Red Flags
- CAP with septic shock or respiratory failure — ICU; broad-spectrum empirical within 1 hour[1]
- CURB-65 ≥3 — admit; ICU consideration if other major or 3 minor severity criteria[1]
- Cavitation or non-resolving CAP — exclude pulmonary TB (sputum GeneXpert), structural lung disease, malignancy[1]
- CAP in immunocompromised host — opportunistic pathogens (PCP, fungi, atypical mycobacteria); empirical broad cover plus ID consult[1]
First-line treatment
Interventions
- Vaccination[1]Pneumococcal (PCV13/PPSV23) for ≥65 years and high-risk; annual influenza; COVID-19
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Amoxicillin-clavulanate (co-amoxiclav)[1] | Beta-lactam plus beta-lactamase inhibitor | The cited 2022 adult CAP table does not state a dose; consult the applicable dosing guidance and product label. | — | Adult outpatient CAP without comorbidities: ICMR preferred drug. Alternatives: macrolide, cefuroxime or cefpodoxime. Beta-lactam preferred over macrolides because of high pneumococcal macrolide resistance in India; doxycycline monotherapy not recommended. Outpatient duration: 5 days. |
| Co-amoxiclav PLUS a macrolide or doxycycline[1] | Beta-lactam-inhibitor plus macrolide/tetracycline | The cited 2022 adult CAP table does not state doses; consult applicable dosing guidance and product labels. | — | Adult outpatient CAP with comorbidities or antimicrobial use in the previous 3 months: preferred combination. Alternative: cefuroxime or cefpodoxime PLUS a macrolide or doxycycline. Outpatient duration: 5 days. |
| Ceftriaxone + azithromycin (inpatient non-ICU)[1] | 3rd-gen cephalosporin + macrolide | Ceftriaxone 1–2 g IV daily plus azithromycin 500 mg IV/PO daily for 5–7 days | Ceftriaxone 50 mg/kg/day | Standard inpatient regimen; respiratory fluoroquinolone alternative monotherapy in penicillin allergy |
| Piperacillin-tazobactam + azithromycin (severe CAP / ICU)[1] | Antipseudomonal beta-lactam-inhibitor + macrolide | Piperacillin-tazobactam 4.5 g IV q8h + azithromycin 500 mg IV daily; add MRSA cover (vancomycin or linezolid) if cavitation, post-influenza, IV drug use | — | Severe CAP requiring ICU; structural lung disease or prior MDR colonisation drives Pseudomonas cover |
| Oseltamivir (when influenza co-suspected)[1] | Neuraminidase inhibitor | 75 mg PO BD × 5 days | Weight-based | Add during influenza season |
Amoxicillin-clavulanate (co-amoxiclav)[1]
Beta-lactam plus beta-lactamase inhibitor
- Adult
- The cited 2022 adult CAP table does not state a dose; consult the applicable dosing guidance and product label.
- Paediatric
- —
Adult outpatient CAP without comorbidities: ICMR preferred drug. Alternatives: macrolide, cefuroxime or cefpodoxime. Beta-lactam preferred over macrolides because of high pneumococcal macrolide resistance in India; doxycycline monotherapy not recommended. Outpatient duration: 5 days.
Co-amoxiclav PLUS a macrolide or doxycycline[1]
Beta-lactam-inhibitor plus macrolide/tetracycline
- Adult
- The cited 2022 adult CAP table does not state doses; consult applicable dosing guidance and product labels.
- Paediatric
- —
Adult outpatient CAP with comorbidities or antimicrobial use in the previous 3 months: preferred combination. Alternative: cefuroxime or cefpodoxime PLUS a macrolide or doxycycline. Outpatient duration: 5 days.
Ceftriaxone + azithromycin (inpatient non-ICU)[1]
3rd-gen cephalosporin + macrolide
- Adult
- Ceftriaxone 1–2 g IV daily plus azithromycin 500 mg IV/PO daily for 5–7 days
- Paediatric
- Ceftriaxone 50 mg/kg/day
Standard inpatient regimen; respiratory fluoroquinolone alternative monotherapy in penicillin allergy
Piperacillin-tazobactam + azithromycin (severe CAP / ICU)[1]
Antipseudomonal beta-lactam-inhibitor + macrolide
- Adult
- Piperacillin-tazobactam 4.5 g IV q8h + azithromycin 500 mg IV daily; add MRSA cover (vancomycin or linezolid) if cavitation, post-influenza, IV drug use
- Paediatric
- —
Severe CAP requiring ICU; structural lung disease or prior MDR colonisation drives Pseudomonas cover
Oseltamivir (when influenza co-suspected)[1]
Neuraminidase inhibitor
- Adult
- 75 mg PO BD × 5 days
- Paediatric
- Weight-based
Add during influenza season
Safety-net
- Take antibiotics for the full prescribed course even when feeling better — usually 5 days outpatient[1]
- Worsening breathlessness, increasing chest pain, confusion, low urine output — same-day care[1]
- Persistent symptoms despite 48–72 h antibiotics — return for review; consider TB workup in non-resolving cases[1]
Referral criteria
- Severe CAP with septic shock or respiratory failureICU; broad-spectrum empirical including MRSA/Pseudomonas if risk factors[1]
- CURB-65 ≥3Hospital admission; ID consult if MDR risk[1]
- Pleural effusion >1 cm or empyema suspicionDiagnostic thoracentesis; respiratory medicine for chest drain[1]
- Failure to improve at 48–72 hReassess: cultures, atypicals, MDR, complication, TB co-infection, alternative diagnosis[1]
Clinical summary
ICMR-aligned diagnosis and antimicrobial therapy of CAP in adults; severity-driven inpatient vs outpatient pathway with TB exclusion in endemic settings.