eMedicine Specialties > Pulmonology > Infectious Lung Diseases
Chlamydial Pneumonias: Treatment & Medication
Updated: Oct 15, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- C psittaci
- Tetracycline or doxycycline is the treatment of choice. Continue treatment for 10-21 days. A longer course to prevent relapse is controversial.
- Erythromycin is the alternative treatment, but this drug may be less efficacious in severe cases.
- C pneumoniae
- Clinicians must treat empirically because rapid testing is not readily available and antibiotic therapy is usually completed before the results of serology testing become available.
- Doxycycline is the treatment of choice except in children younger than 9 years and in pregnant women. Treatment should be continued for at least 10-14 days after defervescence. If symptoms persist, a second course with a different class of antibiotics is usually effective.
- In outpatient settings, use doxycycline (100 mg PO bid) or tetracycline hydrochloride (500 mg PO qid).
- In inpatient settings, use doxycycline hyclate (100 mg IV bid).
- Alternatives include erythromycin (500 mg PO/IV qid) and newer macrolides such as azithromycin (500 mg PO/IV qd for 7-10 d) and clarithromycin (1 g PO qd [Biaxin XL] or 500 mg PO bid for 10 d). Newer macrolides are better tolerated than erythromycin. Shorter courses of the newer macrolides appear to be effective.
- Telithromycin is the first antibiotic in a new class called ketolides and is approved for C pneumoniae pneumonia by the US Food and Drug Administration. It is more expensive than doxycycline. Telithromycin is a potent inhibitor of CYP3A4 and can cause potentially dangerous increases in serum concentrations of simvastatin, lovastatin, atorvastatin, midazolam, and other drugs. If telithromycin is used, statins should be withheld for the duration of therapy. Hepatotoxicity (some fatal cases) has been reported. It is contraindicated in patients with myasthenia gravis.
- Fluoroquinolones, including levofloxacin (500 mg PO/IV qd for 10-14 d or 750 mg PO/IV qd for 5 d) and moxifloxacin (400 mg PO/IV qd for 10-14 d), also have some activity, although less than that of tetracyclines or macrolides. Gatifloxacin is no longer marketed in the United States.
- C trachomatis infant pneumonia
- Treatment for infant pneumonia mirrors the treatment for conjunctivitis. The efficacy is approximately 80-90%.
- Treat with erythromycin (50 mg/kg/d PO divided q6h for 10-14 d).
- Doxycycline is contraindicated in children younger than 9 years.
Surgical Care
Valve replacement may be required for patients with endocarditis.
Consultations
- C psittaci: Patients may require consultation with infectious disease and/or pulmonary specialists. In most states, physicians are required to report cases of psittacosis to the appropriate health authorities.
- C pneumoniae: Consultations with infectious disease and/or pulmonary specialists may be required if a patient needs hospitalization or does not respond to therapy.
- C trachomatis: Mothers of infected children may need consultations with ophthalmologists and/or sexually transmitted disease specialists.
Medication
The goals of pharmacotherapy are to eradicate infection, reduce morbidity, and prevent complications.
Antibiotics
Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.
Tetracyclines and macrolides are the drugs of choice for this indication.15 Tetracyclines are bacteriostatic in nature; they work by inhibiting protein synthesis. As a class, tetracyclines have similar antimicrobial profiles, and cross-resistance is likely. Macrolides inhibit bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, thus causing cessation of RNA-dependent protein synthesis.
Tetracycline (Sumycin)
Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections.
Adult
500 mg PO qid
Pediatric
<8 years: Not recommended
>8 years: 20-40 mg/kg/d PO divided q6h
Bioavailability of oral dose decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; can increase hypoprothrombinemic effects of anticoagulants; concurrent use with methoxyflurane may cause severe renal impairment and, possibly, death
Documented hypersensitivity; severe hepatic dysfunction; renal failure
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Doxycycline (Vibramycin)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Treatment of choice for C pneumoniae infection.
Adult
100 mg PO/IV bid for 10-14 d
Pediatric
<8 years: Not recommended
>8 years: 4.4 mg/kg/d PO/IV divided bid; not to exceed 200 mg/d on day 1 or 2.2 mg/kg/d PO/IV qd/bid; not to exceed 100 mg/d
Bioavailability of oral dose decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; however, absorption not markedly influenced by simultaneous ingestion of food or milk; can increase hypoprothrombinemic effects of anticoagulants; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction; myasthenia gravis
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; esophageal ulcerations
Erythromycin (E.E.S., E-Mycin, Ery-Tabs)
Considered bacteriostatic, but may be bactericidal in high concentrations against low inoculum of bacteria. In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half the total daily dose may be taken q12h. For more severe infections, double the dose.
Adult
500 mg PO/IV q6h; may be intolerable at higher doses
Pediatric
<4 months: 20-40 mg/kg/d PO divided q6h
>4 months: 30-50 mg/kg/d PO divided q6h or 50 mg/kg/d IV divided q6h; avoid IM use
Coadministration may increase toxicity of protease inhibitors, theophylline, digoxin, carbamazepine, methylprednisolone, disopyramide, ergotamine, terfenadine, astemizole, triazolam, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis; monitor phenytoin and hexobarbital levels
Documented hypersensitivity; hepatic impairment; coadministration with terfenadine (recalled from US market) or astemizole (recalled from US market)
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur; transient deafness may occur with high doses
Clarithromycin (Biaxin)
Semisynthetic macrolide antibiotic. Treats mild-to-moderate infections. May be bacteriostatic or bacteriocidal, depending on concentration used.
Adult
500 mg PO bid or 1 g PO qd (Biaxin XL) for 7-14 d; dose should be halved or dosing interval doubled in patients with severe renal impairment (CrCl <30 mL/min)
Pediatric
<6 months: Not established
>6 months: 7.5 mg/kg PO bid for 10 d; not to exceed 1000 mg/d
Decreased zidovudine levels; may increase sildenafil (Viagra) levels; toxicity increases with coadministration of fluconazole, astemizole (recalled from US market), and pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants (carefully monitor PT during therapy), cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; cardiac arrhythmia may occur with coadministration of cisapride; arrhythmia and increase in QTc intervals occur with disopyramide
Documented hypersensitivity; coadministration of pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; administer half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies; adverse effects include diarrhea, nausea, abnormal taste, dyspepsia, abdominal discomfort, and headache in adults; diarrhea, vomiting, abdominal pain, rash, and headache are more common pediatric adverse effects
Postmarketing experience and rare adverse effects include Stevens-Johnson syndrome, glossitis, stomatitis, oral moniliasis, reversible hearing loss, alterations in sense of smell, behavioral changes, confusional states, depersonalization, hallucinations, insomnia, nightmares, tinnitus, vertigo, hepatocellular and/or cholestatic hepatitis with or without jaundice, hepatic failure, and ventricular arrhythmia (including ventricular tachycardia and torsades de pointes in individuals with prolonged QTc intervals)
Azithromycin (Zithromax)
Derived from erythromycin. Treats mild-to-moderate microbial infections.
Adult
Day 1: 500 mg PO
Days 2-5: 250 mg PO qd
Community-acquired pneumonia: 500 mg PO/IV qd for 7-10 d
Pediatric
<6 months: Not established
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d
<16 years: IV use not established
May increase toxicity of theophylline, ergots, warfarin, and digoxin; increases effect and decreases excretion of triazolam; elevated levels of carbamazepine, hexobarbital, and phenytoin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzyme levels and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Adverse effects include diarrhea, nausea, and abdominal pain; rare adverse effects include chest pain, dyspepsia, constipation, anorexia, flatulence, pseudomembranous colitis, gastritis, headache (otitis media dosage), reversible hearing loss, hyperkinesia, dizziness, agitation, nervousness, insomnia, fever, fatigue, malaise, erythema multiforme, pruritus, urticaria, and conjunctivitis
Telithromycin (Ketek)
First antibiotic in a new class called ketolides. Blocks protein synthesis by binding to 50S ribosomal subunit (23S rRNA at domain II and V). Resistance and cross-resistance have not been observed.
Adult
800 mg PO qd for 7-10 d
Pediatric
<13 years: Not established
Many drug interactions; HMG-CoA reductase inhibitors (eg, simvastatin, atorvastatin, lovastatin) should be avoided because of increased myopathy risk when coadministered; withhold HMG-CoA reductase inhibitors for duration of therapy; CYP3A4 inhibitor and substrate; coadministration with other CYP3A4 inhibitors (eg, itraconazole, ketoconazole) decreases elimination and increases C max and AUC; CYP3A4 inducers (eg, rifampin) decrease C max and AUC by 79% and 86%, respectively; increases C max and AUC of other CYP3A4 substrates (eg, cisapride, pimozide, simvastatin, lovastatin, atorvastatin, midazolam, triazolam); increases digoxin and theophylline serum levels; decreases sotalol C max and AUC secondary to decreased absorption; caution with other drugs that increase QTc interval (eg, quinidine, procainamide, dofetilide)
Documented hypersensitivity; coadministration with cisapride, pimozide, quinidine, procainamide, dofetilide, rifampin, or ergot alkaloids; myasthenia gravis (black box warning); history of hepatitis and/or jaundice with use of macrolides
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in severe renal impairment (data limited); consider diagnosis of pseudomembranous colitis if diarrhea occurs following antibiotic treatment; may prolong QTc interval, caution with heart conduction abnormalities; common adverse effects include diarrhea and nausea (7-10%); may rarely cause visual disturbances or increased liver enzyme levels; acute hepatic failure and severe liver injury (in some cases fatal) have been reported—if clinical hepatitis or liver enzyme level elevations combined with other systemic symptoms occur, permanently discontinue
Levofloxacin (Levaquin)
Second-generation quinolone. Acts by interfering with DNA gyrase in bacterial cells.
Adult
500 mg PO/IV qd for 7-14 days or 750 mg PO/IV qd for 5 d
Pediatric
Not recommended
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal function impairment; tendon rupture can occur (black box warning), especially in older patients with the concurrent use of steroids; discontinue if a patient experiences pain or tendon rupture
Moxifloxacin (Avelox)
Inhibits the A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription.
Adult
400 mg PO qd for 7–14 d
Pediatric
Not recommended
Antacids and electrolyte supplements reduce absorption; loop diuretics, probenecid, and cimetidine increase serum levels; NSAIDs enhance CNS-stimulating effect; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity; pediatric patients, unless benefits outweigh risks (as in cystic fibrosis)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; prolonged QT interval on ECG and ventricular arrhythmias may occur
Tendon rupture can occur (black box warning), especially in older patients with the concurrent use of steroids; discontinue if a patient experiences pain or tendon rupture
More on Chlamydial Pneumonias |
| Overview: Chlamydial Pneumonias |
| Differential Diagnoses & Workup: Chlamydial Pneumonias |
 Treatment & Medication: Chlamydial Pneumonias |
| Follow-up: Chlamydial Pneumonias |
| References |
| « Previous Page | Next Page » |
References
Crosse BA. Psittacosis: a clinical review. J Infect. Nov 1990;21(3):251-9. [Medline].
Ewig S, Torres A. Is Chlamydia pneumoniae an important pathogen in patients with community-acquired pneumonia?. Eur Respir J. May 2003;21(5):741-2. [Medline]. [Full Text].
Centers for Disease Control and Prevention. Compendium of measures to control Chlamydia psittaci infection among humans (psittacosis) and pet birds (avian chlamydiosis), 2000. MMWR Recomm Rep. Jul 14 2000;49:3-17. [Medline]. [Full Text].
Fine MJ, Smith MA, Carson CA, Mutha SS, Sankey SS, Weissfeld LA, et al. Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis. JAMA. Jan 10 1996;275(2):134-41. [Medline].
File TM Jr, Tan JS, Plouffe JF. The role of atypical pathogens: Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila in respiratory infection. Infect Dis Clin North Am. Sep 1998;12(3):569-92, vii. [Medline].
Marrie TJ, Peeling RW, Reid T, De Carolis E. Chlamydia species as a cause of community-acquired pneumonia in Canada. Eur Respir J. May 2003;21(5):779-84. [Medline]. [Full Text].
Tipple MA, Beem MO, Saxon EM. Clinical characteristics of the afebrile pneumonia associated with Chlamydia trachomatis infection in infants less than 6 months of age. Pediatrics. Feb 1979;63(2):192-7. [Medline].
Edelman RR, Hann LE, Simon M. Chlamydia trachomatis pneumonia in adults: radiographic appearance. Radiology. Aug 1984;152(2):279-82. [Medline].
Cunha BA. The atypical pneumonias: clinical diagnosis and importance. Clin Microbiol Infect. May 2006;12 Suppl 3:12-24. [Medline].
Centers for Disease Control and Prevention. Case definitions for infectious conditions under public health surveillance. MMWR Recomm Rep. May 2 1997;46:1-55. [Medline].
Dowell SF, Peeling RW, Boman J, Carlone GM, Fields BS, Guarner J, et al. Standardizing Chlamydia pneumoniae assays: recommendations from the Centers for Disease Control and Prevention (USA) and the Laboratory Centre for Disease Control (Canada). Clin Infect Dis. Aug 15 2001;33(4):492-503. [Medline]. [Full Text].
Kumar S, Hammerschlag MR. Acute respiratory infection due to Chlamydia pneumoniae: current status of diagnostic methods. Clin Infect Dis. Feb 15 2007;44(4):568-76. [Medline].
Littman AJ, Jackson LA, White E, Thornquist MD, Gaydos CA, Vaughan TL. Interlaboratory reliability of microimmunofluorescence test for measurement of Chlamydia pneumoniae-specific immunoglobulin A and G antibody titers. Clin Diagn Lab Immunol. May 2004;11(3):615-7. [Medline].
Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. March 2007;44:Suppl 2:S27-72. [Medline]. [Full Text].
Kauppinen M, Saikku P. Pneumonia due to Chlamydia pneumoniae: prevalence, clinical features, diagnosis, and treatment. Clin Infect Dis. Dec 1995;21 Suppl 3:S244-52. [Medline].
Grayston JT. Infections caused by Chlamydia pneumoniae strain TWAR. Clin Infect Dis. Nov 1992;15(5):757-61. [Medline].
Ieven MM, Hoymans VY. Involvement of Chlamydia pneumoniae in atherosclerosis: more evidence for lack of evidence. J Clin Microbiol. Jan 2005;43(1):19-24. [Medline].
Andersen P. Pathogenesis of lower respiratory tract infections due to Chlamydia, Mycoplasma, Legionella and viruses. Thorax. Apr 1998;53(4):302-7. [Medline].
Johnston WB, Eidson M, Smith KA, Stobierski MG. Compendium of chlamydiosis (psittacosis) control, 1999. Psittacosis Compendium Committee, National Association of State Public Health Veterinarians. J Am Vet Med Assoc. Mar 1 1999;214(5):640-6. [Medline].
Massachusetts General Hospital. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 16-1998. Pneumonia and the acute respiratory distress syndrome in a 24-year-old man. N Engl J Med. May 21 1998;338(21):1527-35. [Medline].
Schneeberger PM, Dorigo-Zetsma JW, van der Zee A, van Bon M, van Opstal JL. Diagnosis of atypical pathogens in patients hospitalized with community-acquired respiratory infection. Scand J Infect Dis. 2004;36(4):269-73. [Medline].
Telfer BL, Moberley SA, Hort KP, Branley JM, Dwyer DE, Muscatello DJ, et al. Probable psittacosis outbreak linked to wild birds. Emerg Infect Dis. Mar 2005;11(3):391-7. [Medline].
Thom DH, Grayston JT. Infections with Chlamydia pneumoniae strain TWAR. Clin Chest Med. Jun 1991;12(2):245-56. [Medline].
Further Reading
Keywords
chlamydial pneumonia, psittacosis , ornithosis, Chlamydophila pneumoniae, Chlamydia pneumoniae, C pneumoniae, Chlamydophila psittaci, Chlamydia psittaci, C psittaci, Chlamydophila trachomatis, Chlamydia trachomatis, C trachomatis, Chlamydophila pneumoniae pneumonia, Chlamydophila trachomatis pneumonia, Taiwan acute respiratory pneumonia, TWAR pneumonia, parrot fever, avian chlamydiosis
