Lefamulin (Xenleta – Nabriva), a semisynthetic pleuromutilin antibiotic, has been approved by the FDA for IV and oral treatment of community-acquired bacterial pneumonia (CABP) in adults. It is the first systemic pleuromutilin antibiotic to be approved in the US; retapamulin (Altabax), a 1% topical ointment for treatment of impetigo, was approved in 2007.¹

CABP is a leading cause of hospitalization and death in adults, especially the elderly.² Causative bacterial pathogens include Streptococcus pneumoniae, Mycoplasma pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Chlamydophila pneumoniae, and Legionella species.

For outpatient treatment of CABP in otherwise healthy adults without recent antibiotic exposure, monotherapy with a macrolide such as azithromycin has been the regimen of choice, but rates of macrolide resistance among S. pneumoniae in parts of the US currently exceed 40%. Doxycycline is a reasonable alternative, but resistance to doxycycline is also increasing among S. pneumoniae. A respiratory fluoroquinolone (levofloxacin or moxifloxacin) is often used for adults with comorbidities or antibiotic exposure during the previous 90 days. These drugs can also be considered for otherwise healthy adults in areas where the rates of pneumococcal resistance to macrolides and doxycycline are ≥25%, but they can cause serious adverse effects.³ Combining a beta-lactam (such as high-dose amoxicillin or cefpodoxime) with a macrolide or doxycycline is another option in areas with high rates of macrolide or doxycycline resistance.^4,5