Therapeutics in Practice

Treating Foal Pneumonia*

Column Editor

Harold C. McKenzie III, DVM, MS, DACVIM

Virginia Polytechnic Institute and State University

Debra Deem Morris, DVM, MS

Lower respiratory tract infections are common in foals and account for substantial
morbidity and mortality. Foals are at risk for the development of pneumonia due to
interactions between innate immunologic factors and management risk factors.
Immunologic factors include failure of passive transfer, delayed endogenous
immunoglobulin production, and impaired cellular immunologic responses to challenge
with organisms such as Rhodococcus equi.1 Management risks include the stresses of
weaning, sale preparation, transport, and/or confinement in crowded or dusty conditions, which can result in heavy exposure to potential respiratory pathogens.2

Banfield,The Pet Hospital

401 Palisade Avenue
Cliffside Park, NJ 07010
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fax 201-944-3244
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Therapeutics in
Practice features
current medical protocols
used to treat a variety of

CLINICAL SYNDROMES
Neonates
Pneumonia in neonates is most often associated with septicemia but may also occur
secondary to meconium or milk aspiration or hematogenous spread. Gram-negative
bacteria are most commonly involved in neonatal pneumonia, although gram-positive
and mixed infections do occur. Treatment with a broad-spectrum drug or drug combination is recommended. Neonatal foal pneumonia may also be complicated by rib fractures, inadequate surfactant production associated with prematurity, or severe systemic
inflammation. Antiinflammatory therapy may aid in controlling pulmonary inflammation, thereby improving pulmonary function and patient comfort. Supplemental oxygen
by nasal insufflation (5 to 10 L/min) is beneficial in severely affected neonates. Viral
pneumonia (resulting from equine herpesvirus [EHV] 1, equine arteritis virus, or adenovirus) rarely occurs in neonates but is usually fatal.
Older Foals
Although still relatively rare, viral pneumonias (resulting from EHV1, EHV2, or
EHV4; equine arteritis virus; or equine influenza virus) are more common in older foals
than in neonates. Viral infections cause pulmonary inflammation and impair pulmonary
immunity, predisposing foals to subsequent bacterial infections. Treatment consists of
antiinflammatory therapy and supportive care because premature use of antibiotics may
result in resistant organisms. Bacterial pneumonia in older foals typically involves grampositive bacteria, especially Streptococcus equi zooepidemicus and R. equi. Secondary infection with gram-negative organisms is not uncommon, and affected foals may exhibit a
poor response to treatment or deteriorate clinically despite treatment.

conditions in horses.
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ANTIMICROBIAL THERAPIES
Selection of an antimicrobial regimen (Table 1) in foals with pneumonia is based on:

The most likely organisms involved

The severity of illness
The ability to administer the drug by the route prescribed

*A related article appears on p. 14.

47

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Therapeutics in Practice

Table 1. Antimicrobials for Treating Foal Pneumonia

Trade Name,
Manufacturer

Drug

Penicillin

Ga

Dose

Route

Frequency

Numerous

20,000 IU

IM (procaine penicillin)
IV (potassium or sodium
penicillin)

q12h (IM)
q6h (IV)

Ampicillin sodiuma

Amp-Equine, Pfizer

1020 mg/kg

IV, IM

q8h

Amoxicillin
trihydratea

Amoxi-Inject,
Amoxi-Tabs,
Pfizer Animal Health

1020 mg/kg
2030 mg/kg

IM
PO

q8h
q68h

Ticarcillina

Ticillin, Pfizer

44 mg/kg

IV

q6h

Imipenemcilastatin

Primaxin, Merck

510 mg/kgb
1020 mg/kg7

IM
IV

q12h
q6h

Ceftiofur sodium

Naxcel, Pfizer
Animal Health

2.26.6 mg/kg
210 mg/kg7

IM, IV

q812h

Ceftiofur sodium

1 mg/kg as a 25 mg/ml
solution in sterile water17

Aerosol (nebulized)

q812h

Cephalexin4

Keflex, Dista

30 mg/kg

PO

q8h

Cefazolina

Ancef, SmithKline
Beecham

25 mg/kg

IM

q68h

Cefepime5

Maxipime, Elan
Pharmaceuticals

11 mg/kg

IV, IM

q8h

Cefpodoxime
proxetil3

Vantin, Pharmacia
& Upjohn

10 mg/kg

PO

q612h

Gentamicin sulfate8

Gentocin,
Schering-Plough
Animal Health

1113 mg/kg (neonates)

6.6 mg/kg (weanlings)

IV, IM (provides
lower peak serum
concentrations)

q24h

Gentamicin sulfate8

2.2 mg/kg as a
50 mg/ml solution

Aerosol (nebulized)

q24h

Amikacin sulfate9,a

Amiglyde-V,
Fort Dodge

2125 mg/kg (neonates)

714.5 mg/kg (weanlings)

IV, IM

q24h

Sulfadiazine
trimethoprima

Tribrissen,
Schering-Plough
Animal Health

30 mg/kg

PO

q12h

Doxycycline
hyclate10,11

Vibramycin,
Pfizer

1020 mg/kg

PO

q1224h

Erythromycin
estolatea

Ilosone, Dista

25 mg/kg

PO

q68h

Erythromycin
phosphatea
(compounded)

2537.5 mg/kg

PO

q612h

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Spring 2006

Treating Foal Pneumonia

49

Table 1. Antimicrobials for Treating Foal Pneumonia (continued)

Trade Name,
Manufacturer

Drug
13

Route

Frequency

Azithromycin

Zithromax, Pfizer
Animal Health

10 mg/kg

PO

q24h for 5 days,

then q48h

Clarithromycin14

Biaxin, Abbott
Laboratories

7.5 mg/kg

PO

q12h

Rifampina

Rifadin, Hoechst
Marion Roussel

510 mg/kg

PO

q1224h

Chloramphenicol16

Chloromycetin,
Parke-Davis

50 mg/kg

PO

q6h

aPapich MG: Current concepts in antimicrobial

bBased on the authors clinical experience.

Dose

therapy for horses. Proc AAEP 47:94102, 2001.

Tissue distribution of the drug (therapeutic concentrations must be reached at the site of infection)

Foals with pneumonia secondary to septicemia require

broad-spectrum therapy because of either gram-negative or gram-positive involvement. Older foals with
uncomplicated pneumonia may initially be treated with
a gram-positive regimen, but a poor response to treatment represents a clear indication for institution of
broad-spectrum therapy. Evidence of pulmonar y
abscessation or a high index of suspicion for rhodococcal pneumonia in older foals requires treatment with a
macrolide.
-Lactam antimicrobials are widely used in foal pneumonia. Wide variations in bioavailability have limited
the use of semisynthetic penicillins and cephalosporins
by the oral route. A recent study suggested that cefpodoxime proxetil may be useful in foals at a dosage of 10
mg/kg PO q612h. 3 Cephalexin at a dosage of 30
mg/kg PO q8h achieved appropriate serum levels in
adult horses.4 Because clinical efficacy has not been
established for these oral agents, -lactams continue to
be primarily administered parenterally. Because of their
gram-positive spectrum, penicillins are often combined
with an aminoglycoside to provide gram-negative coverage. Use of a third-generation cephalosporin, such as
ceftiofur, broadens the spectrum of coverage as a sole
therapy but can be improved by adding an aminoglycoside. New fourth-generation cephalosporins exhibit better activity against gram-positive organisms, and the
pharmacokinetics of cefepime have been examined in
foals.5 Use of cefepime has been limited primarily to
Spring 2006

neonates with poor aminoglycoside kinetics or documented multiresistant infections, and the drug should
be administered at 11 mg/kg IV or IM q8h. A new class
of synthetic -lactams, the carbapenems, exhibits a high
degree of stability in the presence of -lactamases and
may be useful in critically ill foals with documented
multiresistant infections. Imipenemcilastatin has been
used in foals at an empiric dosage of 5 to 10 mg/kg IM
bid with apparent safety and efficacy. 6 Intravenous
administration substantially increases the expense7 and
is associated with an increased incidence of adverse
effects in humans.
Aminoglycosides continue to be a primary class of
antimicrobials used in treating foal pneumonia, despite
the potential for nephrotoxicity, because of their excellent gram-negative spectrum and synergy with -lactam
agents. Both the efficacy and safety of these compounds
can be enhanced by extended-interval dosing. Higher
peak serum concentrations improve efficacy because of
the concentration-dependent nature of aminoglycosides,
whereas safety is improved by allowing a longer period of
time in which the drug is at trough level. Amikacin
should be administered to neonatal foals at 21 to 25
mg/kg IV q24h,8,9 whereas gentamicin should be administered at 11 to 15 mg/kg IV q24h.8 As foals mature, the
dose administered should be gradually decreased to the
adult range (i.e., 6.6 mg/kg IV q24h for gentamicin, 7 to
14.5 mg/kg IV q24h for amikacin).8,9 The volume of distribution and half-life of aminoglycosides decrease as
foals mature. These factors, combined with potentially
substantial variations resulting from severe systemic disease and renal insufficiency, can cause unpredictable
COMPENDIUM: EQUINE EDITION

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Therapeutics in Practice

aminoglycoside pharmacokinetics. The serum concentrations of these drugs should be monitored, especially if
they are to be used for more than 5 days.8 Serum samples
should be collected at 30 minutes and 8 hours following
drug administration, with the goal being a 30-minute
peak concentration of greater than 25 g/ml for gentam-

have not been established, an empiric dosage of 10

mg/kg PO q12h has been used based on adult horse
pharmacokinetics established by Bryant et al.10 A more
recent study,11 also of adult horses, suggests that a dosage
of 20 mg/kg PO q1224h may be more appropriate. In
humans, it is recommended that doxycycline not be

Evidence of pulmonary abscessation or a high index of suspicion for

rhodococcal pneumonia in older foals requires treatment with a macrolide.
icin and greater than 40 g/ml for amikacin, with an 8hour trough concentration of 3 to 5 g/ml for
gentamicin or 15 to 20 g/ml for amikacin.8,9 Failure to
achieve an adequate peak should be addressed by
increasing the dose administered, whereas a high 8-hour
trough concentration must be addressed by increasing
the treatment interval or decreasing the dose.8
Tetracycline antimicrobials have not been widely used
in treating foal pneumonia but are of interest because of
their broad spectrum and good tissue penetration.
Although the pharmacokinetics of doxycycline in foals

taken with milk because of the possibility of impaired

absorption, but doxycycline administered to calves in
milk replacer has a reported bioavailability of 70%.12
The treatment of rhodococcal pneumonia has traditionally included oral erythromycin in combination with
rifampin. However, use of erythromycin can be associated with hyperthermia and colitis (in both the foal and
dam). Newer macrolides that do not cause these adverse
effects are available. Azithromycin with rifampin
appears to be as effective as erythromycin with rifampin
and should be administered at 10 mg/kg PO q24h for 5
days, then q48h.13 With a broad spectrum of action,
azithromycin is a reasonable choice in treating foal
bronchopneumonia of an unknown cause. Administration of clarithromycin and rifampin appears to be more
effective than either of the previous combinations in
treating rhodococcal pneumonia, and clarithromycin
should be dosed at 7.5 mg/kg PO q12h.14
Oral chloramphenicol has broad-spectrum activity
and excellent tissue penetration, but use of this drug in
treating foal pneumonia has been limited by concerns
regarding potential human toxicity (fatal aplastic anemia). Reducing exposure of persons handling this drug
is best accomplished by dissolving the tablets in water
or obtaining a compounded paste formulation and having the administrator wear gloves. There is evidence
that the actual incidence of aplastic anemia associated
with chloramphenicol is dramatically lower than originally believed, and this drug continues to be widely
used in human medicine. 15 Chloramphenicol does
appear to be very useful clinically in treating foal pneumonia when its use is typically limited to patients with
documented multiresistant infections. Chloramphenicol should be administered to foals at a dosage of 50
mg/kg PO q6h.16
Topical administration of antimicrobials via the
aerosol route has been investigated in adult horses, and
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Spring 2006

Treating Foal Pneumonia

this technique has been shown to achieve high levels of

antimicrobial within the airway lumen.17 This treatment
modality has efficacy in humans and has been used clinically to treat foal pneumonia, typically in conjunction
with systemic antimicrobial therapy. Aminoglycosides
are particularly well suited for intermittent topical
administration, although cephalosporins may be administered by aerosolization, as well. Gentamicin should be
administered by nebulization at 2.2 mg/kg q24h, using a
50-mg/ml solution, whereas ceftiofur should be administered at 1 mg/kg q12h using a 25-mg/ml solution.17

ANTIINFLAMMATORY THERAPIES
NSAIDs are commonly used in treating foal pneumonia to control fever and decrease patient discomfort
(Table 2). There is evidence in pneumonic calves that
NSAIDs not only control fever but also improve inflammation and clinical signs associated with lower respiratory infections.18 However, administering NSAIDs
to foals can be problematic because the most widely
available products have a narrow therapeutic index.19,20
The use of steroidal antiinflammatory drugs (SAIDs)
in treating lower respiratory infections is much more
controversial than the use of NSAIDs. The rationale behind the use of SAIDs in cases of pneumonia is that
production of the primary proinflammatory mediators
involved is best suppressed by SAIDs because of their
ability to interfere with nuclear transcription of the genes
encoding these proinflammatory mediators.21 The primary concern when considering the use of SAIDs in
treating infectious disease is the potential for immunosuppression, which is very real but primarily dose related.
The most interesting evidence concerning the use of
SAIDs in foal pneumonia was provided by a study by
Lakritz et al22 in which foals with severe bronchointerstitial or interstitial pneumonia exhibited extremely poor
survival rates unless treated with SAIDs. Low-dose oral
steroids (primarily prednisolone at 1 mg/kg PO sid) may
be clinically beneficial in some cases of foal pneumonia
in terms of lessening the severity of pulmonary dysfunction and shortening the course of illness, although controlled studies are required to definitively establish their
efficacy and safety.
ANCILLARY THERAPIES
The most important ancillary therapy is rest. Activity
is likely to worsen respiratory distress by exacerbating
the inflammatory response within the lower respiratory
tract resulting from irritation associated with inhalation
Spring 2006

COMPENDIUM: EQUINE EDITION

51

of cold and/or dry air and stimulation of irritant receptors within the respiratory mucosae.23 Ill foals should
not undergo stressful events such as weaning, transport,
or sale. Temperature control is also important because
foals with pneumonia exhibit impaired thermoregulation and are predisposed to hyperthermia. Environmental management is best achieved by turnout in a small
grass paddock and/or by providing a stall with low-dust
bedding such as pine shavings, rather than straw. Prolonged rest is often required because chronic inflammation may follow resolution of clinical disease.
Foals with pneumonia often benefit from treatment
with bronchodilators because they decrease the work of
breathing and improve patient comfort and attitude
(Table 2). Methylxanthines (i.e., aminophylline, theophylline) are not recommended because of their narrow
therapeutic index. 2-Agonists (i.e., albuterol, clenbuterol) are readily used because they are easily administered by the oral or aerosol route and have additional
benefits, including enhancement of mucociliary clearance. Use of the aerosol route allows the use of smaller
doses, thereby reducing the risk for systemic toxicity.
The anticholinergic bronchodilator ipratropium bro-

52

Therapeutics in Practice

Table 2. Ancillary Drugs for Treating Foals with Pneumonia

Drug

Trade Name,
Manufacturer

Dose

Route

Frequency

Phenylbutazone

Butazolidin,
Schering-Plough

0.250.5 mg/kg
1.12.2 mg/kg

IV, PO

q1224h

Flunixin
meglumine

Banamine,
Schering-Plough
Animal Health

0.251.5 mg/kg

IV, PO

q1224h

Ibuprofen19

Advil, Wyeth

25 mg/kg

PO

q12h

Carprofen20

Rimadyl, Pfizer
Animal Health

0.7 mg/kg (adults)

PO

q24h

Albuterola

Generic

0.010.02 mg/kg

PO

q812h

Albuterol

Ventolin,
GlaxoSmithKline

90180 g (young foals)

360 g (weanlings)

Aerosol MDI

q812h

Clenbuterol

Ventipulmin,
Boehringer Ingelheim
Pharmaceuticals, Inc.

0.8 g/kg (initial)

0.32 g/kg (maximum)

PO

q12h

Ipratropium
bromide

Atrovent,
Boehringer Ingelheim
Pharmaceuticals, Inc.

0.35 g/kg
25 g/kg (1,200
2,400 g/horse)

Aerosol MDI

q12h

Ipratropium
bromide with
albuterola

Combivent,
Boehringer Ingelheim
Pharmaceuticals, Inc.

12 actuations
(90180 g [albuterol],
1836 g [ipratropium])

Aerosol MDI

q12h

Prednisolonea

Delta-Cortef, Upjohn

12.2 mg/kg

PO

q1224h

Interferon-23

Roferon-A, Roche
(recombinant)

50 U (natural human
interferon-)
90 U (recombinant
human interferon-)

PO

q24h

Omeprazole24

Gastrogard, Merial

4 mg/kg

PO

q24h

Ranitidine

Zantac, Glaxo
Wellcome

6.6 mg/kg

PO

q8h

aBased

on authors clinical experience.

MDI = metered-dose inhaler.

mide (Atrovent, Boehringer Ingelheim) can be used

alone or in combination with a 2-agonist (Combivent,
Boehringer Ingelheim). Ipratropium is available only as
an aerosol preparation, either as a metered-dose inhaler
or a solution for nebulization, and must therefore be
administered by inhalation using a facemask.
Clinically ill foals are at risk for gastrointestinal ulceration due to altered feeding patterns and physiologic
stress, and the risk is worsened by administration of
COMPENDIUM: EQUINE EDITION

either NSAIDs or SAIDs. Therefore, it is prudent to

treat foals with pneumonia with gastric acid suppressive
drugs. Oral omeprazole (Gastrogard, Merial) is
extremely effective at suppressing gastric acid production24 and is my preferred prophylactic therapy. The
effect of ranitidine in suppressing gastric acidity is less
profound and much shorter. Ranitidine must be administered every 8 hours as opposed to once-daily therapy
with omeprazole.
Spring 2006

Treating Foal Pneumonia

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characteristics as risk factors for development of Rhodococcus equi pneumonia
in foals. JAVMA 222:467475, 2003.
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