Haemophilus influenzae epiglottitis
Cefotaxime.

If history of immediate hypersensitivity reaction to penicillin or to cephalosporins, chloramphenicol

Chronic bronchitis: acute exacerbations
Treat if increase in sputum purulence accompanied by an increase in sputum volume or increase in dyspnoea.
Amoxicillin, or a tetracycline

Some pneumococci and Haemophilus influenzae strains tetracycline-resistant; approx. 20% H. influenzae strains amoxicillin-resistant.

Suggested duration of treatment 5 days; longer treatment may be necessary in severely ill patients

Alternative, clarithromycin.

Suggested duration of treatment 5 days; longer treatment may be necessary in severely ill patients

Pneumonia: low-severity community-acquired
Amoxicillin.

Pneumococci with decreased penicillin sensitivity being isolated.

If atypical pathogens suspected, add clarithromycin.

If staphylococci suspected (e. g. in influenza or measles), add flucloxacillin.

Suggested duration of treatment 7 days (14–21 days for infections caused by staphylococci)

Alternatives, doxycycline or clarithromycin.

Suggested duration of treatment 7 days (14–21 days for infections caused by staphylococci)

Pneumonia: moderate-severity community-acquired
Amoxicillin + clarithromycin(3) or doxycycline alone

Pneumococci with decreased penicillin sensitivity being isolated, but not yet common in UK.

If meticillin-resistant Staphylococcus aureus suspected, add vancomycin(4).

Suggested duration of treatment 7 days (14–21 days for infections caused by staphylococci)

Pneumonia: high-severity community-acquired
Benzylpenicillin + clarithromycin, or benzylpenicillin + doxycycline

If meticillin-resistant Staphylococcus aureus suspected, add vancomycin(4).

Suggested duration of treatment 7–10 days (may extend treatment to 14–21 days in some cases e.g. if staphylococci suspected)

If life-threatening infection, or if Gram-negative infection suspected, or if co-morbidities present, or if living in long-term residential or nursing home, co-amoxiclav + clarithromycin.

If meticillin-resistant Staphylococcus aureus suspected, add vancomycin.

Suggested duration of treatment 7–10 days (may extend treatment to 14–21 days in some cases e.g. if staphylococci or Gram-negative enteric bacilli suspected)

Alternatives if life-threatening infection, or if Gram-negative infection suspected, or if co-morbidities present, or if living in long-term residential or nursing home, cefuroxime + clarithromycin, or cefotaxime, + clarithromycin.

If meticillin-resistant Staphylococcus aureus suspected, add vancomycin.

Suggested duration of treatment 7–10 days (may extend treatment to 14–21 days in some cases e.g. if staphylococci or Gram-negative enteric bacilli suspected)

Pneumonia possibly caused by atypical pathogens
Clarithromycin.

If high-severity Legionella infection, add rifampicin for the first few days.

Suggested duration of treatment 14 days (usually 7–10 days for Legionella)

Alternative if Legionella infection suspected, a quinolone

If high-severity Legionella infection, add clarithromycin(3) or rifampicin for the first few days.

Suggested duration of treatment usually 7–10 days

Alternative for chlamydial or mycoplasma infections, doxycycline

Suggested duration of treatment 14 days

Pneumonia: hospital-acquired
Early-onset infection (less than 5 days after admission to hospital), co-amoxiclav or cefuroxime

If life-threatening infection, or if history of antibacterial treatment in the last 3 months, or if resistant micro-organisms suspected, treat as for late-onset hospital-acquired pneumonia.

Suggested duration of treatment 7 days

Late-onset infection (more than 5 days after admission to hospital), an antipseudomonal penicillin (e.g. piperacillin with tazobactam) or a broad-spectrum cephalosporin (e.g. ceftazidime) or another antipseudomonal beta-lactam or a quinolone (e.g. ciprofloxacin)

If meticillin-resistant Staphylococcus aureus suspected, add vancomycin.

For severe illness caused by Pseudomonas aeruginosa, consider adding an aminoglycoside.

Suggested duration of treatment 7 days (longer if Pseudomonas aeruginosa confirmed)

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Addendum.
1Where cefotaxime is suggested ceftriaxone may be used

2Where amoxicillin is suggested ampicillin may be used

3Where clarithromycin is suggested azithromycin or erythromycin may be used

4Where vancomycin is suggested teicoplanin may be used.

Ref:British National Formulary.

G Mohan.