Continuity of Care: Pneumonia: Targeting Treatments and Monitoring the Response

Dr. Grandinetti is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Rockville, Maryland. The views expressed are those of the author and not those of any government agency.

Infected or inflamed lung parenchymais generally described as community-acquiredpneumonia (CAP) or nosocomialpneumonia (NP).^1-3 Influenza andpneumonia combined is the seventhleading cause of death in the UnitedStates. Pneumonia-associated mortalityremains high in patients who are elderly,critically ill, immunocompromised,and with preexisting cardiopulmonarydisease.^1,4

Types of Pneumonia

Table

Pneumonia Risk Factors

Alcoholism

Chronic liver or lung disease

Smoking

Heart failure

Coronary artery disease

Dementia

Diabetes

Drug abuse

Elderly

Immunosuppression

Malignancy

Medications that alter consciousness

Renal failure

Seizures

Strokes

Additional risk factors for NP and NHAP

Dysphagia

Enteral feedings

Impaired mental status

Inadequate oral care

Malnutrition

Medication or therapies that impair lung defenses

Medications that reduce gastric acidity (ie, proton pump inhibitors, histamine2 antagonists)

Nasogastric and endotracheal tubes

Surgery

Trauma

NP = nosocomial pneumonia; NHAP = nursing home?acquired pneumonia.

Adapted from references 2,4,5.

Each type of pneumonia is associatedwith causative bacteria, viruses,parasites, or fungi with unique clinicalpresentations but similar risk factors.Difficulty obtaining sputum samplesand results confounded by oropharyngealcolonization make identifyingthe causative microorganism difficult.Antimicrobial therapy, therefore, isoften empiric.^5,6

Community-Acquired Pneumonia

CAP is acquired more than 14 daysfrom a stay in a hospital or long-termcare facility. Most CAP patients can betreated safely as outpatients, and mortalityis <5%; however, some patientsneeding close observation, respiratorysupport, or intravenous (IV) antibioticsrequire admission to the hospital.Mortality approaches 40% in patientswho require intensive care. Prompttreatment (within 4 hours of admission)can improve mortality.^1,7,8

Nosocomial Pneumonia

NP, occurring 48 hours or more afterhospitalization, is the leading hospital-acquiredcause of mortality. NP includesventilator-associated pneumonia andhealth care?associated pneumonia(HCAP). HCAP occurs in patients whowere hospitalized in an acute care hospitalfor ≥2 days within 90 days of infection;resided in a long-term care facility;received IV antibiotics, chemotherapy, orwound care within 30 days of infection;or attended a hospital or hemodialysisclinic. Recent antibiotic therapy, hospitalization(within 3 months), and late-onsetNP (≥5 days after admission), increasethe risk for colonization with a multidrugresistant (MDR) organism.^2,5,9,10

Nursing Home?Acquired Pneumonia

Nursing home residents are at greaterrisk for pneumonia with antibiotic-resistantorganisms, and pneumonia is theleading cause of death among residents.²The elderly are prone to conditionscausing aspiration and reflux (ie, oversedation,excessive narcotic use, supinepositioning, and confusion). Respiratorycare interventions and good oral careare important to reduce oropharyngealcolonization with potential respiratorypathogens that can be aspirated.

Monitoring and Counseling Tips for Pharmacists

In All Settings:

• Recommend antibiotics with longer half-lives that permit once-daily administration, improve adherence and outcomes, and decrease costs
• Counsel patients on:

• Completing entire treatment course
• Maintaining adequate nutrition and exercise for recovery and to prevent subsequent infections
• Preventing and spreading CAP: hand washing, using masks or tissues, and vaccinations
• Smoking cessation programs, if applicable

• Assess adherence

In the Hospital:

• Ensure accurate pneumonia diagnosis
• Recognize patients at risk for MDR
• Ensure use of most appropriate, safe, and cost-effective antibiotic; avoid indiscriminate antibiotic use
• Administer antibiotics as early as possible
• Assess vaccination status
• Switch patients to oral therapy when clinically indicated
• Discharge patients as soon as they are clinically stable

At Discharge:

• Vaccinate at discharge or during outpatient treatment
• Remind patients of the importance of annual influenza vaccine

In Long-Term Care Facilities:

• Emphasize the importance of good oral hygiene
• Use central nervous system depressants cautiously

CAP = community-acquired pneumonia; MDR = multidrug resistance.Adapted from references 2,4-6.

Treatment

Treatment goals are to eradicate causativepathogens, resolve clinical signsand symptoms, minimize hospitalization,and prevent reinfection. TheInfectious Diseases Society of America/American Thoracic Society consensusguidelines recommend empiric therapywith macrolides, fluoroquinolones, ordoxycycline.^4-6 The Centers for DiseaseControl and Prevention recommendsfluoroquinolone use only when patientsfail first-line regimens, are allergic toalternative agents, or have a documenteddrug-resistant pneumococcal infection.Clinicians should consider localepidemiologic and resistant patternsand patient circumstances when basing therapy choices onpublished guidelines.^5,6

Prolonged and unnecessary broad-spectrum anti-infectivesare associated with development of resistant organisms.Clinicians should avoid antibiotic overuse and tailor empirictreatment to the causative microorganism as soon as possible.Antibiotics are generally administered for 7 to 14 days; longertreatment durations may be necessary in immunocompromisedpatients or those infected with atypical pathogens (Legionellapneumophilia, Mycoplasma pneumoniae, Chlamydia pneumoniae).Oral therapy is indicated once patients are clinicallystable and able to tolerate oral intake.^1,7,9

Preventive Strategies

For patients ≥50 years of age, those with chronic medical conditions,long-term care facility residents, household contacts ofhigh-risk persons, and health care workers, annual vaccinationwith inactivated influenza vaccine is crucial. The intranasallive attenuated vaccine is indicated for healthy persons aged 5to 49 years. A one-time pneumococcal vaccine is indicated forpatients aged ≥65 and younger patients who are immunocompromisedor have long-term medical conditions.¹¹

Pharmacists can influence patient care by ensuring thattherapy is initiated quickly with the most appropriate, cost-effectiveanti-infective, monitoring patient response, and suggestingconversion to oral therapy to shorten hospitalization.

Table

Risk Factors for Multi-Drug Resistant Pathogens

Hospitalization for ≥2 days or antimicrobials in preceding 90 days

Current hospitalization of ≥5 days

High frequency of antibiotic resistance in the community or specific hospital unit

Resident in extended care facility

Home infusion therapy

Chronic dialysis within 30 days

Home wound care

Family member with MDR pathogen

Immunosuppression

MDR=multidrug resistant

Adapted from reference 5.

Table

Empiric Therapy Choices for Pneumonia Treatment

Types of Pneumonia

Patient Type and Setting

Common Pathogens

Empiric Therapy Recommendations

CAP

Previously healthy outpatients, no risk factors for MDR pathogens

Streptococcus pneumoniae; Haemophilus influenzae; Mycoplasma pneumoniae; Chlamydia pneumoniae; Moraxella catarrhalis; Staphylococcus aureus

Azithromycin, clarithromycin, or erythromycin

Alternatives: doxycycline

Outpatients with comorbidities or macrolide-resistant infection

Fluoroquinolone^a or high-dose amoxicillin or amoxicillin/clavulanate plus a macrolide or doxycycline

Alternatives: ceftriaxone, cefpodoxime, and cefuroxime plus a macrolide or doxycycline

Inpatient, non-ICU treatment

S pneumoniae; M pneumoniae; C pneumoniae; H influenzae Legionella species

Fluoroquinolone,a beta-lactam (cefotaxime, ceftriaxone, or ampicillin; ertapenem for selected patients) plus a macrolide or doxycycline

Penicillin-allergic patients: fluoroquinolone^a

Inpatient, ICU treatment

S pneumoniae; S aureus; Legionella pneumophilia; Gram-negative bacilli; H influenzae; Pseudomonas aeruginosa

Cefotaxime, ceftriaxone, or ampicillin-sulbactam plus azithromycin or fluoroquinolone^a

Penicillin-allergic patients: fluoroquinolone^a and aztreonam

For pseudomonas infection: piperacillin/tazobactam, cefepime, imipenem, or meropenem plus ciprofloxacin or levofloxacin

ORbeta-lactam plus an aminoglycoside and azithromycin or fluoroquinolone^a; penicillin-allergic patients: substitute aztreonam for a beta-lactam.

For MRSA infection: add vancomycin or linezolid.

Viral CAP

Outpatient/inpatient non-ICU treatment

Influenza; Respiratory syncytial virus; Adenovirus; Parainfluenza virus

Oseltamivir, zanamavir (within 48 hours of the onset of symptoms)

Alternatives: amantadine, rimantadine

NHAP

Nursing home

Klebsiella pneumoniae; S aureus; Escherichia coli; MRSA; Anaerobes

Fluoroquinolone or amoxicillin/clavulanate plusazithromycin or clarithromycin

Hospital ward

Parenteral third-generation cephalosporin or ampicillin/sulbactam plus azithromycin or clarithromycin or parenteral levofloxacin, gatifloxacin, or moxifloxacin

NP, VAP, HCAP

Early onset, no risk factors for MDR pathogens, any disease severity

S pneumoniae; H influenzae; Methicillin-sensitive S aureus; Antibiotic-sensitive enteric gram-negative bacilli; E coli; K pneumoniae; Enterobacter species; Proteus species; Serratia marcescens

Ceftriaxone, levofloxacin, moxifloxacin, ciprofloxacin, ampicillin/sulbactam, or ertapenem

Late-onset disease or risk factors for MDR pathogens

All microorganisms listed under early onset plus MDR pathogens:

P aeruginosa; E coli; K pneumoniae; Acinectobacter species;

MRSA;

Legionella species

Cefepime, ceftazidime, imipenem, meropenem, or piperacillin/tazobactam,

plus

Ciprofloxacin, levofloxacin, or aminoglycoside

plus

If MRSA+: linezolid or vancomycin

If legionella+: replace aminoglycoside with a macrolide or a fluoroquinolone

*The Infectious Diseases Society of America recommends moxifloxacin, gemifloxacin, and levofloxacin. Avoid ciprofloxacin and ofloxacin because they lack activity against Spneumoniae.

CAP = community-acquired pneumonia; HCAP = health care associated?pneumonia; ICU = intensive care unit; MDR = multidrug resistant; MRSA = methicillin-resistant Staphylococcus aureus; NP = nosocomial pneumonia; NHAP = nursing home?acquired pneumonia; VAP = ventilator-associated pneumonia.

Adapted from references 2,5,6.