Inpatient Therapy Regimen A

(Note two or three drug therapy) Cefotaxime (Claforan) 2 g IV q8h [B] OR Ceftriaxone (Rocephin) 2 g IV qd [B] PLUS

Erythromycin 5 mg/kg/dose IV qid (max 1 g/dose) [B, except estolate contraindicated] OR

Azithromycin (Zithromax) 500 mg IV qd [B]

PLUS/MINUS (if suspect drug-resistant Strep. pneumoniae)

Vancomycin (Vancocin) 15 mg/kg IV q6h (max 1 g/dose; monitor serum levels) [C]

Regimen B (Note one or two drug therapy) Levofloxacin (Levaquin) 500 mg IV qd [C] PLUS/MINUS (if aspiration suspected) Clindamycin 600 mg IV q8h [B] OUTPATIENT THERAPY Notes:

1. Initial antibiotic selection may differ in areas with community-wide erythromycin (macrolide) resistant S. pneumoniae.

2. Erythromycin variably effective against H. influenzae.

3. Consider initiating outpatient therapy with a single dose of the parenteral antibiotics listed above for inpatient therapy.

1. Azithromycin (Zithromax) 500 mg PO initial dose, then 250 mg PO qd for 4 days [B]

2. Clarithromycin (Biaxin) 250-500 mg PO bid [C]

3. Erythromycin 500 mg PO qid OR erythromycin ethylsuccinate (EES) 400 mg PO bid [B, except estolate contraindicated]

4. Levofloxacin (Levaquin) 500 mg PO qd [C]

5. Doxycycline (Vibramycin) 100 mg PO bid [D]

Course: 10-14 days (except azithromycin as noted) (levofloxacin preferred in areas with S. pneumoniae macrolide resistance) Organisms: S. pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae (TWAR), Legionella sp., H. influenzae

D. ADULTS (OLDER THAN 60 YEARS OF AGE, SMOKER, CHRONIC ILLNESS, ALCOHOLIC) INPATIENT THERAPY

Note: Treat as for adults (60 years old, community acquired, no comorbidity), above. OUTPATIENT THERAPY

Note: Consider initiating outpatient therapy with a single dose of the parenteral antibiotics listed above for inpatient therapy. Regimen A

Azithromycin (Zithromax) 500 mg PO initial dose then 250 mg PO qd for 4 days [B] Clarithromycin (Biaxin) 250-500 mg PO bid [C]

Regimen B (if suspect Drug Resistant S. pneumoniae) Levofloxacin (Levaquin) 500 mg PO qd [C]

Sparfloxacin (Zagam) 400 mg PO initial dose, then 200 mg PO qd [C] Grepafloxacin (Raxar) 600 mg PO qd [C]

Regimen C (if suspect aspiration) Amoxicillin/clavulanate (Augmentin) 500 mg PO tid [B] Course: 10-14 days (except azithromycin as noted)

Organisms: S. pneumoniae, H. influenzae, M. catarrhalis, Legionella sp., Chlamydia pneumoniae, coliforms Pulmonary Tuberculosis

(Chest x-ray positive, active disease) Many regional variations and conflicting recommendations exist. Unless local/regional sensitivities are well established, consider initiating treatment with four drug therapy.

A. CHILDREN Notes:

1. Patients with positive chest x-rays (active disease) must be isolated.

2. All cases must be reported to the local health department.

3. Antituberculosis medications have inherent toxicities and side effects: INH (hepatitis, peripheral neuropathy), rifampin (hepatotoxicity, flu-like syndrome, discoloration of body fluids/staining of contact lenses), PZA (arthralgias, hyperuricemia, hepatitis), ethambutol (optic neuritis), and streptomycin (ototoxicity). Close monitoring is essential.

4. Consider adding pyridoxine (vitamin B6) 25-50 mg PO qd [A] to decrease NIH-induced neuropathy. Isoniazid (INH) 10-20 mg/kg/day PO (max 300 mg/day) [C]

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