ALiEMU Capsules Module 9: Hospital Acquired Pneumonia

2017-10-01T21:07:02+00:00

We are proud to present CAPSULES Module 9: Hospital Acquired Pneumonia (HAP), now published on ALiEMU. Here is a summary of the key points from a stellar module by Drs. Jamie Rosini and Matt Stanton. When you’re finished, head over to the Capsules page for even more practical pharmacology for the EM provider.

Course Contributors

Role Team Member Background
Authors Jamie M. Rosini, PharmD, MS, BCPS, BCCCP, DABAT @jrozzini Clinical Pharmacy Specialist, Emergency Medicine; Christiana Care Health System
Matthew Stanton, PharmD, BCPS, SPI, DABAT @RxMilwaukee Emergency Medicine Pharmacist; Froedtert & The Medical College of Wisconsin
Craig Cocchio, PharmD, BCPS @iEMPharmD Emergency Medicine Pharmacist, Trinity Mother Frances Hospital
PharmD Reviewers Chris Edwards, PharmD, BCPS @emergencypharm Emergency Medicine Pharmacist, University of Arizona Medical Center
Cole Sloan, PharmD @DrugInfoGeek Emergency Medicine Pharmacist, University of Utah
Physician Reviewer Michael Winters, MD FAAEM, FACEP @critcareguys Associate Professor of Emergency Medicine and Internal Medicine, University of Maryland
Copy Editor Meghan Groth, PharmD, BCPS @EMPharmgirl Emergency Medicine Pharmacist, UMass Memorial Medical Center
Associate Editor  Nadia Awad, PharmD, BCPS @Nadia_EMPharmD  Emergency Medicine Pharmacist, Robert Wood Johnson University Hospital

Summary: Hospital-Acquired Pneumonia

In the era of multi-drug resistant bacteria and promotion of quality antimicrobial stewardship, treatment of pneumonia can be a challenging task. This timely CAPSULE discusses the recent update by the Infectious Diseases Society of America (IDSA) guidelines and will assist the reader in risk-factor identification for HAP patients and appropriate antibiotic treatment.

2016 IDSA Guidelines Update

Antibiotic management in patients presenting to the ED with possible pneumonia can be challenging. The new IDSA guidelines for hospital-acquired/ventilator-associated (HAP/VAP) address risk factors for multi-drug resistant (MDR) organisms and methicillin-resistant Staphylococcus aureus (MRSA). The guidelines remove the term ‘healthcare-associated pneumonia.’ Risk stratification can assist with antibiotic decisions. This module focuses on HAP only.

Bugs and Drugs: Identifying Potential Organisms and Optimizing Treatment

Empiric treatment should utilize facility-specific antibiograms and cover the 2 most common pathogens associated with HAP: P. aeruginosa and S. aureus. The use of 2 beta-lactams should be avoided as well as aminoglycoside monotherapy.

CAPSULE: Antibiotic Selection for Hospital Acquired Pneumonia
All patients with suspected HAP should receive an antibiotic that covers Pseudomonas and MSSA, with additional/modified coverage for MRSA or other resistant Gram negative organisms depending on risk factors.

1 Antibiotic Is Good, But 2 Must Be Better?

P. aeruginosa is associated with a high mortality rate and rapid disease progression. As such, every HAP treatment regimen should include pseudomonal coverage. However, monotherapy is appropriate for patients not considered high risk for death. Theoretical advantages of double coverage for pseudomonal infections include in vitro synergy, avoidance of emerging bacterial resistance on therapy, and enhanced adequacy of the empiric regimen with at least 1 active agent.

CAPSULE: Risk factors warranting empiric double coverage for Pseudomonas
  • IV antibiotics within 90 days
  • Structural lung disease
  • High risk of mortality

Over-Diagnosing or Under-Treating: To Add or Not Add MRSA Coverage?

MRSA pneumonia can be over-diagnosed if contamination cannot be distinguished from true infection. The Shorr score – an MRSA risk-stratification tool –  can be used to determine if MRSA coverage is warranted.1 The increase in antimicrobial resistance underscores how important it is to review past culture data for more resistant Gram-negative pathogen coverage.

Capsule: Risk factors warranting MRSA coverage
  • IV antibiotics within 90 days
  • Clinical unit has >20% methicillin resistance in S. aureus isolates
  • Prior history of MRSA by culture or non-culture screening
  • Prevalence of MRSA unknown
  • High risk of mortality
  • Mechanical ventilation
  • Septic shock
Capsule: Review past culture data
Past culture data should be reviewed if available to determine the need for coverage of more resistant Gram-negative pathogens.

What is the Capsules series?

ALiEMU Capsules is a free, online e-curriculum of high-quality, current, and practical pharmacology knowledge for the EM practitioner. About once a month a new course module is released, which has lessons to read about (or watch) and brief quizzes to complete. With each step, your personal dashboard will keep track of what you have completed. The Capsules series’ primary focus is bringing EM pharmacology education to the bedside. Our expert team distills complex pharmacology principles into easy-to-apply concepts. It’s our version of what-you-need-to-know as an EM practitioner.

1.
Shorr A, Myers D, Huang D, Nathanson B, Emons M, Kollef M. A risk score for identifying methicillin-resistant Staphylococcus aureus in patients presenting to the hospital with pneumonia. BMC Infect Dis. 2013;13:268. [PMC]

Bryan D. Hayes, PharmD, FAACT, FASHP

Bryan D. Hayes, PharmD, FAACT, FASHP

Chief Science Officer, ALiEM
Creator and Lead Editor, Capsules series, ALiEMU
Attending Pharmacist, EM and Toxicology, MGH
Assistant Professor of EM, Harvard Medical School