Rise of the Macrolide Resistance: Community Acquired Pneumonia Treatment Update

Last updated on September 4th, 2024 at 01:57 pm

After growing into Emergency Medicine during the COVID pandemic, everyone that comes through the doors with a cough and fever looks like an ideal target for a nasal swab. But let’s not forget that long ago, in a galaxy not so far away, community acquired pneumonia (CAP) was on the differential (along with the other respiratory viruses), and with that, let’s talk about the treatment for CAP.

The last update to the Infectious Disease Society of America (IDSA) guidelines on treatment of CAP was more than a decade ago, and in 2019 they provided updated guidance on antibiotic regimens for the outpatient management which simplifies things and shines a light on the world of antibiotic resistance.^​1​ This post will focus on Question 8 of the IDSA guideline – In the Outpatient Setting, Which Antibiotics Are Recommended for Empiric Treatment of CAP in Adults? Let’s assume you have a patient with CAP who can be managed outpatient and jump straight to management by dividing our patients into two groups:

1. If the patient has no comorbidities
2. If the patient has comorbidities: chronic heart, lung, liver, renal disease; any immunocompromised state (IDSA specifically references diabetes mellitus, alcoholism, malignancy, or asplenia but we’ll be a little more broad here) OR risk factors for MRSA or Pseudomonas

This recommendation to avoid macrolides in areas with higher resistance rates comes as a departure from the prior CAP guidelines, in which macrolide monotherapy was recommended more strongly. This leaves us with the question of what our local pneumococcal macrolide resistance is, and unfortunately, you cannot just google the answer (I tried). The natural answer you get when asking this question is to look at your local department of health/hospital antibiogram, and although I think it is a noble thing to do, I have found it difficult to locate the antibiogram in a timely manner on a busy shift. Luckily (or unluckily), the rise of the resistance is not only a fantastic ride at Disney, but is also the phenomena present across the United States, regardless of geography. This study published in July 2021 with isolates from 329 hospitals across the US shows an average of 39% resistance to macrolides.^​2​

So where does that leave us? In the patient with CAP who is otherwise healthy and with no comorbidities, I will not prescribe monotherapy with a macrolide, amoxicillin or doxycycline is the way.

Cite this post: Jordan Feltes, MD, Arman Hussain, MD. “Rise of the Macrolide Resistance: Community Acquired Pneumonia Treatment Update”. GW EM Blog. April 25, 2023. Available at: https://gwemblog.com/idsa-cap-2019/.

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