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Risk factors for MRSA and PsA include previous isolation and hospitalization with antibiotics within the past 90 days. Empiric therapy for community-acquired pneumonia (CAP) should target S. pneumoniae, H. influenzae, M. catarrahlis, L. pneumophila, and C. pneumoniae. Legionella and Chlamydia are considered atypical pathogens due to their limited detection on standard assays. The ATS/IDSA 2019 CAP Guideline provides antibiotic recommendations.
High-dose amoxicillin at 1000 mg orally three times a day has been proven effective even without atypical pathogen coverage. Doxycycline and macrolides cover common CAP pathogens, including atypical ones, and monotherapy with one of these three can be considered for patients without comorbidities.
Patients with comorbidities are at a higher risk for broader and emerging resistant organisms, such as those with chronic organ disease, alcoholism, malignancy, and asplenia. Combination therapy is recommended with amoxicillin/clavulanate or a cephalosporin like cefuroxime and cefpodoxime, along with atypical coverage using doxycycline or macrolides.
For patients requiring hospital admission for CAP, initial treatment involves intravenous antibiotics. Combination therapy with beta-lactams and macrolides is recommended, commonly involving ceftriaxone and azithromycin.
Patients with risk factors for MRSA or Pseudomonas should include vancomycin and switch the beta-lactam to piperacillin-tazobactam or cefepime as appropriate.
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