Updated Therapeutic Approach to Community and Nosocomial Pneumonia

SEPTEMBER 02, 2016
This article was collaboratively written with Kara K. White and Kathryn Chappell, PharmD Candidates 2017, Auburn University Harrison School of Pharmacy.

Pneumonia occurs year-round and presents in a large patient demographic. Seen most severely in young, elderly, and chronically ill patients, it begins when microorganisms enter the lower respiratory tract through inhalation of aerosolized particles, contamination of the bloodstream, or aspiration of oropharyngeal contents.

Pneumonia is the most common cause of sepsis, hospitalizing about 1 million adults per year. Community-acquired pneumonia (CAP) is commonly caused by S. pneumoniae or atypical bacteria like M. pneumoniae and C. pneumoniae, with about 5.6 million cases per year. Patients at increased risk for CAP often have underlying medical conditions or an aspiration risk.1

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are prevalent nosocomial infections. They account for 22% of all hospital-acquired infections and may result in serious complications like respiratory failure, pleural effusions, septic shock, and acute kidney injury.2 HAP and VAP patients are 2 separate entities with a wide range of pathogenic organisms.

In 2007, the Infectious Diseases Society of America (IDSA) and American Thoracic Society created consensus guidelines for CAP management in adults. They recommend using CURB 65 criteria to identify CAP patients who may be candidates for outpatient treatment.3 The IDSA also recommends otherwise-healthy patients with no risk factors for drug-resistant S. pneumoniae (DRSP) be treated with a macrolide or doxycycline. For patients with chronic health conditions, a respiratory fluoroquinolone or beta-lactam in combination with a macrolide should be considered. Some study results also suggest the use of steroids in the treatment of CAP, but there hasn’t yet been a consensus on their role.3 However, an updated guideline for CAP is scheduled to be published in 2017.

The IDSA recently published new guidelines for the treatment of HAP/VAP, introducing several new concepts, including the removal of health care-associated pneumonia (HCAP). Recent studies have produced evidence that patients with defined HCAP aren’t at high risk for multidrug-resistant (MDR) pathogens and underlying patient characteristics are important determinants for them. Consequently, HCAP was removed and will possibly be a separate entity in the upcoming CAP guidelines.2 Other updates include risk factors for MDR pathogens and treatment of HAP/VAP.

Risk Factors
Recognizing early signs is key to preventing complications and the spread of illness. At general risk for pneumonia are those who are younger than 2 years or older than 65 years; have lung disease, other serious disease, or immunosuppression; or experience trouble coughing and swallowing due to aspiration risk.4

There are risk factors unique for community and nosocomial pneumonia which set these infections apart. CAP risks include diabetes mellitus, asplenia, chronic cardiovascular, renal and/or liver disease, and smoking or alcohol abuse.3 Nosocomial infection risks include acute respiratory distress syndrome (ARDS), coma, head trauma, enteral nutrition/nasogastric tube, intubation, and prior antibiotic exposure.1,4

Marilyn Bulloch, PharmD, BCPS, FCCM
Marilyn Bulloch, PharmD, BCPS, FCCM
Marilyn Novell Bulloch, PharmD BCPS, is an Associate Clinical Professor of Pharmacy Practice at the Auburn University School of Pharmacy and an Adjunct Associate Professor at the University of Alabama-Birmingham School of Medicine and the University of Alabama College of Community Health Sciences . She completed a post-graduate pharmacy practice residency at the University of Alabama-Birmingham Hospital and a post-graduate specialty residency in critical care pharmacy at Charleston Area Medical Center in Charleston, West Virginia. Dr. Bulloch also completed a Faculty Scholars Program in geriatrics through the University of Alabama-Birmingham Geriatric Education Center in 2011. She serves on multiple committees and in leadership positions for many local, state, and national pharmacy and interdisciplinary medical organizations.