Community Acquired Pneumonia Transition to Oral Antibiotic and Discharge Criteria

What is the recommended total length of antibiotic therapy?

-We strongly recommend based on low quality evidence transition to oral high dose amoxicillin (80-100 mg/kg/day divided twice a day) when clinically indicated and at discharge to complete a total course of antibiotics of 5-7 days.

Patients with mild to moderate pneumonia may receive the same benefit from oral antibiotics as parenteral therapy if they are able to tolerate oral fluids and show compliance with oral therapy (Atkinson, Lakhanpaul et al. 2007). The British Thoracic society guideline reserves IV antibiotics for patients unable to tolerate oral fluids or patients presenting with septicemia or complicated pneumonia (Harris, Clark et al. 2011).

Treatment with high-dose amoxicillin (80-100 mg/kg/day divided twice a day) is recommended when bacterial pneumonia is suspected (Kabra, Lodha et al. 2006). High-dose amoxicillin has high lung tissue penetration and can overcome S. pneumoniae resistance (Deeks, Palacio et al. 1999), which has been identified in multiple studies as the most common bacterial pathogen in children (Heiskanen-Kosma, Korppi et al. 1998; Wubbel, Muniz et al. 1999; Juven, Mertsola et al. 2000; Michelow, Olsen et al. 2004; Madhi, Kuwanda et al. 2005). 

The British Thoracic Society guideline recommends amoxicillin as first line oral therapy due to its effectiveness against common pathogens as well as its safety and tolerability (Harris, Clark et al. 2011). 

The PIDS/IDSA guideline has the same recommendation; amoxicillin as first line therapy in patients suspected of bacterial disease. In addition to amoxicillin’s effectiveness, treating with a limited spectrum antimicrobial will help decrease the development of antibiotic resistance (Bradley, Byington et al. 2011). 

In review of the implementation of CMH’s guideline, we were able to identify that amoxicillin was a safe and effective oral treatment for patients discharged from the hospital with ICD9 codes for uncomplicated bacterial pneumonia. Patients discharged on amoxicillin did not have significant treatment failures identified as either readmission to the hospital or necessitating a change in antibiotics therapy after discharge (Newman, Hedican et al. 2012).

 

Uncomplicated CAP and Step Down Therapy

 


These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.

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