Dosing of amoxicillin changed from 1000 mg TID to 1000 mg BID to simplify dosing options in mild CAP. Amoxicillin-clavulanate 875 mg BID is equivalent to amoxicillin-clavulanate 500 mg TID. Penicillin resistance in S. pneumonia is not through a beta-lactamase mechanism and therefore not impacted by the dosing of clavulanate. Furthermore, H. influenza is a rare cause of mild CAP (1 in 200) and most isolate are amoxicillin susceptible (75%). Therefore, amoxicillin alone at 1000 mg BID will be equally as effective against S. pneumonia and most H. influenzae CAP as amoxicillin-clavulanate 875 mg BID
Cefuroxime removed from low severity CAP in order to simplify options
Role of atypical coverage in moderate and severe CAP has undergone review. Recent randomized controlled trials showed no mortality benefit with addition of a macrolide to beta-lactam therapy. The most recent Cochrane review of the topic showed clinical benefit with atypical coverage only in the subset of patients with Legionella. This has resulted in the following changes:
Doxycycline has been removed as an option given lack of evidence showing demonstrable benefit when added to beta-lactam monotherapy, and limited data for treatment of Legionella
Guidance on Legionella pneumonia added to first page
Updated severe CAP with Pseudomonas risk factors due to recent availability of levofloxacin PO and IV on unrestricted formulary
Clarification to use of vancomycin when MRSA is possible in severe CAP
Incorporated antibiotic discontinuation criteria under duration of therapy
Guidance added for discontinuation of empiric vancomycin with negative microbiology studies