HM14 Special Report: Pneumonia State-of-the-Art Practice that Improves Outcomes

Presenters: Scott Flanders, MD, FACP, MHM

Summation: Patients with pneumonia often represent the most common DRG for hospitalist groups. Pneumonia process/outcome measures for hospitals are publicly available on CMS Hospital Compare website, so optimizing care of this patient group has never been more important.

Key Takeaways

Use risk assessment scores to stratify patients. Examples of widely used scoring systems favored by this speaker are: Pneumonia Severity Index (PSI) and CURB 65. Neither scoring system is reliable for HCAP or influenza.
Antibiotic Therapy: Follow the Guidelines to Meet the Quality Measure. CAP- IDSA/ATS 2007 + modifications
- Which patients are at risk for pseudomonas? Bronchiectasis; structural lung disease (COPD/ILD); AND documented history of repeated antibiotics or long-term chronic steroids in past 3 months

Does Azithromycin kill patients? Yes, some patients (high cardiovascular risk patients) and under particular circumstances (during treatment period and when on other medications that also prolong the QT interval). Remember that doxycycline is an option for high cardiovascular risk patients when atypicals are suspected- and doxycycline may protect against C.difficile infection.
Stopping antibiotics: Rx >7days not better than Rx=7days (or less), patients would be afebrile for 48-72 hrs. Deescalate therapy quickly when cultures are negative.
Aspiration Pneumonia:
- All pneumonia is essentially aspiration pneumonia.
- When patients have no risk factors for multi drug resistant organisms then treat as CAP (ex. ceftriaxone + macrolide or doxy).
- When patients have risk factors for multi drug resistant organisms: Vanco + Pip/Tazo (+/- macrolide/doxy) or Vanco + resp. fluoroquinolone.
- For patients with risk factors for anaerobes add clindamycin, unless patient already on Pip/Tazo, in which case clindamycin adds no additional benefit.
- It is difficult to differentiate aspiration pneumonia from pneumonitis- when patients improve within 48 hours, consider discontinuing antibiotics in <5 days.
HCAP: Strong risk factors for resistant organisms: prior hospitalization within 90 days, LTAC/SNF IF prior abx or poor functional status, critically ill, prior MRSA or Pseudomonas, bronchiectasis/COPD (specifically recurrent abx or chronic steroids).
Blanket coverage for resistant organisms in all patients unnecessary- risk stratify and customize therapy AND document.

Julianna Lindsey, MD MBA FHM is a Principal, COO & Strategist for Synergy Surgicalists, and a member of Team Hospitalist.

All Content

HM14 Special Report: Pneumonia State-of-the-Art Practice that Improves Outcomes

Which patients are at risk for pseudomonas? Bronchiectasis; structural lung disease (COPD/ILD); AND documented history of repeated antibiotics or long-term chronic steroids in past 3 months

All pneumonia is essentially aspiration pneumonia.

When patients have no risk factors for multi drug resistant organisms then treat as CAP (ex. ceftriaxone + macrolide or doxy).

When patients have risk factors for multi drug resistant organisms: Vanco + Pip/Tazo (+/- macrolide/doxy) or Vanco + resp. fluoroquinolone.

For patients with risk factors for anaerobes add clindamycin, unless patient already on Pip/Tazo, in which case clindamycin adds no additional benefit.

It is difficult to differentiate aspiration pneumonia from pneumonitis- when patients improve within 48 hours, consider discontinuing antibiotics in <5 days.

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