Continuity of Care: Pneumonia: Targeting Treatments and Monitoring the Response
Pneumonia and influenza together represent the seventh leading cause of death in the United States. Pharmacists can influence care by ensuring that appropriate therapy is initiated quickly and closely monitoring patients.
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
Pneumonia Risk Factors
Chronic liver or lung disease
Coronary artery disease
Medications that alter consciousness
Additional risk factors for NP and NHAP
Impaired mental status
Inadequate oral care
Medication or therapies that impair lung defenses
Medications that reduce gastric acidity (ie, proton pump inhibitors, histamine2 antagonists)
Nasogastric and endotracheal tubes
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
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
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
- 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 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
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.
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
Adapted from reference 5.
Empiric Therapy Choices for Pneumonia Treatment
Types of Pneumonia
Patient Type and Setting
Empiric Therapy Recommendations
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
Outpatients with comorbidities or macrolide-resistant infection
Fluoroquinolonea 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: fluoroquinolonea
Inpatient, ICU treatment
S pneumoniae; S aureus; Legionella pneumophilia; Gram-negative bacilli; H influenzae; Pseudomonas aeruginosa
Cefotaxime, ceftriaxone, or ampicillin-sulbactam plus azithromycin or fluoroquinolonea
Penicillin-allergic patients: fluoroquinolonea and aztreonam
For pseudomonas infection: piperacillin/tazobactam, cefepime, imipenem, or meropenem plus ciprofloxacin or levofloxacin
ORbeta-lactam plus an aminoglycoside and azithromycin or fluoroquinolonea; penicillin-allergic patients: substitute aztreonam for a beta-lactam.
For MRSA infection: add vancomycin or linezolid.
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
Klebsiella pneumoniae; S aureus; Escherichia coli; MRSA; Anaerobes
Fluoroquinolone or amoxicillin/clavulanate plusazithromycin or clarithromycin
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;
Cefepime, ceftazidime, imipenem, meropenem, or piperacillin/tazobactam,
Ciprofloxacin, levofloxacin, or aminoglycoside
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.