Initial antimicrobial and antiviral treatment is empirical (Mandell, 2015). Because most adult bacterial pneumonias are caused by pneumococci, mycoplasma, or chlamydophila, monotherapy initially is with a macrolide-azithromycin, clarithromycin, or erythromycin (Table 51-4). Yost and colleagues (2000) reported that erythromycin mono therapy, given IV and then orally, was efective in all but one of 99 pregnant women with uncomplicated pneumonia. During inluenza season, we routinely administer oseltamivir treatment along with empirical therapy for bacterial pneumonia.
For women with severe disease according to criteria in Table 51-3, Mandell and associates (2007) summarized IDSAI ATS guidelines, which call for either: (1) a respiratory luoroquinolone-Ievofloxacin, moxifloxacin, or gemiloxacin; or (2) a macrolide plus a preferred �-lactam-either high-dose amoxicillin or amoxicillin-clavulanate. �-Lactam alternatives include ceftriaxone, cefpodoxime, or cefuroxime (see Table 51-4). In areas in which the resistance of pneumococcal isolates to macrolides is great, these latter regimens are preferred. he teratogenicity risk of luoroquinolones is low, and these should be given if indicated (Briggs, 2015). IfCA-MRSA is suspected, then vancomycin or linezolid is added (Mandell, 2015; Moran, 2013; Wunderink, 2013).
Clinical improvement is usually evident in 48 to 72 hours with resolution of fever in 2 to 4 days. Radiographic abnormalities may take up to 6 weeks to completely resolve (Torres, 2008). Worsening disease is a poor prognostic feature, and subsequent radiography is recommended if fever persists. Even with improvement, however, approximately 20 percent of women develop a pleural eusion. Treatment of uncomplicated pneumonia is recommended for 5 to 7 days (Musher, 2014). Treatment failure may occur in up to 15 percent of cases, and a wider antimicrobial regimen and more extensive diagnostic testing is warranted.
During the preantimicrobial era, as many as a third of pregnant women with pneumonia died (Finland, 1939). Although much improved, maternl and perinatl morbidity and mortality remain formidable. In ive studies with a total of 632 women published ater 1990, almost 7 percent required intubation and mechanical ventilation, and the maternal mortality rate was 0.8 percent.
Prematurely ruptured membranes and preterm delivery are frequent complications and have been reported in up to a third of cases of acute lung infection (Getahun, 2007; Shariatzadeh, 2006). Likely related are older studies reporting a twofold increase in low-birthweight neonates (Sheield, 2009). In one populationbased study from Taiwan of nearly 219,000 births, incidences of preterm and growth-restricted newborns and of preeclampsia and cesarean delivery were significantly increased (Chen, 2012).
Two pneumococcal vaccines, a 23-serotype older preparation and a newer 13-serotype vaccine, are used in children (Swamy, 2015). he 23-serotype vaccine is 60-to 70-percent protective, and its use lowers emergence of drug-resistant pneumococci (Kyaw, 2006). he 13-serotype vaccine is not recommended for
TABLE 51-4. Empirical Antimicrobial Treatment for Community-Acquired Pneumonia