Coverage targeted at S. pneumoniae, H. influenzae. M. pneumoniae, C. pneumoniae, and Legionella
No comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) and no or risk factors for MRSA or Pseudomonas aeruginosa (include prior respiratory isolation of MRSA or P. aeruginosa or recent hospitalization AND receipt of parenteral antibiotics (in the last 90 d))
Amoxicillin 1 g three times daily (strong recommendation, moderate quality of evidence), OR
Doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence), OR
Macrolide in areas with pneumococcal resistance to macrolides <25% (conditional recommendation, moderate quality of evidence).
Azithromycin 500 mg on first day then 250 mg daily OR
Clarithromycin 500 mg BID or clarithromycin ER 1,000 mg daily
Duration of therapy 5 days minimum
Azithromycin 500 mg on first day then 250 mg daily OR
Clarithromycin 500 mg BID or clarithromycin ER 1,000 mg daily
If patient has comorbidities or risk factors for MRSA or Pseudomonas aeruginosa
Combination therapy:
Amoxicillin/Clavulanate
500 mg/125 mg TID OR amox/clav 875 mg/125 mg BID OR 2,000 mg/125 mg BID. Duration is for a minimum of 5 days and varies based on disease severity and response to therapy; patients should be afebrile for ≥48 hours and clinically stable before therapy is discontinued
OR cephalosporin
Cefpodoxime 200 mg BID OR cefuroxime 500 mg BID
AND macrolide
Azithromycin 500 mg on first day then 250 mg daily
OR clarithromycin 500 mg BID OR clarithromycin ER 1,000 mg daily]) (strong recommendation, moderate quality of evidence for combination therapy)
OR doxycycline 100 mg BID (conditional recommendation, low quality of evidence for combination therapy)
Monotherapy: respiratory fluoroquinolone (strong recommendation, moderate quality of evidence):
Levofloxacin 750 mg daily OR
Moxifloxacin 400 mg daily OR
Gemifloxacin 320 mg daily
Amoxicillin/Clavulanate
500 mg/125 mg TID OR amox/clav 875 mg/125 mg BID OR 2,000 mg/125 mg BID. Duration is for a minimum of 5 days and varies based on disease severity and response to therapy; patients should be afebrile for ≥48 hours and clinically stable before therapy is discontinued
OR cephalosporin
Cefpodoxime 200 mg BID OR cefuroxime 500 mg BID
AND macrolide
Azithromycin 500 mg on first day then 250 mg daily
OR clarithromycin 500 mg BID OR clarithromycin ER 1,000 mg daily]) (strong recommendation, moderate quality of evidence for combination therapy)
OR doxycycline 100 mg BID (conditional recommendation, low quality of evidence for combination therapy)
500 mg/125 mg TID OR amox/clav 875 mg/125 mg BID OR 2,000 mg/125 mg BID. Duration is for a minimum of 5 days and varies based on disease severity and response to therapy; patients should be afebrile for ≥48 hours and clinically stable before therapy is discontinued
Cefpodoxime 200 mg BID OR cefuroxime 500 mg BID
Azithromycin 500 mg on first day then 250 mg daily
OR clarithromycin 500 mg BID OR clarithromycin ER 1,000 mg daily]) (strong recommendation, moderate quality of evidence for combination therapy)
Levofloxacin 750 mg daily OR
Moxifloxacin 400 mg daily OR
Gemifloxacin 320 mg daily
Monotherapy or combination therapy is acceptable
Combination therapy includes a cephalosporin and macrolide targeting atypicals and Strep Pneumonia 
The use of adjunctive corticosteroids (methylprednisolone 0.5 mg/kg IV BID x 5d) in CAP of moderate-high severity (PSI Score IV or V; CURB-65 ≥ 2) is associated with:
↓ mortality (3%)
↓ need for mechanical ventilation (5%)
↓ length of hospital stay (1d)
↓ mortality (3%)
↓ need for mechanical ventilation (5%)
↓ length of hospital stay (1d)
Coverage against community acquired organisms plus M. catarrhalis, Klebsiella, S. aureus
β-lactam (e.g. ceftriaxone 1–2g daily OR ampicillin-sulbactam 1.5–3g q6h OR cefotaxime 1–2g q8h OR ceftaroline 600mg q12h) PLUS
Macrolide (e.g. azithromycin 500 mg daily or clarithromycin 500 mg BID)OR
Doxycycline 100mg IV/PO BID (if contraindications to both macrolides and fluoroquinolones ) OR
Levofloxacin 750mg IV/PO once daily OR
Moxifloxacin 400mg IV/PO once daily
Macrolide (e.g. azithromycin 500 mg daily or clarithromycin 500 mg BID)OR
Doxycycline 100mg IV/PO BID (if contraindications to both macrolides and fluoroquinolones ) OR
3-drug regimen recommended options:
Cefepime 1-2gm q8-12h OR ceftazidime 2gm q8h + Levofloxacin 750 mg PO/IV every 24 hours + Vancomycin 15mg/kg q12 OR
Imipenem 500mg q6hr + cipro 400mg q8hr + vanco 15mg/kg q12 OR
Piperacillin-Tazobactam 4.5gm q6h + cipro 400mg q8h + vanco 15mg/kg q12
Consider tobramycin in place of fluoroquinolones given FDA 2016 warnings
Of note, the combination of vanco+ piperacillin-tazobactam carries higher risk of AKI when compared to cefepime + vanco’’’
Cefepime 1-2gm q8-12h OR ceftazidime 2gm q8h + Levofloxacin 750 mg PO/IV every 24 hours + Vancomycin 15mg/kg q12 OR
Imipenem 500mg q6hr + cipro 400mg q8hr + vanco 15mg/kg q12 OR
Piperacillin-Tazobactam 4.5gm q6h + cipro 400mg q8h + vanco 15mg/kg q12
High Risk of MRSA: Use 3-Drug Regimen. Several options are available, but recommendation is to include an antibiotic from each of these categories:
1. MRSA Antibiotic: Vancomycin 15mg/kg q12h OR Linezolid 600 mg IV q12h PLUS
2. Antipseudomonal Antibiotic: Piperacillin-Tazobactam 4.5gm q6h OR Cefepime 2 g IV q8h OR Imipenem 500 mg IV q6h OR Aztreonam 2 g IV q8h  PLUS
3. GN Antibiotic With Antipseudomonal Activity: Cipro 400 mg IV q8h
1. MRSA Antibiotic: Vancomycin 15mg/kg q12h OR Linezolid 600 mg IV q12h PLUS
2. Antipseudomonal Antibiotic: Piperacillin-Tazobactam 4.5gm q6h OR Cefepime 2 g IV q8h OR Imipenem 500 mg IV q6h OR Aztreonam 2 g IV q8h  PLUS
3. GN Antibiotic With Antipseudomonal Activity: Cipro 400 mg IV q8h
Ceftriaxone 1gm IV + Azithromycin 500mg IV OR
Ceftriaxone 1gm IV + (moxifloxacin 400mg IV or levofloxacin 750mg IV)
Penicillin allergy
(Moxifloxacin or levofloxacin) + (aztreonam 1-2gm IV or clindamycin 600mg IV)
(Moxifloxacin or levofloxacin) + (aztreonam 1-2gm IV or clindamycin 600mg IV)
Cefepime, Imipenem, OR Piperacillin/Tazobactam + IV cipro/levo
Cefepime, imipenem, OR piperacillin-tazobactam + gent + azithromycin
Cefepime, imipenem, OR piperacillin-tazobactam + gent + cipro/levo
Pulmonary antibiotics
Thoracic lavage
Thoracentesis
Thoracotomy
Thoracotomy 
Needle thoracostomy
Lung recruitment maneuver
ENT antibiotics