Community-acquired Pneumonia

CORAM S VOLUME 7 Coram, LLC. is a leading national provider of home infusion services, including alternate site of care and specialty pharmacy distribution. 12450 E. Arapahoe Rd, Suite A, Centennial, CO 80112 For the branch nearest you, visit coramhc.com Community-acquired Pneumonia Pneumonia is an acute infection of the lungs that causes fluid to collect in the alveoli. It can be caused by bacteria, viruses or even fungi, but the most common type, and the focus of this educational piece, is bacterial pneumonia. Communityacquired pneumonia (CAP) is caused by pathogens within the community, as opposed to hospital-acquired pneumonia, which is caused by pathogens within the hospital. CAP is an important disease state in large part due to its significant incidence. It is the most common cause of infection-related deaths in the U.S. and it is the ninth most common cause of death overall. 1 CAP is the most common indication for both inpatient and outpatient use of antibiotics. CAP accounts for 600,000 to 1.1 million hospital admissions in the United States, at an annual cost of $8.4 million to $10 million. 2 While most patients do well with treatment, pneumonia is not a benign illness; certain patients develop severe pneumonia, often resulting in death. CAP is primarily a disease of the elderly. Approximately one-third of the three million cases of pneumonia reported in the U.S. each year develop in people over age 65. Approximately 4% of people 65 years and older present with pneumonia each year. And about 60,000 patients will die from this disease. 3,4,5 Given the advancing age of our population, the burden of pneumonia is likely to increase. Most patients with CAP are successfully treated on an outpatient basis. The majority of these patients are younger than than 65 and the mortality rate associated with outpatient pneumonia is low typically <1%, although 7 10% of those who begin outpatient treatment ultimately require hospitalization. Among patients with CAP who require hospitalization, the mortality rate is up to 23%. 2 The mortality rate increases, for example, in patients with bacteremia and in those who reside in nursing homes, and approaches 40% in those who require admission to the ICU. 4 As with so many disease states, there is an increasing emphasis on costeffectiveness when treating CAP, which necessarily addresses standards of care and site-of-care options. Risk Factors In addition to age, several risk factors for CAP exist. Persons with compromised immune systems whether chemicallyinduced, such as those undergoing chemotherapy or post-transplant, or due to such diseases as HIV or immunodeficiencies are at increased risk for pneumonia. In addition, comorbidities including diabetes, chronic obstructive pulmonary disease (COPD), cardiac disease, and sickle cell disease increase the pneumonia risk. Patients with an impaired ability to cough or otherwise clear their lungs such as during a post-operative period and patients who are intubated, in the ICU, or are otherwise bedridden are at increased risk, as are asplenic patients. Further risk presents in patients who are addicted to cigarettes and/or alcohol. Causative Organisms The causative organisms for CAP are identified only about half of the time, but they are quite predictable for the most part. Most cases of CAP continue to be caused by Streptococcus pneumoniae. Other causes include Haemophilus influenzae, respiratory viruses such as influenza, and Mycoplasma pneumoniae. However, more and more pathogens are found to cause CAP, many of which are increasingly antibiotic-resistant. Bacterial CAP is generally caused by a single organism, although approximately 30% of cases are due to bacterial and viral coinfections. 6 Other organisms may be suspected in certain situations; for example, patients with chronic alcoholism are likely to be infected with Klebsiella pneumoniae, while Psuedomonas is a common causative organism in patients with cystic fibrosis. Pseudomonas is particularly significant because, after infection with Pseudomonas, it is extremely difficult to eradicate it. Staphylococcus aeureus is an uncommon cause of CAP, but it is significant because of its high incidence of methicillin resistance and its associated rapid mortality. 7 C O N T I N U I N G E D U C A T I O N P R O G R A M

Signs and Symptoms Signs and symptoms associated with pneumonia vary widely, in large part dependent on host factors rather than the type, number or virulence of the involved pathogen. Disease severity is largely impacted by the patient s preexisting cardiac, pulmonary and splenic function. The most common symptoms of CAP are listed in the box below. Less commonly described symptoms include: Headache Nausea and vomiting Diarrhea Tachypnea Tachycardia Fatigue Arthralgia/myalgia New-onset or worsening confusion (primarily in the elderly) Possible physical findings with chest examination include: Dullness to percussion Vocal fremitus Increased tactile fremitus (indicates an underlying consolidated lung) Decreased tactile fremitus (indicates pleural fluid) Egophony or whispering pectoriloquy (fluid or consolidation causes the sound of the voice to be transmitted loudly to the periphery of the lungs, where it is normally not heard) Crackles Pleural friction rub There are also more specific patient complaints that depend on multiple variables. For example, elderly or debilitated patients with pneumonia often present with nonspecific complaints and may not demonstrate the classic symptoms, such as acute confusion or a deterioration of baseline function. Elderly patients may have only a slight temperature elevation or be afebrile, but are more likely to have an increased respiratory rate. Certain clinical symptoms can also serve as clues to the causative organism. For example: Fever alone is a nonspecific finding, but a pulse-temperature disparity (normal pulse in the setting of high fever) suggests pneumonia from mycoplasma, Legionella, chlamydia, or a virus. The classic presentation of pneumococcal pneumonia is a sudden onset of a single shaking chill followed by fever, rust-colored productive cough, and pleuritic chest pain. Adults with chronic lung disease who develop pneumonia caused by H. influenzae typically present with an insidious worsening of baseline cough and sputum production. Klebsiella pneumoniae can cause sputum production that is often described as currant-jelly because of the necrotizing, hemorrhagic nature of the infection. Patients with severe CAP typically present with one or more of the symptoms listed in the box below. Diagnosis Given that a number of infectious or non-infectious illnesses can present with symptoms similar to those of CAP, a differential diagnosis is important. Diagnosis for CAP is typically made based on clinical, laboratory and radiologic data, including: Rales or bronchial breath sounds detected during a physical exam Elevated white blood cell count Positive culture (if attainable) Thoracentesis if a pleural effusion (>5 cm) is present CT scans are very sensitive, even more so than a chest x-ray (CXR), but are costly, not necessary and not endorsed by the America Thoracic Society (ATS) or Infectious Disease Society of American (IDSA) as a routine diagnostic study for CAP. The CXR is the diagnostic gold standard. A CXR is obtained to confirm the diagnosis and help determine the severity of the pneumonia and/ or the presence of micro abscesses or other lung disease. The CXR should be repeated in 6 to 10 weeks to document the resolution of the pneumonia and to exclude underlying malignancy, which can mimic an infectious infiltrate. A CXR may also indicate specific causative pathogens, since some organisms tend to cause specific patterns within the lungs. Common CAP Symptoms Fever Productive, purulent cough Non-productive cough Dyspnea Pleuritic chest pain Shaking chills Signs and Symptoms Severe CAP Admission RR >35 breaths per minute Need for mechanical ventilation Chest x-ray showing either a 50% increase in the infiltrate over 48 hours or multilobular infiltrates Need for vasopressors to support BP Severe lung injury Urine output <20 cc/hr Acute renal failure requiring dialysis 2 VOLUME NO. 7

Patterns of Infiltrate on Chest X-ray Pattern Lobar Patchy Interstitial Cavitary Large effusion Possible Causative Organisms Strep. pneumonia, H. influenzae, Klebsiella, gram-negatives Atypical bacteria, virus, Legionella Virus, PCP, Legionella Anaerobes, Klebsiella, TB, Staph. aureus, fungi Staph, anaerobes, Klebsiella Site-of-Care Options Recognizing that hospitalization is the primary cost driver for CAP, purposeful evaluation of the most appropriate site of care is essential. For many lower-risk patients, fewer hospital days is often a viable option and can be achieved by hospital avoidance or decreased length of stay (LOS). Patients may also be able to be diverted from the ER to home, again avoiding hospital days. For patients with severe disease, hospitalization is often necessary and the best site-of-care option. However, it is suggested throughout the literature that: Physicians have tended to hospitalize more patients with CAP than necessary, There are not consistent standards for determining the need for hospitalization, and Physicians tend to overestimate the risk of death in patients with pneumonia. Such factors can often be associated with the decision to hospitalize patients who are, in fact, at low risk of death or other negative outcomes. Avoiding hospital days minimizes risk of exposure to nosocomial, often resistant, pathogens. Site of Care/Risk Classification Several determinants have been developed to sort patients into high- and low-risk categories depending on their risk of pneumonia-related complications and other factors. Patients in the highrisk category are typically admitted to the hospital for treatment and may or may not be able to be discharged to complete therapy at home. Patients in the low-risk category may be able to avoid hospitalization with the proper assessment, monitoring and communication throughout a course of home infusion. Since site-of-care decisions can be quite subjective, the ATS and IDSA recommend using mortality prediction rules such as those validated by PORT (Pneumonia Patient Outcomes Research) also called the Pneumonia Severity Index or PSI (see below) or the CURB-65 (see page 4). Both systems help predict mortality and determine the most appropriate site of care. Mortality risk is based on factors including age; the presence, severity and types of comorbidities; and the severity of the pneumonia symptoms. The image below illustrates the PSI scoring system, which is based on patient age, comorbidities, clinical status, and blood and radiology results. Patients are assigned points beginning with age 1 point for every year of age (age minus 10 for women). Points are added for comorbidities, presenting symptoms, and blood and radiology test results. The points are totaled and, depending on where the patient falls, results indicate validated predictability of mortality and best site of care. Similarly, the CURB-65 supports risk classification based on specific symptoms as well as age, with the resulting risk class as a determinant for best practice site of care. PSI = Pneumonia Severity Index for immunocompetent adults (Fine N Engl J Med 1997; 336:243) Step 1 without score Step 2 with scoring age > 50 y yes age m (in years) no Co-Morbidity: yes active neoplastic diseases 1y + 30 heart failure (with systalic or + 10 distolic ventricular dysfunction) stroke / TIA + 10 renal disease / abnormal creatinine + 10 chronic liver disease + 20 no Clinical: desorientation heart rate > 125/min respiratory rate > 30/min RRsyst < 90 mmhg temp < 35 / > 40 no Class 1: Mortality 0.1% yes + 20 + 10 + 20 + 20 + 15 f (in years - 10) nursing home + 10 Blood tests & radiology art. PH < 7.35 + 30 P-urea > 11 mmol/l + 20 P-sodium < 130 mmol/l + 20 P-glucose > 14 mmol/l + 10 Hematokrit < 30% + 10 PaO2 < 60 mm Hg + 10 effusion + 10 total score < 70 Class II Mortality 0.6% 71-90 Class III Mortality 0.9% 91-130 Class IV Mortality 9.3% > 130 Class V Mortality 27.0% Class 1-111: consider outpatient rx CONTINUING EDUCATION 3

CURB-65 Classification Of note, in December 2010, the U.S. Food and Drug Administration (FDA) approved ceftaroline fosamil (Teflaro ), an antibiotic in the cephalosporin group, to treat adults with CAP and skin and skin structure infections (SSIs), including methicillin-resistant Staphylococcus aureus (MRSA). Risk class Mortality (%) Recommended site of care 0 0.7 Outpatient 1 2.1 Outpatient 2 9.2 Short hospital stay / supervised outpatient 3 14.5 Hospital, assess for ICU 4 40 Hospital, assess for ICU 5 57 Hospital, assess for ICU Best Practice Treatment Options In 2007, the IDSA and ATS presented consensus treatment guidelines for CAP; this is important as compliance with guidelines has proven to positively impact survival, hospitalization, time to antibiotic administration, and costs of care. The primary practitioners who see CAP have consistent recommendations available to them, and the hope is that compliance with clear guidelines will support best practice and positive outcomes. The treatment guidelines address appropriate site of care given the patient s clinical condition and risk factors, appropriate diagnostic testing, and means of prevention (primarily vaccinations). The guidelines also consider appropriate antibiotic therapy, as indicated by specific recommended antibiotics, the timing from symptom presentation to first antibiotic dose administration, when and if to switch from IV to oral antibiotics, and length of therapy. 8 Treatment recommendations are given according to the assumed causative organisms, severity of illness, comorbidity status, and site of care. For example, a macrolide or doxycycline is recommended for a patient appropriate for outpatient care, with a flouroquinolone added if the patient had a recent course of antibiotics. For patients on a general unit, a beta-lactam plus a macrolide or a flouroquinolone is recommended. For patients in the intensive care unit (ICU), a ß-lactam plus azithromycin or a respiratory flouroquinolone is recommended. In fact, combination therapy should always be prescribed for the most severe cases. Wrong Organism Drug-resistant pathogen: (bacteria, mycobacteria, virus, fungus) Inadequate antimicrobial therapy Complications Empyema or lung abscess Clostridium difficile colitis Occult infection Drug fever The current treatment guidelines recommend that CAP therapy be administered as soon as possible after the diagnosis is considered likely. However, in 2012 the United States National Pneumonia Medicare Quality Improvement Project and the National Quality Forum retired that guideline as a quality measure. 9 Patients admitted to the hospital with severe CAP initially require intravenous empiric therapy. When these patients have clinically improved, usually after 48 72 hours, they may be switched to an equivalent oral agent. The same treatment plan may be used for patients with moderate disease, although there is an increasing trend toward treating this patient population with oral therapy at the outset. Assessment of Nonresponders ARDS = acute respiratory distress syndrome Adapted from Nederaman MS et al. Am J Repir Cnt. Care Med 2005. 171 408. Fig. 3 Wrong Diagnosis Atelectasis Pulmonary embolus ARDS Pulmonary hemorrhage Underlying disease Neoplasm 4 VOLUME NO. 7

Duration of outpatient therapy is typically 10 to 14 days if oral antibiotics are administered, and about seven days for infusion therapy. Longer duration of therapy may be needed depending on, for example, the causative organisms, patient risk classification and response to therapy. It is recommended that therapy continue until the patient has been afebrile for 48 to 72 hours. The situation is somber for patients who do not respond to therapy. It is essential, then, to consider noninfectious illnesses, less common pathogens, further serologic testing, additional or other antibiotic therapy,and/or bronchoscopy. Switch/Sequential Therapy There is a trend toward switch or sequential therapy. Switch therapy refers to using the same antibiotic initially as IV and then switching to oral therapy. Sequential therapy uses one IV antibiotic at first, then switches to an oral drug from another class of antibiotics. Both provide opportunities for decreased usage time of costlier IV therapy, fewer hospital days, fewer hospital-related complications (such as phlebitis, falls, and nosocomial infections), and overall decreased costs, without compromising outcomes. In fact, just taking a half day off the LOS can save over $1,200 per episode. Given the incidence of CAP, that can total approximately $1.37 billion saved per year. 10 Switching from IV to oral therapy may also support greater patient satisfaction. In order to consider a change to oral therapy, the patient must demonstrate resolution of fever, improvement in heart rate and respiratory symptoms, normal blood pressure, adequate oxygenation, and a decreased WBC. In addition, the patient must be able to take in food orally and have normal gastrointestinal absorption. Site-of-Care Savings There is a big difference between the costs of treating a pneumonia patient in the hospital versus treatment in the home. The literature reports various costs, but the range appears to be approximately $7,500 to $13,000 per patient in the hospital per pneumonia episode, as compared to $150 to $300 per patient for outpatient management. Prevention Vaccines targeting pneumococcal disease and influenza remain the mainstay for preventing CAP. The pneumococcal vaccine is recommended at least for all patients over 65, for patients with asplenia, and for other patients at risk. To maintain immunity, revaccination every five years is necessary. The flu vaccine is also important for many patients. Its effectiveness, while good overall, does depend on host factors and on how closely the antigens in the vaccine are matched with the current circulating strain of influenza. The best time for getting the flu vaccine is October and November, although vaccination in December and later is recommended for those who were not vaccinated earlier. The inactivated flu virus, injected intramuscularly, is indicated for all persons 50 years of age and older as well as younger patients at highrisk, household contacts of high-risk persons, and healthcare providers. Patients should be vaccinated annually to ensure protection from each year s particular strain(s). References 1. Murphy SL, Xu JQ, Kochanek KD. Deaths: final data for 2010. www.cdc.gove/nchs/data/dvs/ deaths_2012_release.pdf. Accessed March 11, 2013. 2. Srinivasan S. Community-acquired pneumonia. University of South Dakota Sanford School of Medicine; Internal Medicine Grand Rounds. May 2012. http://cmetracker.net/usdcme/files/ Brochures/2683.pdf. Accessed April 23, 2013. 3. File TM Jr, Marrie TJ. Burden of communityacquired pneumonia in North American adults. Postgrad Med. Mar 2010;122(2):130-41. 4. Fung HB, Monteagudo-Chu MO. Community-acquired pneumonia in the elderly. Am J Geriatr Pharmacother. Feb 2010;8(1):47-62. 5. Jackson ML, Neuzil KM, Thompson WW, Shay DK, Yu O, Hanson CA, et al. The burden of community-acquired pneumonia in seniors: results of a population-based study. Clin Infect Dis. Dec 1 2004;39(11):1642-50. 6. Jennings L, Anderson TP, Beynon KA, et. al. Incidence and characteristics of viral community-acquired pneumonia in adults. Thorax. 2008;63(1):42-48. 7. Hageman JC, Uyeki TM, Francis JS, Jernigan DB, et al. Severe community-acquired pneumonia due to Staphylococcus aeureus, 2003-04 influenza season. Emerging Infectious Disease. June 2006;12(6). 8. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, et al. Infectious Disease Society of America. American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia. Clinical Infectious Diseases. 2007:44:S27-S72. 9. Centers for Medicare and Medicaid Services and the Joint Commission. Specifications manual for national hospital inpatient quality measures. www.jointcommission. org/specifications_manual_for_national. Accessed April 23, 2013. 10. Raut M, Schein J, Mody S, Grant R, Benson C, Olson W. Estimating the economic impact of a half-day reduction in length of hospital stay among patients with communityacquired pneumonia in the U.S. Current Medical Research and Opinion. September 2009;25(9):2151-2157(7). CONTINUING EDUCATION 5

CORAM S VOLUME 7 Coram LLC is a leading national provider of home infusion services, including alternate site of care and specialty pharmacy distribution. 12450 E. Arapahoe Rd, Suite A, Centennial, CO 80112 For the branch nearest you, visit coramhc.com Community-acquired Pneumonia LEARNING GOAL To understand community-acquired pneumonia. LEARNING OBJECTIVES Upon completion of this continuing education program, the reader will be able to: 1. Define community-acquired pneumonia (CAP), including its incidence and risk factors. 2. List common symptoms of pneumonia, the challenges of finding the causative organisms, and the resulting challenges with treatment. 3. Discuss current treatment guidelines and site-of-care options, including home infusion. To obtain two contact hours toward CE credit, please circle the correct answer (on the next page) for each question and forward to: Coram s Healthline Coram LLC 12450 E. Arapahoe Rd, Suite A Centennial, CO 80112 Please allow approximately seven days to process your test and receive the certificate upon achieving a passing score. SELF-ASSESSMENT QUESTIONS Please circle the correct answer for each question. The passing score for this test is 100%. 1. Community-acquired pneumonia: a. Is the most common cause of infection-related deaths in the U.S. b. Is the most common indication for antibiotic prescription. c. Leads to hospitalization in approximately 50% of patients. d. Is diagnosed in approximately one million persons over the age of 65. e. All of the above. f. a, b and d. 2. Causative organisms for communityacquired pneumonia can be cultured in the majority of cases, providing for pathogen-specific Provider approved by the California Board of Registered Nursing, Provider #15200. Coram LLC is approved by the Delaware Board of Nursing, Provider #DE-14-010517. Coram LLC is approved by The Commission for Case Manager Certification to provide continuing education credit to CCM board certified case managers. This healthline is approved by the above accreditations for 2.0 contact hours. therapy at the outset. 3. CAP is often caused by multiple bacterial pathogens. 4. Staphylococcus aeureus is an uncommon cause of communityacquired pneumonia, but significant if it is causative because of its high incidence of methicillin resistance and high, rapid mortality. 5. A chest x-ray: a. Is the gold standard diagnostic tool. b. Can help provide a differential diagnosis. c. Should be repeated in 6 to 10 weeks. d. May indicate specific causative pathogens. e. All of the above. f. a, b and d. g. a, b and c. 6. If clinically stable, patients may be able to be switched to oral antibiotics after 48 72 hours. C O N T I N U I N G E D U C A T I O N P R O G R A M

7. Antibiotic therapy should be continued until the patient has been afebrile for at least 48 hours. 8. Which of the following statements is FALSE? Patients who do not respond to antibiotic therapy: a. Typically have poor outcomes. b. Should be evaluated for viral or fungal pathogens. c. Do not have a bacterial infection. d. May require additional antibiotic therapy. e. May require bronchoscopy. 9. Which of the following statements is (are) FALSE. Switch therapy: a. Refers to using the same antibiotic, initially as IV and switching to oral therapy. b. Refers to using one antibiotic intravenously at first, then switching to an oral drug from another class of antibiotic. c. Provides opportunities for decreased total cost of care. d. Is an option for patients who are febrile but improving symptomatically. e. a and c. f. b and d. g. a and d. PLEASE CUT OFF BOTTOM PORTION 10. Pneumovax is an important component of preventive therapy for CAP. ANSWERS Vol 7: Community-acquired Pneumonia Mark answers below to receive continuing education credit. 1. a b c d e f 2. a b 3. a b 4. a b 5. a b c d e f g 6. a b 7. a b 8. a b c d e 9. a b c d e f g 10. a b To obtain continuing education credit, please complete information in full. Please print clearly. Name: Address: City: State: Zip: License Number: (required to receive CEs) RN LPN Certified Case Manager Employer: Work Phone: Coram Representative: Date: Return to: Coram s Healthline 12450 E. Arapahoe Rd, Suite A Centennial, CO 80112 CEDept@coramhc.com Fax: 949.462.8990 Coram, LLC offers other continuing education booklets on home care topics. Call your Coram representative for more information. Was this material: Useful in your practice? Yes No Comprehensive enough? Yes No Well organized? Yes No I would like my certificate emailed to me at: (ex: john.smith@coramhc.com) I would like my certificate mailed to the address provided above. COR16026-0614 VOLUME NO. 7

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