Individualize Therapy for Healthcare-Associated Pneumonia

Troy Brown

April 26, 2012

April 26, 2012 (San Diego, California) — Patients with healthcare-associated pneumonia might not need as many antibiotics as was once believed, according to a presentation here at Hospital Medicine 2012: Society of Hospital Medicine Annual Meeting.

Scott Flanders, MD, SFHM, clinical professor in the Department of Internal Medicine at the University of Michigan in Ann Arbor, discussed evidence-based strategies for treating patients with healthcare-associated pneumonia.

Risk Factors

Risk factors for healthcare-associated pneumonia, outlined by Dr. Flanders, are home intravenous (IV) therapy, wound care, or nursing care from a home health agency; dialysis or any IV treatment in a hospital or dialysis clinic in the previous 30 days; hospitalization for 2 or more days in the previous 90 days; and residing in a nursing home or long-term care facility.

These patients are at risk for multidrug-resistant organisms and need coverage for those organisms, said Dr. Flanders. However, it is important to individualize therapy to avoid overkill, he explained.

Some of the risk factors for healthcare-associated pneumonia — recent perfusions, specifically receiving IV infusions or dialysis in a clinic and receiving wound care — are not strong predictors of resistant organisms.

In an interview with Medscape Medical News, Dr. Flanders said that after "looking at risk factors for isolating a multidrug-resistant organism that warrants broad-spectrum coverage, there are variable levels of predictability.... In patients who have very few of these risk factors, there's a low risk of isolating a resistant organism; it's probably overkill to give those patients broad-spectrum therapy.... When people have multiple risk factors for a resistant organism, the literature suggests that they do better with broad-spectrum coverage, and most of it recommends you cover for a multidrug-resistant organism."

Arjun Srinivasan, MD, FSHEA, associate director for healthcare-associated infection prevention programs in the division of healthcare quality promotion at the Centers for Disease Control and Prevention in Atlanta, Georgia, discussed the issue with Medscape Medical News. "There are a couple of really important opportunities that physicians who are taking care of patients with healthcare pneumonia have to improve the way we treat [these patients]. The first is to make sure that we get proper cultures before we start treatment.... Healthcare pneumonia is one of those conditions where microbiologic data to guide therapy are critically important because there are so many different things that can cause pneumonia in hospitalized patients. I would say that's the first really important opportunity" for improving the treatment of healthcare-associated pneumonia, said Dr. Srinivasan.

Deescalating Antibiotic Treatment

Dr. Flanders explained that eliminating unnecessary antibiotics is important, and that patients should be reevaluated 48 to 72 hours after the initiation of antibiotic therapy.

He noted that "in most patients who warrant initial broad-spectrum antibiotic therapy, there are a lot of opportunities to minimize that antibiotic use after about 48 to 72 hours. [Then] you have a chance to see if the patient [has] improved. Are they doing better? Have I isolated an organism?"

"I think we should have a 48- to 72-hour time out, and then ask: 'Have I grown something that's susceptible to an oral antibiotic, as opposed to IV? Can I get them from 3 drugs down to 1 drug?" Dr. Flanders said. "In particular, if they've gotten better, and you haven't grown anything at all, maybe you consider an alternative diagnosis like heart failure." Perhaps you can use that time period to make the decision to stop antibiotics.

"Those are the key points — risk stratify and then rethink after 2 or 3 days whether they need all these broad-spectrum antibiotics," he said.

"It's important to critically assess how long we give antibiotics for when we're treating patients with healthcare-acquired pneumonia. We used to treat patients for very long times, [but] there is an increasing body of evidence suggesting that those very long treatment durations were not necessary," Dr. Srinivasan noted.

"One great example of that is a study a few years ago that showed that for ventilator-associated pneumonia, 8 days of therapy is highly effective in most circumstances....which is much shorter" than the 14 or even 21 days we had been doing, he explained.

"Making sure that we are looking at the duration of therapy and working to make that duration consistent with another opportunity for improvement," Dr. Srinivasan said.

Proton Pump Inhibitors Increase Risk for Pneumonia

There is a fairly large body of evidence that suggests that patients taking proton pump inhibitors at are increased risk of developing pneumonia. Dr. Flanders explained that proton pump inhibitors and H2 blockers decrease gastric acidity. Several studies of hospitalized patients have shown that this leads to bacterial overgrowth in the stomach and oropharyngeal cavity.

All pneumonia is basically aspiration pneumonia, and this bacterial overgrowth is thought to contribute to the development of pneumonia, he added.

There is additional literature linking proton pump inhibitors to increased risks for hip fracture, Clostridium difficile, and mortality in elderly residents of nursing homes. These are ample reasons to not overuse proton pump inhibitors in hospitalized patients, Dr. Flanders said.

The authors have disclosed no relevant financial relationships.

Hospital Medicine 2012: Society of Hospital Medicine (SHM) Annual Meeting. Presented on April 3, 2012.