suitable for treatment in the community Review if symptoms are not improving as expected with antibiotics and escalate therapy, or consider hospital referral.
Amoxicillin PLUS Clarithromycin	500mg - 1g every 8 hours 500mg every 12 hours	5 days	Avoid amoxicillin in penicillin allergy. Macrolides should be used with caution in pregnancy. Clarithromycin suitable only in 2nd and 3rd trimester in pregnancy. Alternative macrolide for all trimesters of pregnancy: Azithromycin 500mg stat then 250mg every 24 hours from Day 2 to Day 5.
OR Doxycycline	200mg every 24 hours*	5 days	Avoid in pregnancy. Advise to take with a glass of water and sit upright for 30 minutes after taking. Can take with food or milk if gastritis is an issue. Absorption of doxycycline significantly impaired by antacids, iron/calcium/magnesium/zinc-containing products.
CRB 65 Score 3 or more : urgent hospital admission
Administer Benzylpenicillin prior to transfer	1.2g IV/IM	N/A	Avoid in penicillin allergy Urgent hospital admission Seek risk factors for Legionella and Staph.aureus infection
Or Amoxicillin	1g PO	N/A

*Alternative doxycycline dose: 100mg every 12 hours.
In non-severe infection, 200mg stat then 100mg every 24 hours can be considered.

Pleuritic pain should be relieved using simple analgesia, and consider pulmonary embolism.
Consider advising patients on hydration and smoking cessation where appropriate.
Consider time off work for patients with CAP dependent on clinical assessment.
Advise to consult pharmacist for symptom relief.

Patient Information

We recommend patients use the website developed by HSE/ICGP/IPU partnership www.undertheweather.ie for tips on how to get better from common infections without using antibiotics, what you can do for yourself or a loved one and when to seek help.
HSE > Symptoms, Condition and Treatment: Pneumonia

Safe Prescribing (visit the safe prescribing page)

Doses are oral and for adults unless otherwise stated
Clarithromycin and other macrolides warning
Penicillin allergy – tips on prescribing in penicillin allergy
Renal impairment dosing table
Safety in Pregnancy and Lactation
Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed May 2022