4. Recommendations and Guidelines for the
Treatment of Pneumonia in Taiwan
• Epub: Dec 6, 2018
• Pub date: Feb 2019
2018
J Microbiol Immunol Infect 2019 Feb; 52(1):172-199.
7. Why guidelines for pneumonia?
• 按照指引治療可降低死亡率
− Dean NC. Decreased mortality after implementation of a treatment guideline
for CAP. Am J Med 2001; 110: 451–57.
− Martinez R. Impact of guidelines on outcome: the evidence. Semin Respir Crit
Care Med 2009; 30: 172–78.
• 減少住院日數
− McCabe C. Arch Intern Med. 2009;169(16):1525-1531
• 改善正確抗生素使用，減少抗生素使用日數
− Capelastegui A. Improvement of Process-of-Care and Outcomes after
Implementing a Guideline for the Management of CAP: A Controlled Before-
and-After Design Study. Clin Infect Dis 2004; 39:955–63
8. Reduced mortality in CAP & HAP patients with
Guideline implementation
Soo Hoo GW. Chest 2005;128(4):2778-87Dean NC. Am J Med 2001;110:451-7.
CAP HAP
30% reduction in 30 day mortality
Lower mortality at 14 days
14 day mortality: 8% vs 23%, (p=0.03)
10. Major Changes in Pneumonia Guidelines
Taiwan 2018 vs 2007: What’s in it?
Major changes
• Use of modified GRADE methodology
• Healthcare-associated pneumonia (HCAP)
• Pediatric pneumonia
What’s in it ?
• CAP
• HAP/VAP, pneumonia in RCW
• HCAP: NHAP & HDAP
• Pediatric pneumonia
Recommendations and guidelines for treatment of pneumonia in Taiwan. JMII 2018 Dec 6 Epub.
11. Major changes
§ Use of modified GRADE methodology
§ Healthcare-associated pneumonia (HCAP)
§ Pediatric pneumonia
What’s in it ?
§ CAP
§ HAP/VAP, pneumonia in RCW
§ HCAP: NHAP & HDAP
§ Pediatric pneumonia
Recommendations and guidelines for treatment of pneumonia in Taiwan. JMII 2018 Dec 6 Epub.
§ CAP was defined as a pulmonary parenchymal acute infection in
patients who acquire the condition in the community.
§ HAP was defined an infection of pulmonary parenchyma in
patients who acquire the condition
§ at least 48 hours after admission to hospital, or
§ within 14 days after discharge from hospital.
§ VAP was defined as an infection of pulmonary parenchyma
occurring at least 48 hours after endotracheal intubation.
Recommendations and guidelines for treatment of pneumonia in Taiwan.
J Microbiol Infect Immunol 2019 Feb; 52(1):172-199
於社區得到肺部間質急性感染
於醫療院所得到肺部間質急性感染
使用呼吸器 48 小時之後得到肺部間質急性感染
入院後 48 小時之後
前次出院後 14 天以內
12. §HCAP was defined as a pulmonary
parenchymal infection in patients who was
1. Previously hospitalized in an acute care
hospital for two or more days within 90 days
prior to current infection;
2. resided in a nursing home or long term care
facility;
3. received recent intravenous antibiotic therapy,
chemotherapy, wound care or HD within 90
days prior to the current infection
Recommendations and guidelines for treatment of pneumonia in Taiwan. JMII 2019;52(1):172-199.
於以下情況得到肺部間質急性感染：
感染前 90 天內曾經住院超過兩天
居住於護理之家或安養院
感染前 90 天內曾經接受抗生素靜脈注射、化療、傷口照護或洗腎
13. HCAP: A distinct clinical entity in Taiwan
• Unique medical care system in Taiwan
− Numerous RCWs, caring for chronically ventilated patients, an
− HD clinics, covered by the universal NHI
− Recurrent hospitalization of patients in long term care facilities
• A different epidemiology and antimicrobial resistance
patterns in this patient population.
• Stratified by risk of MDROs, subcategorized into two
populations with special concern:
1. Hemodialysis-associated pneumonia (HDAP)
2. Nursing home-associated pneumonia (NHAP).
Recommendations and guidelines for treatment of pneumonia in Taiwan. JMII 2019;52(1):172-199.
15. Yen MY. J Formos Med Assoc 2005 Oct;104(10):724-30.
26%
20%
13%
9%
5%
27%
Etiology of Mild-to-Moderate CAP
in Taiwan (N=100)
S. pneumoniae
Mycoplasma pneumoniae
Chlaymydia pneumoniae
Haemophilus influenzae
Klebsiella pneumoniae
Undetermined
72% had etiology
Co-infection: 16 %
Etiology of CAP in Taiwan (2002)
16. Etiology of Hospitalized CAP in Taiwan
Pathogen Multicenter
(2001-2002)
N=168
Lauderdale TL
Taipei
(2001-2002)
N=85
Ngeow YF
Kaohsiung
(2001-2002)
N=100
Yen MY
Taipei
(2002-2004)
N=65
Song JH
S. pneumoniae 24% -- 26% 14%
H. influenzae 5% -- 9% 2%
S. aureus 2% -- 1% 1%
K. pneumoniae 5% -- 5% 14%
Other GNBs 2% -- 2% --
M. pneumoniae 14% 5% 20% --
C. pneumoniae 7% 6% 13% --
Legionella spp. 1% 4% 3% --
Viruses 10% -- 1% 2%
M. tuberculosis 1% -- 2% --
Peto L. Trans R Soc Trop Med Hyg 2014; 108: 326–337
18. Etiology of Severe CAP in Taiwan
Northern Taiwan
(2001)
N=169
Taipei
(2001-2003)
N=62
Taichung
(2002-2003)
N=22
S. pneumoniae 2% 15% 14%
H. influenzae 3% 3% 5%
S. aureus 4% 10% 5%
K. pneumoniae 11% 8% 9%
Other GNBs 21% 16% 18%
M. pneumoniae -- 2% 0
C. pneumoniae -- -- 5%
Legionella spp. -- 2% 0
Viruses -- 2% --
M. tuberculosis -- -- --
Peto L. Trans R Soc Trop Med Hyg 2014; 108: 326–337
Severe CAP: ICU admission, ARDS, or ATS criteria for severe CAP
19. International CAP guidelines
US &
CANADA
EUROPE ASIA OTHERS
ATS/IDSA
2007
(2019)
BTS 2009
NICE 2014
Taiwan 2018 South Africa
2017
CTS/CIDS
2000
ERS/ESCMID
2011
Japan 2006
Dutch SWAB
2012
Philippines
2016
Spanish
SEPAR 2010
NEW!
20. CAP Guideline Logic
Diagnosis
Risk
Stratification
Additional Tests
Site of Care
Antibiotics
Outpatient
Inpatient
ICU
De-escalation
Oral switch
Tx Duration
PSI: pneumonia severity index
ICU: intensive care unit, Tx: treatment
CAP: community acquired pneumonia
Comorbidity
Severity Score
CURB-65, PSI
Clinical +
Radiologic
Microbiological
Biomarkers
Empiric
Target
21. CURB-65 Score for Mortality Risk Assessment
NICE guidelines for pneumonia in adults 2014
Score Risk Mortality Site of Care
0-1 Low < 3 % Home
2 Intermediate 3-15 % Hospital
3-5 High > 15 % ICU
Uremia (BUN > 19mg/dL)
Respiratory Rate ≥ 30/min
Blood Pressure drop (sBP < 90 or dBP < 60mmHg)
Age ≥ 65 years
Confusion (Abbreviated Mental Test score £ 8, or
new disorientation in person, place or time)C
U
R
B
65
Lim WS. Defining CAP severity on presentation to hospital: an international derivation
and validation study. Thorax 2003;58;377-382.
22. Simplified CRB-65 Score
Lim WS. Defining CAP severity on presentation to hospital: an international derivation and validation study.
Thorax 2003;58;377-382.
1.2% 8.2% 31%
Confusion
Respiratory rate ≥ 30
Blood pressure drop
(sBP < 90, dBP £ 60)
≥ 65 years
Mortality
0 or 1 1 or 2 3 or 4
23. Pneumonia Severity Index (PSI)
Fine MJ et. al N Engl J Med 1997; 336(4): 243-250
Risk Class Points Mortality (%) Recommended Site of
Care
I < 50 0.1 Outpatient
II 51-70 0.6 Outpatient
III 71-90 2.8 Outpatient or Brief Inpatient
IV 91-130 8.2 Inpatient
V > 130 29.2 Inpatient
•Age (1 point per
year)
•Male: Yr
•Female: Yr-10
•Nursing home
residency +10
Demographics
•Neoplasia +30
•Liver disease +20
•CHF +10
•Cerebrovascular
disease +10
•Renal disease +10
Co-morbidities
•Mental confusion
+20
•RR ≥ 30/min, +20
•sBP < 90, +20
•Temp < 35 / ≥40 °C,
+15
•HR ≥ 125/min, +15
Physical exam/
Vital signs
•pH < 7.35, +30
•BUN ≥ 30, +20
•Na < 130 +20
•Glucose ≥ 250, +10
•Hct < 30%, +10
•Pleural effusion +10
•PaO2 < 60, +10
Laboratory / Imaging
24.
25. IDSA Guidelines for CAP (2019)
Severity Antibiotics
Outpatients
+comorbidity
• Amoxicillin
• Doxycycline
• Macrolide
• Dual therapy: amoxicillin/Augmentin, ceftriaxone/cefuroxime
+ macrolides/doxycycline, OR respiratory fluoroquinolone
Inpatients • Levofloxacin, moxifloxacin or
• Dual therapy: ampicillin/ceftriaxone/cefotaxime/ertapenem
+ macrolides
(Fluroquinolones [FQ] if penicillin-allergic)
ICU Ceftriaxone/cefotaxime/Unasyn + macrolides or FQ
(FQ if penicillin allergic)
P. aeruginosa Pip/tazo, cefepime, imipenem, meropenem
+ ciprofloxacin/levofloxacin or +/- aminoglycosides
Or + azithromycin + aminoglycosides
MRSA + vancomycin or linezolid
26. UK NICE Guidelines for CAP (2014)
Severity Antibiotics Duration
Low • Amoxicillin
• Macrolide or tetracycline if allergic to
penicillin
5 days
(7 days)*
Moderate • Dual therapy: Amoxicillin + macrolide 7-10 days
(7 days)*
High • Dual therapy:
Amoxcillin-clavulanate + clarithromycin
Penicillin + levofloxacin/ciprofloxacin
Cefuroxime/ceftriaxone + clarithromycin
Levofloxacin (Legionella)
7-10 days
NICE guidelines for pneumonia in adults 2014 / BTS 2009*
Lim WS, et al. Thorax 2015;0:1–3
27. ERS/ESCMID Guidelines for CAP (2011)
Severity Antibiotics (in alphabetical order)
Outpatients
Moderate Aminopenicillin or +β-lactamase inhibitor ± macrolide
Cefotaxime or ceftriaxone ± macrolide
Levofloxacin /Moxifloxacin
Penicillin G ± macrolide
Severe Cefotaxime/ceftriaxone + macrolide
moxifloxacin or levofloxacin ± cefotaxime/ceftriaxone
Severe with
Risk factors
for
P. aeruginosa
Antipseudomonal cephalosporin or
acylureidopenicillin/β-lactamase inhibitor or
carbapenem (meropenem preferred, up to 6 g possible,
3 · 2 in 3-h infusion)
PLUS
ciprofloxacin / macrolide + aminoglycoside (gentamicin,
tobramycin or amikacin)
Woodhead M. Clin Microbiol Infect 2011; 17 (Suppl. 6): 1–24
28.
29. Monotherapy or Combined Therapy
for Empiric Treatment of Hospitalized CAP?
• Cochrane Review 2012
• 28 trials, encompassing 5939 randomized patients.
• Atypical antibiotic was monotherapy in all but 3 studies.
• Only one study assessed a beta-lactam combined with a macrolide
compared to the same beta-lactam.
• No difference in mortality between the atypical arm
and the non-atypical arm (RR 1.14; 95% CI 0.84 to 1.55),
RR < 1 favors the atypical arm
• No benefit of survival or clinical efficacy was shown
with empirical atypical coverage in hospitalized patients
with CAP (mostly FQ monotherapy vs b-lactams)
Eliakim-Raz N. Cochrane Datab Syst Rev 2012;9. Art. No.: CD004418
30. CAP-START: b-lactam monotherapy noninferior to
combined therapy in Hospitalized, non-ICU, CAP
Strategy
Results
b-lactam b-lactam +
Macrolide
Fluoro-
quinolone
No of patients 656 739 888
Median age, yrs 70 (60-79) 70 (59-80) 71 (59-79)
CURB-65 score (median) 1 (1-2) 1 (1-2) 1 (1-2)
PSI score 84.6±29.0 84.8±27.8 85.4±28.5
90-day mortality 59 (9.0%) 82 (11.1%) 78 (8.8%)
ITT: Risk of death + 1.9% (-0.6~4.4) - 0.6% (-2.8~1.9)
Median LOS 6 days 6 days 6 days
Median time to oral tx 4 (IQR 3-5) 4 (IQR 3-5) 3 (IQR 0-4)
Postma DF. NEJM 2015 Apr;372:415-427.
A cluster-randomized, crossover trial with strategies rotated in 4-month
periods, non-ICU hospitalized CAP, in 7 hospitals in Netherlands (2011-2013).
31. Open-label, noninferior RCT: b-lactam Monotherapy vs
Combination b-lactam + macrolide in moderate-severe
CAP Switzerland (N=580) (2009-2013)
• Primary Outcome:
• Clinical Instability:
% not reaching clinical
stability at Day 7
Clinical stability defined as:
• Heart rate < 100/min,
• Systolic blood pressure >
90mmHg,
• Temperature < 38.0°C,
• Respiratory rate < 24/min
• Oxygen saturation > 90%
on room air
Garin N. JAMA Intern Med. 2014;174(12):1894-1901
32. 7.9%
3.1%
0%
2%
4%
6%
8%
10%Readmissions
30-day
Monotherapy
b-lactam
Combination
b-lactam + macrolide
Combination
b-lactam + macrolide
Mortality, intensive care unit admission, complications, length of stay, and
recurrence of pneumonia within 90 days did not differ between the 2 arms.
Garin N. JAMA Intern Med. 2014;174(12):1894-1901
P=0.01
Difference = 7.6%
P = 0.07
Atypical pathogens (HR 0.33)
PSI category IV (HR 0.81)
Monotherapy
b-lactam
1-sided 90% CI: 13%
d = 8%, NOT noninferior
Difference =
7.6%
(95% CI:
-0.8 to 16%)
P = 0.07
Open-label, noninferior RCT: b-lactam Monotherapy vs
Combination b-lactam + macrolide in moderate-severe
CAP Switzerland (N=580) (2009-2013)
33. CAP: 門診 - 低嚴重度 (sCRB-65: 0-1)
Disease severity Disposition Preferred Alternative Duration
Low severity
CRB-65=0-1a
No comorbidities,
no history of
antibiotic treatment
in recent 3 months
Outpatient Amoxicillin 500 mg-1g PO q8h
Amoxicillin/clavulanate 1-2 g
PO q12h
Ampicillin/sulbactam 375-750
mg PO q12h
Cefaclor 500 mg PO q8hb
Presumed atypical pathogen
Azithromycin 500 mg PO qd
Clarithromycin 500 mg PO
q12h
Doxycycline 100 mg PO q12h
Minocycline 100 mg PO q12h
5-7
dayse
3-5
dayse
With comorbidities,
or history of
antibiotic treatment
in recent 3 months
Outpatient Amoxicillin 500 mg -1 g PO q8h
Amoxicillin/clavulanate 1-2 g
PO q12h
Ampicillin/sulbactam 375-750
mg PO q12h
Cefaclor 500 mg PO q8hb
+/-
Azithromycin 500 mg PO qd
Clarithromycin 500 mg PO
q12h
Moxifloxacin 400 mg PO qdc
Levofloxacin 500-750 mg PO
qdc
Gemifloxacin 320 mg PO qd
Nemonoxacin 500 mg PO
qdd
5-7
dayse
3-5
daysf
Recommendations and guidelines for treatment of pneumonia in Taiwan. JMII 2019;52(1):172-199.
34. CAP: 門診 - 低嚴重度 (sCRB-65: 0-1)
Disease severity Disposition Preferred Alternative Duration
Low severity
CRB-65=0-1a
No comorbidities,
no history of
antibiotic treatment
in recent 3 months
Outpatient Amoxicillin 500 mg-1g PO q8h
Amoxicillin/clavulanate 1-2 g
PO q12h
Ampicillin/sulbactam 375-750
mg PO q12h
Cefaclor 500 mg PO q8hb
Presumed atypical pathogen
Azithromycin 500 mg PO qd
Clarithromycin 500 mg PO
q12h
Doxycycline 100 mg PO q12h
Minocycline 100 mg PO q12h
5-7
dayse
3-5
dayse
With comorbidities,
or history of
antibiotic treatment
in recent 3 months
Outpatient Amoxicillin 500 mg -1 g PO q8h
Amoxicillin/clavulanate 1-2 g
PO q12h
Ampicillin/sulbactam 375-750
mg PO q12h
Cefaclor 500 mg PO q8hb
+/-
Azithromycin 500 mg PO qd
Clarithromycin 500 mg PO
q12h
Moxifloxacin 400 mg PO qdc
Levofloxacin 500-750 mg PO
qdc
Gemifloxacin 320 mg PO qd
Nemonoxacin 500 mg PO
qdd
5-7
dayse
3-5
daysf
以目前台灣對肺炎鏈球
菌的流行病學研究，
azithromycin對肺炎鏈
球菌的治療已不可信
Recommendations and guidelines for treatment of pneumonia in Taiwan. JMII 2019;52(1):172-199.
35. CAP: 住院(非ICU) 低中度嚴重度
Disease severity Dispositi
on
Preferred Alternative Duration
Low severity
CURB-65 = 0-1a
Hospitalized due to
reasons other than
disease severity (e.g.
living alone, difficult
to follow up, or
accompanied with
other clinical
conditions requiring
hospitalization.)
Non-ICU Amoxicillin 500 mg-1 g PO q8h
Amoxicillin/clavulanate 1-2 g PO q12h
Ampicillin/sulbactam 375-750 mg PO
q12h
Cefaclor 500 mg PO q8hb
Penicillin G 1-2 MU IV q6h-q4h
Ampicillin 1-2 g IV q6h
Amoxicillin/clavulanate 1.2 g IV q8h
Ampicillin/sulbactam 1.5-3 g IV q6h
Cefuroxime 1.5 g IV q8hf
+/-
Azithromycin 500 mg PO QD
Clarithromycin 500 mg PO q12h
Moxifloxacin 400 mg PO/IV
qdc
Levofloxacin 500-750 mg
PO/IV qdc
Gemifloxacin 320 mg PO qd
Nemonoxacin 500 mg PO
qdd
5-7 dayse
3-5 daysf
Moderate
severity
CURB-65 = 2-3a
Non-ICU Amoxicillin/clavulanate 1.2 g IV q8h
Ampicillin/sulbactam 1.5-3 g IV q6h
Cefuroxime 1.5 g IV q8hg
Ceftriaxone 2 g IV qd
Cefotaxime 1-2 g IV q8h
Ertapenem 1 g IV qdh
+
Azithromycin 500 mg PO qd
Clarithromycin 500 mg IV/PO q12h
Moxifloxacin 400 mg IV qdc
Levofloxacin 500-750 mg IV
qdc
Tigecyclinei 100 mg loading,
then 50mg IV q12h
Ceftaroline 500mg IV q12h
5-7 dayse
3-5 daysf
Combination 優於monotherapy (1B)JMII 2019;52(1);171-199.
36. CAP: 住院(非ICU) 低中度嚴重度
Disease severity Dispositi
on
Preferred Alternative Duration
Low severity
CURB-65 = 0-1a
Hospitalized due to
reasons other than
disease severity (e.g.
living alone, difficult
to follow up, or
accompanied with
other clinical
conditions requiring
hospitalization.)
Non-ICU Amoxicillin 500 mg-1 g PO q8h
Amoxicillin/clavulanate 1-2 g PO q12h
Ampicillin/sulbactam 375-750 mg PO
q12h
Cefaclor 500 mg PO q8hb
Penicillin G 1-2 MU IV q6h-q4h
Ampicillin 1-2 g IV q6h
Amoxicillin/clavulanate 1.2 g IV q8h
Ampicillin/sulbactam 1.5-3 g IV q6h
Cefuroxime 1.5 g IV q8hf
+/-
Azithromycin 500 mg PO QD
Clarithromycin 500 mg PO q12h
Moxifloxacin 400 mg PO/IV
qdc
Levofloxacin 500-750 mg
PO/IV qdc
Gemifloxacin 320 mg PO qd
Nemonoxacin 500 mg PO
qdd
5-7 dayse
3-5 daysf
Moderate
severity
CURB-65 = 2-3a
Non-ICU Amoxicillin/clavulanate 1.2 g IV q8h
Ampicillin/sulbactam 1.5-3 g IV q6h
Cefuroxime 1.5 g IV q8hg
Ceftriaxone 2 g IV qd
Cefotaxime 1-2 g IV q8h
Ertapenem 1 g IV qdh
+
Azithromycin 500 mg PO qd
Clarithromycin 500 mg IV/PO q12h
Moxifloxacin 400 mg IV qdc
Levofloxacin 500-750 mg IV
qdc
Tigecyclinei 100 mg loading,
then 50mg IV q12h
Ceftaroline 500mg IV q12h
5-7 dayse
3-5 daysf
Combination 優於monotherapy (1B)
美國FDA曾對 tigecycline發出警訊，以靜脈途徑
用於FDA核准/ 非核准適應症時，死亡風險會提高，
因此建議在考慮選用 tigecycline時，照會感染症
專科醫師做評估。
JMII 2019;52(1);171-199.
37. FDA warning: Tigecycline increased
all-cause mortality
2010/09 Pooled analysis of 13 Phase III & IV trials by FDA, showed higher risk of death,
esp VAP, but nonsignificant. Adjusted risk difference 0.6% (95% CI: 0.1, 1.2)
2013/09 Higher risk of death for FDA approved indications: 2.5% (66/2640) vs. 1.8% (48/2628),
adjusted RD 0.6% (95% CI 0.1,1.2) FDA new boxed warning in label
Patients with Outcome of Death by Infection Type
Mortality Rate
Infection Type Tygacil Comparator drug Risk difference (95%CI)
cSSSI 12/834 (1.4%) 6/813 (0.7%) 0.7 (-0.3, 1.7)
cIAI 42/1382 (3.0%) 31/1393 (2.2%) 0.8 (-2.0, 2.4)
CAP 12/424 (2.8%) 11/422 (2.6%) 0.2 (-2.0, 2.4)
HAP 66/467 (14.1%) 57/467 (12.2%) 1.9 (-2.4, 6.3)
Non-HAP 41/336 (12.2%) 42/345 (12.2%) 0.0 (-4.9, 4.9)
VAP 25/131 (19.1%) 15/122 (12.3%) 6.8 (-2.1, 15.7)
RP 11/128 (8.6%) 2/43 (4.7%) 3.9 (-4.0, 11.9)
DFI 7/553 (1.3%) 3/508 (0.6%) 0.7 (-0.5, 1.8)
Overall adjusted 150/3788 (4.0%) 110/3646 (3.0%) 0.6 (0.1, 1.2)
38. Severe CAP: Combination b-lactam + macrolide
vs monotherapy
Horita N et al. Respirology 2016; 21(7): 1193-200.
Adding macrolide had a favorable effect on mortality
only for severe CAP (observational studies)
Meta-analysis
14 interventional studies
(N= 1,011)
11 observational studies
(N=33,332)
Severity-based
subgroup analysis and
meta-regression
39. Meta-analysis: Severe CAP
Combination b-lactam + FQ /Macrolide
Vardakas KZ et al. Clin Microbiol Infect 2017; 23(4): 234-41.
17 studies, N=16,684, low quality evidence
Mortality higher in b-lactam + FQ than +macrolide (RR 1.33), in American, not EU studies
40. Combination b-lactam + FQ /Macrolide
Vardakas KZ et al. Clin Microbiol Infect 2017; 23(4): 234-41.
In the meta-analysis of adjusted mortality data, a non-
significant difference between b-lactam + FQ vs
b-lactam + Macrolide (8 studies, adjusted RR=1.26)
41. CAP: 住院(ICU) 高度嚴重度
Disease severity Dispos
ition
Preferred Duration
High severity
CURB-65=3-5a
ICU b-lactam based combination
Amoxicillin/clavulanate 1.2 g IV q8h
Ampicillin/sulbactam 1.5-3 g IV q6h
Cefuroxime 1.5g IV q8hg
Ceftriaxone 2 g IV qd
Cefotaxime 1-2 g IV q8h
Ertapenem 1 g IV qdh
One of the above b-lactam antibiotics
plus
one of the following macrolides:
Clarithromycin 500 mg IV/PO q12h
Azithromycin 500 mg PO qd
or
one of the following fluoroquinolones:
Moxifloxacin 400 mg IV qdc
Levofloxacin 500-750 mg IV qdc
7 dayse
Recommendations and guidelines for treatment of pneumonia in Taiwan. JMII 2019;52(1):171-199.
42. CAP: 治療療程
• 輕至中嚴重度肺炎: 如達到臨床穩定狀態，抗生
素療程 5-7 天為安全且有效1-3 (1B)
• 高嚴重度肺炎: 如達到臨床穩定狀態，抗生素療
程 7 天為安全且有效4 (2C)
• 輕至重度嚴重度肺炎: 如達到臨床穩定狀態，在
2-4天轉換針劑為口服抗生素為安全且有效（1B）
1. Li JZ, Winston LG. Efficacy of short-course antibiotic regimens for CAP: a meta-analysis. Am J Med 2007; 120(9): 783-90.
2. Dimopoulos G. Short- versus long-course antibacterial therapy for community-acquired pneumonia : a meta-analysis. Drugs 2008; 68(13): 1841-54.
3. Uranga A et al. Duration of Antibiotic Treatment in CAP: A Multicenter Randomized Clinical Trial. JAMA Intern Med 2016; 176(9): 1257-65.
4. Choudhury G. Seven-day antibiotic courses have similar efficacy to prolonged courses in severe CAP-a propensity-adjusted analysis. Clin Microbiol
Infect 2011; 17(12): 1852-8.
資料來源: 台灣肺炎診治指引 2018年
臨床穩定狀態定義為: 體溫 ≤ 37.8 °C; ⼼跳 ≤ 100 下/每分鐘;
呼吸速率 ≤ 24 次/分鐘; 收縮壓 ≧ 90 mm Hg; 未使用氧氣時
的血氧濃度 ≧ 90% 或 pO2 ≧ 60 mm Hg; 能穩定地由口進食;
正常意識狀態（最後兩項為出院或改為口服抗生素需考慮之
條件；並非用來判斷感染治療無效之標準）
43. Early Switch to Oral Treatment for CAP
Early oral switch vs IV groups Odds Ratio (95% CI)
Treatment success
• Intention-to-treat
0.76 (0.36〜1.59)
• Per-protocol 0.92 (0.6〜1.39)
Mortality 0.81 (0.49〜1.33)
Recurrence of CAP 1.81 (0.70〜4.72)
Drug-related adverse events 0.65 (0.48〜0.89)*
Athanassa Z. Drugs 2008; 68 (17): 2469-2481
Mean difference
Duration of hospitalization - 3.34 (-4.42〜 -2.25)*
44. 7-day course in Severe CAP
Propensity-adjusted analysis
In the multivariable analysis, incorporating the propensity score as a covariate,
7-day antibiotic courses were not associated with:
• 30-day mortality (adjusted OR (AOR) 0.67, 95% CI 0.21–2.16, p=0.5)
• Mechanical ventilation and/or inotropic support (AOR 0.92, 95% CI 0.27–
3.16, p=0.9)
• Complicated pneumonia (AOR 0.63, 95% CI 0.23–1.71, p=0.4).
Therefore, none suggest a harmful effect of 7-day antibiotic course
Choudhury G et al. Clin Microbiol Infect 2011; 17(12): 1852-8.
Lee RWW et al. Respirology 2007; 12: 111-6 .20. Capelategui et al. CID 2004; 39: 995-63
Marrie TJ et al. JAMA 2000; 283: 749-55.
46. CAP: Pseudomonas aeruginosa
Special condition Preferred
Risk of
Pseudomonas
infection
Piperacillin/tazobactam 4.5 g IV q8h-q6h
Ticarcillin/clavulanate 3.1 g IV q6h
Cefoperazone/sulbactam 4 g IV q12h
Cefepime 2 g IV q8h
Imipenem 500 mg IV q6h-1g IV q8h
Meropenem 1 g IV q8h
+/- *
Ciprofloxacin 400 mg IV q8h-12h
Levofloxacin 750 mg IV qd
Risk factors for P. aeruginosa
1. Recent hospitalization
2. Frequent (> 4 events per year) or recent administration of antibiotics (last 3 months),
3. Severe chronic pulmonary disease (FEV1 < 30%)
4. Oral steroid use (>10 mg of prednisolone daily in the last 2 weeks)
P. aeruginosa infection may be treated with two antipseudomonal drugs to reduce the
chance of treatment failure. When the drug susceptibility test of the pathogen is available,
antibiotics regimens should be deescalated to monotherapy.
* 在治療有P. aeruginosa 感染風險的病患時，可考慮使用合併治療避免因抗
藥性造成治療失敗。但是⼀旦有確認的藥物敏感性試驗報告，就應該降階為
有效的單⼀療法。
Recommendations and guidelines for treatment of pneumonia in Taiwan. JMII 2019;52(1):171-199.
47. CAP Special considerations: MRSA
Special condition Preferred
Risk of MRSA
infection
Vancomycin 15-20 mg/kg IV q8-12h
Teicoplanin 6-12 mg/kg/dose IV q12h x 3-5
doses, then 6-12 mg/kg/dose qd
Linezolid 600 mg PO/IV q12h
Risk factors for Methicillin-resistant Staphylococcus aureus (MRSA)
• History of MRSA acquisition
• Admission to a unit where MRSA ≥ 20% of S .aureus isolates
1.由於 methicillin-resistant Staphylococcus aureus (MRSA)感染比例在台
灣並不算高，不建議例行性給予治療抗MRSA之抗生素。
2.但若是病人之前曾培養出MRSA，或是該醫療單位MRSA菌感染的風險較高
時 (≥ 20% of S. aureus isolates)，可考慮經驗性加上治療MRSA的藥物。
Recommendations and guidelines for treatment of pneumonia in Taiwan. JMII 2019 Feb;52(1):171-199.
48. CAP: Aspiration & anaerobic infection
Special condition Preferred
Risk of aspiration
pneumonia and
anaerobic
infection
Amoxicillin/clavulanate 1-2 g PO q12h
Ampicillin/sulbactam 375-750 mg PO q12h
Amoxicillin/clavulanate 1.2 g IV q8h
Ampicillin/sulbactam 1.5-3 g IV q6h
Moxifloxacin 400 mg PO/IV qdc
Ertapenem 1 g IV qd
Or
metronidazole 500 mg PO/IV q8h
plus
one of the following b-lactams:
Cefaclor 500 mg PO q8hb
Cefuroxime 1.5 g IV q8hg
Risk factors for Aspiration pneumonia:
Recommendations and guidelines for treatment of pneumonia in Taiwan. JMII 2019 Feb;52(1):171-199.
50. Meta-analysis: Delayed treatment and
resistance with FQ use
Develop fluoroquinolone resistance: 2.7x
Overall Delays: 19 days
Chen TC e al . FQ are associated with delayed treatment and resistance in tuberculosis:
a systematic review and meta-analysis. Int J Infect Dis 2011; 15(3): e211-6.
51. Meta-analysis: Delayed treatment and
resistance with FQ use
Develop fluoroquinolone resistance: 2.7x
Overall Delays: 19 days
Chen TC e al . FQ are associated with delayed treatment and resistance in tuberculosis:
a systematic review and meta-analysis. Int J Infect Dis 2011; 15(3): e211-6.
Fluoroquinolone經驗性療
法有延遲肺結核的診斷及增
加抗藥性的風險，在臨床已
懷疑結核感染的病人應審慎
評估後使用（2C）
52. CAP: Melioidosis
g. 若是併有深部感染如中樞神經感染，建議加上TMP-SMX ⼀起使用
h. 若病患病況危急、有嚴重肺炎、深部感染、器官膿瘍、骨髓炎、感染性關節炎、中樞神經感染等情況，則
治療可延⻑⾄4 ⾄8 週或更久
i. 對sulphonamides 過敏者可使用amoxicillin/clavulanate
j. 葉酸(Folic acid)可以減少或預防TMP-SMX 所造成之antifolate 的副作用但卻不影響TMP-SMX 的殺菌力
Pathogen Preferred Alternative Duration
Burkholderia
pseudomallei
Intensive
phasei,j
Ceftazidime 50 mg/kg
(up to 2g) IV q6h
Meropenem 25 mg/kg
(up to 1 g) IV q8h
Imipenem 25 mg/kg (up
to1gm) q8h
Imipenem 25 mg/kg up
to 1g IV q6h
14 daysk
Eradication
phase
TMP/SMX PO
< 40kg: 160/800 mg
q12h; 40-60 kg:
240/1200 mg q12h; > 60
kg: 320/1600 mg q12h
plus folic acidm 0.1
mg/kg up to 5 mg PO qd
Amoxicillin/clavulanate
20/5 mg/kg PO q8h,
up to maximum of
1500/375 mg PO q8h
plus
doxycycline 100 mg PO
q12h
≥ 3
months
Recommendations and guidelines for treatment of pneumonia in Taiwan. JMII 2019 Feb;52(1):171-199.
