Recommended antimicrobial therapy for specific pathogens causing community-acquired pneumonia in adults

Organism	Preferred antimicrobial(s)	Alternative antimicrobial(s)
Streptococcus pneumoniae
Penicillin nonresistant; MIC <2 mcg/mL*	Penicillin G, amoxicillin	Macrolide, cephalosporins (oral [cefpodoxime, cefprozil, cefuroxime, cefdinir] or parenteral [cefuroxime, ceftriaxone, cefotaxime]), clindamycin, doxycycline, respiratory fluoroquinolone^¶
Penicillin resistant; MIC ≥2 mcg/mL*	Agents chosen on the basis of susceptibility, including cefotaxime, ceftriaxone, fluoroquinolone	Vancomycin, linezolid, high-dose amoxicillin (3 g/day with penicillin MIC ≤4 mcg/mL)
Haemophilus influenzae
Non-beta-lactamase producing	Amoxicillin	Fluoroquinolone, doxycycline, azithromycin, clarithromycin^Δ
Beta-lactamase producing	Second- or third-generation cephalosporin, amoxicillin-clavulanate	Fluoroquinolone, doxycycline, azithromycin, clarithromycin^Δ
Mycoplasma pneumoniae/Chlamydophila pneumoniae	Macrolide, a tetracycline	Fluoroquinolone
Legionella species	Fluoroquinolone, azithromycin	Doxycycline
Chlamydophila psittaci	A tetracycline	Macrolide
Coxiella burnetii	A tetracycline	Macrolide
Francisella tularensis	Doxycycline	Gentamicin, streptomycin
Yersinia pestis	Streptomycin, gentamicin	Doxycycline, fluoroquinolone
Bacillus anthracis (inhalation)	Ciprofloxacin, levofloxacin, doxycycline (usually with second agent)	Other fluoroquinolones; beta-lactam, if susceptible; rifampin; clindamycin; chloramphenicol
Enterobacteriaceae	Third-generation cephalosporin, carbapenem^◊ (drug of choice if extended-spectrum beta-lactamase producer)	Beta-lactam-beta-lactamase inhibitor^§, fluoroquinolone
Pseudomonas aeruginosa	Antipseudomonal beta-lactam^¥ plus (ciprofloxacin or levofloxacin^‡ or aminoglycoside)	Aminoglycoside plus (ciprofloxacin or levofloxacin^‡)
Burkholderia pseudomallei	Carbapenem, ceftazidime	Fluoroquinolone, TMP-SMX
Acinetobacter species	Carbapenem	Cephalosporin-aminoglycoside, ampicillin-sulbactam, colistin
Staphylococcus aureus
Methicillin susceptible	Antistaphylococcal penicillin^†	Cefazolin, clindamycin
Methicillin resistant	Vancomycin or linezolid	TMP-SMX
Bordetella pertussis	Macrolide	TMP-SMX
Anaerobe (aspiration)	Beta-lactam-beta-lactamase inhibitor^§, clindamycin	Carbapenem
Influenza virus	Refer to associated topic reviews**
Mycobacterium tuberculosis	Isoniazid plus rifampin plus ethambutol plus pyrazinamide	Depends on susceptibility pattern; refer to associated topic reviews
Coccidioides species	For uncomplicated infection in a normal host, no therapy generally recommended; for therapy, itraconazole, fluconazole	Amphotericin B
Histoplasmosis	Itraconazole^¶¶	Amphotericin B^¶¶
Blastomycosis	Itraconazole^¶¶	Amphotericin B^¶¶

Choices should be modified on the basis of susceptibility test results and advice from local specialists. Refer to local references for appropriate doses.
Preferred agent may change over time due to changing resistance patterns and depends on many factors, including severity of illness. Refer to associated UpToDate topic reviews for updated and detailed treatment recommendations for each pathogen.

MIC: minimum inhibitory concentration; ATS: American Thoracic Society; CDC: United States Centers for Disease Control and Prevention; IDSA: Infectious Diseases Society of America; TMP-SMX: trimethoprim-sulfamethoxazole.
* The 2 mcg/mL threshold is for nonmeningitis dosing. The threshold is lower for meningitis dosing.
¶ Levofloxacin, moxifloxacin, gemifloxacin (not a first-line choice for penicillin-susceptible strains); ciprofloxacin is appropriate for Legionella and most gram-negative bacilli (including H. influenzae).
Δ Azithromycin is more active in vitro than clarithromycin for H. influenzae.
◊ Imipenem-cilastatin, meropenem, ertapenem.
§ Piperacillin-tazobactam, ampicillin-sulbactam, ticarcillin-clavulanate (not available in the United States), or amoxicillin-clavulanate.
¥ Ceftazidime, cefepime, aztreonam, imipenem, meropenem, or piperacillin (not available in the United States).
‡ 750 mg daily.
† Nafcillin, oxacillin, flucloxacillin.
** Choice of antiviral regimen depends on type of influenza virus and expected resistance pattern. (Refer to the UpToDate topic on antiviral drugs for the treatment of influenza in adults.)
¶¶ Preferred agent depends on severity of illness. Refer to associated UpToDate topic reviews for full discussions.

Adapted with permission from: Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thorac Society Consensus Guidelines on the Management of Community-acquired Pneumonia in Adults. Clin Infect Dis 2007; 44:S27. Copyright © 2007 University of Chicago Press.

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Recommended antimicrobial therapy for specific pathogens causing community-acquired pneumonia in adults