UpToDate® NAC USA/UK

Comparison of recommendations of published guidelines for empiric antimicrobial therapy of community-acquired pneumonia in adults (from North America, United Kingdom)

Guideline	Site of care
Guideline	Outpatient	General ward	ICU/severe
EEUU Guide (ATS/IDSA; 2007) [1]	If no significant risks for DRSP: Macrolide or doxycycline If risks for DRSP: Antipneumococcal fluoroquinolone OR High-dose amoxicillin (3 gm/day) or high dose amoxicillin/clavulanate (4 gm/day) plus macrolide (if amoxicillin is used and there is a concern for H. influenzae, use macrolide active for -lactamase producing strains) OR Telithromycin	-lactam (ceftriaxone, cefotaxime, ampicillin/sulbactam, ertapenem) plus macrolide (can use doxycycline if macrolide not tolerated) OR Antipneumococcal fluoroquinolone alone	-lactam (ceftriaxone, cefotaxime, ampicillin/sulbactam) plus IV azithromycin or IV fluoroquinolone If concern for Pseudomonas (eg, presence of structural lung disease such as bronchiectasis): antipseudomonal agent (piperacillin/tazobactam, imipenem, meropenem, or cefepime) plus antipseudomonal fluoroquinolone (ciprofloxacin or high dose levofloxacin); If concern for MRSA (see text): add vancomycin or linezolid
British Thoracic Society (2004) [2]	Amoxicillin 500-1000 mg thrice daily; (Alternative therapy: erythromycin or clarithromycin)	If admitted for non-clinical reasons or previously untreated in the community: Amoxicillin (macrolide as alternative) If admitted for pneumonia and oral therapy appropriate: Amoxicillin plus (erythromycin or clarithromycin); (Alternative therapy: antipneumococcal fluoroquinolone) If parenteral therapy appropriate: Ampicillin or benzylpenicillin plus (erythromycin or clarithromycin); (Alternative therapy: IV levofloxacin, note IV moxifloxacin not available in UK)	Co-amoxiclav or 2nd/3rd generation cephalosporin plus (IV erythromycin or clarithromycin, +/- rifampin); (IV levofloxacin plus IV benzylpenicillin as alternative)

ICU: intensive care unit; DRSP: drug resistant S. pneumoniae; UK: United Kingdom; IV: intravenous.
* Antimicrobial therapy within the past 3 months, hospitalization within the past month, alcoholism, immune-suppressive illness (including therapy with corticosteroids), multiple medical comorbidities, exposure to a child in a day care center.

Gemifloxacin, Levofloxacin, Moxifloxacin (Gemifloxacin is only available in oral formulation).

Azithromycin or clarithromycin.

Rare cases of severe liver failure reported.
1. Clin Infect Dis. 2007.
2. British Thoracic Society. Pneumonia Guidelines Committee (John MacFarlane, Chair). Guidelines for the management of community-acquired pneumonia-2004 Update. www.Brit-thoracic.org/guideline.