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Antibiotic treatment for Legionnaires' disease in adults (Legionella pneumonia)

Antibiotic treatment for Legionnaires' disease in adults (Legionella pneumonia)
  Preferred options Alternative options*
Mild pneumonia
  • Azithromycin 500 mg orally once dailyΔ
  • OR
  • Levofloxacin 750 mg orally once dailyΔ◊
  • Ciprofloxacin 500 mg orally twice daily◊
  • OR
  • Moxifloxacin 400 mg orally once daily
  • OR
  • Clarithromycin 500 mg orally twice daily◊
  • OR
  • Erythromycin (base) 500 mg orally four times daily
  • OR
  • Roxithromycin 300 mg orally daily or 150 mg orally twice daily§
Moderate or severe pneumonia¥
  • Azithromycin 500 mg IV or orally once daily
  • OR
  • Levofloxacin 750 mg IV or orally once daily◊
  • Ciprofloxacin 400 mg IV twice daily◊ or 750 mg orally twice daily
  • OR
  • Moxifloxacin 400 mg IV or orally once daily
  • OR
  • Clarithromycin 500 mg IV or orally twice daily◊‡
  • OR
  • Erythromycin (base) 1000 mg IV four times daily or 500 mg orally four times daily
Duration of therapy:
The minimum duration of therapy is 5 days for patients who have been afebrile and clinically stable for 48 hours. Patients with mild infection generally require 5 to 7 days of therapy. Patients with severe infection or chronic comorbidities generally require 7 to 10 days of therapy. Extended courses may be needed for immunocompromised patients or those with complications (eg, empyema or extrapulmonary infection).
IV: intravenously; CRB-65: confusion, respiratory rate, blood pressure, 65 years of age and older; CURB-65: confusion, urea nitrogen, respiratory rate, blood pressure, 65 years of age and older; PSI: pneumonia severity indices.
* Tetracyclines (eg, doxycycline) are active against many Legionella species; however, because resistance is common for L. longbeachae, we generally do not use tetracyclines for treatment.
¶ Mild pneumonia refers to patients with CRB-65 or CURB-65 scores of 0 or PSI of I to II. Moderate to severe pneumonia is defined as any hospitalized patient or patient with a CRB-65 or CURB-65 scores ≥1 or PSI >II. Severity scores must be placed in the context of other clinical information.
Δ For patients with mild pneumonia, it is not necessary to change to a preferred agent if they are responding to an active alternative agent.
◊ Dose adjustment is required for renal dysfunction.
§ Roxithromycin is not available in the United States.
¥ Initial therapy with an intravenous preparation is preferred for most hospitalized patients. Intravenous therapy can be switched to oral therapy once patients are clinically improving, hemodynamically stable, and able to tolerate oral antibiotics.
‡ The intravenous formulation of clarithromycin is not available in the United States.
Graphic 117791 Version 3.0

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