Pneumonia and alcohol use disorder: Implications for treatment

Niyati M. Gupta; Abhishek Deshpande; Michael B. Rothberg

doi:10.3949/ccjm.87a.19105

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TABLE 1

Recommended treatment for pneumonia

Setting	Patients with risk factors for resistant gram-negative organisms	Patients without risk factors
Outpatient	A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin), or A beta-lactam (high-dose amoxicillin or amoxicillin-clavulanate, or ceftriaxone, cefpodoxime, cefuroxime) plus a macrolide (azithromycin, clarithromycin, or erythromycin) Doxycycline can be an alternative to a macrolide	A macrolide (azithromycin, clarithromycin, or erythromycin), or Doxycycline, or Amoxicillin
Inpatient, not in intensive care	An antipneumococcal, antipseudomonal beta-lactam (eg, piperacillin-tazobactam) plus either ciprofloxacin or levofloxacin, or An antipneumococcal, antipseudomonal beta-lactam plus an aminoglycoside and azithromycin, or An antipneumococcal, antipseudomonal beta-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone For penicillin-allergic patients, substitute aztreonam for the beta-lactam	A respiratory fluoroquinolone, or A beta-lactam (cefotaxime, ceftriaxone, ampicillin, or ertapenem) plus a macrolide Doxycycline can be an alternative to macrolide A respiratory fluoroquinolone should be used for penicillin-allergic patients
Intensive care	An antipneumococcal, antipseudomonal beta- lactam plus either ciprofloxacin or levofloxacin, or An antipneumococcal, antipseudomonal beta-lactam plus an aminoglycoside and azithromycin, or An antipneumococcal, antipseudomonal beta-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone For penicillin-allergic patients, substitute aztreonam for the beta-lactam	A beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin or a fluoroquinolone For penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam

Based on information in references 1, 27, and 28.

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TABLE 2

Studies finding a higher prevalence of oropharyngeal colonization with gram-negative organisms in people with alcohol use disorder

Study	Population	Findings
Dao et al,³² 2014	613 men, rural Vietnam	Klebsiella pneumoniae was the most common gram-negative organism, isolated in the nasopharynx in 28% K pneumoniae was found in 23% of light drinkers, 30% of moderate drinkers, and 34% of heavy drinkers Weekly alcohol consumption was associated with K pneumoniae oropharyngeal carriage (OR 1.7; 95% CI 1.04–2.8)
Mackowiak et al,³¹ 1978	124 people with AUD and 84 controls, Dallas, TX	Colonization with gram-negative bacilli in 35% of those with AUD vs 18% of controls Of those with AUD who had gram-negative colonization, 33% had Enterobacter species and 23% had Escherichia coli
Fuxench-Lopez et al,³³ 1978	34 with AUD and 28 controls, Puerto Rico	Gram-negative colonization in 59% of those with AUD and 14% of controls Among AUD samples, K pneumoniae accounted for 40% of the pharyngeal secretions and 76% of the isolates were in the Klebsiella-Enterobacter group of organisms
Golin et al,³⁴ 1998	58 with AUD and 59 controls, Brazil	Gram-negative organisms in 49% of those with AUD and 40% of controls Anaerobic microbes were present in 85% of those with AUD vs 31% of controls

AUD = alcohol use disorder

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TABLE 3

Prevalence of gram-negative organisms in pneumonia patients with or without alcohol use disorder

Study	No. of patients, location	Gram-negative organisms	With AUD	Without AUD	Gram-positive organisms	With AUD	Without AUD
Fernández-Solá et al,¹⁶ 1995	50, Barcelona	Gram-negative bacilli	19%	0^a	Streptococcus pneumoniae	6%	6%
Marik,³⁹ 2000	148, United States and Canada	Pseudomonas aeruginosa and Acinetobacter species	22%	5%^a
Arancibia et al,³⁸ 2002	559, Barcelona	Gram-negative bacilli	11%	11%
Paganin et al,³⁷ 2004	112, Réunion Island	Klebsiella pneumoniae	30%	10%^a
Saitz et al,⁴ 1997	23,198, Massachusetts	Haemophilus influenzae Gram-negative bacilli	5% 2.5%	3.5%^a 4%	S pneumoniae Staphylococcus sp.	15% 3%	6%^a 2%
de Roux et al,² 2006	1,347, Europe	Gram-negative bacilli Pseudomonas aeruginosa H influenzae	9% 5% 2%	11% 3% 4%	S pneumoniae	27%	16%^a
Gupta et al,¹⁸ 2019	137,496, United States	Escherichia coli K pneumoniae P aeruginosa	7% 6% 1%	10%^a 7%^a 1%	S pneumoniae Staphylococcus aureus	6% 4%	2%^a 3%