CARE OF THE ADULT PNEUMONIA PATIENT

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1 Care Guideline CARE OF THE ADULT PNEUMONIA PATIENT Target Audience: The target audience for this Care Guideline is all MultiCare providers and staff, including those associated with our clinically integrated network. The secondary audience includes clinical support staff in these areas: Pharmacy, Nursing, Imaging, Lab, Care Management, Transitions of Care, and Respiratory Therapy. Scope/Patient Population: This guideline applies to all adult patients in MultiCare s adult hospitals to include Tacoma General, Allenmore, Good Samaritan, Auburn Medical Center and all MultiCare Health System s primary care and urgent care clinics. The target patient population includes Community Acquired Pneumonia (CAP), Aspiration Pneumonia, Hospital Acquired Pneumonia (HAP), and Ventilator Associated Pneumonia (VAP). Rationale: Pneumonia and influenza together are ranked as the eighth leading cause of death in the United States. Pneumonia consistently accounts for the overwhelming majority of deaths between the two. In 2006, 55,477 people died of pneumonia. (American Lung Association) The inpatient Community Acquired Pneumonia (CAP) algorithm is designed to guide providers to the appropriate, evidence-based therapy choice. The HAP and VAP algorithm has been updated to reflect new 2016 clinical practice guidelines from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS). The Community Acquired Pneumonia with a Drug Resistance Pathogen Risk algorithm is based on a combination of recent literature, expert infectious disease opinion, and local susceptibility patterns and represents a progressive, algorithm-based approach to the selection of antibiotic therapy stratified by the patient s severity of illness and overall risk factors for a drug resistant pathogen. The outpatient Community Acquired Pneumonia (CAP) algorithm is based on risk from a CURB- 65 Score. If the patients are engaged and involved with their care by use of tools, the outcomes will be improved. Objective: Reduce the mortality rate associated with pneumonia and rates of both admission and readmission to healthcare facilities when avoidable. This will decrease the cost per case, and maintain or improve the length of stay required to treat pneumonia. Page 1 of 8 Care of the Adult Pneumonia Patient Care Guideline

2 Standardize and improve appropriate antibiotic treatment for Pneumonia patients at all MultiCare entities by providing the correct dosage and proper adjustments for weight, allergies, resistant organisms, and renal function using a single, validated order set. Recommendations: Disclaimer: The below Care Guideline serves as a reference for health care professionals and patients within the MultiCare Connected Care affiliated network. The guideline provides an evidence-based* framework for evaluating, treating or preventing various health conditions. The guideline is not meant to replace clinical judgment of individual providers and is not meant for all circumstances. * The process of determining evidence based criteria involves the review of peerreviewed literature and nationally published guidelines in the open literature where there is evidence supporting these recommendations. When possible, along with the reference, the original literature or links are provided to provide accurate assignment of original authorship. Antibiotic Treatment Choices: Based on Severity, Description and Decision to Admit to Hospital Community Acquired Pneumonia (CAP) Outpatient Treatment Previously healthy with no risk o Macrolide factors for drug-resistant S. pneumoniae o Doxycyline if patient has known QT interval prolongation or risk factors Comorbidity or risk factor for o Macrolide +Beta-lactam drug resistant S. pneumoniae o Levofloxacin Community Acquired Pneumonia (CAP) Inpatient Treatment Non-ICU o (Ceftriaxone OR Unasyn) + (Azithromycin OR Doxycycline) o Levofloxacin ICU o Ceftriaxone + (Azithromycin OR Doxycycline) o Ceftriaxone + Levofloxacin Aspiration Suspected o Unasyn +/- Azithromycin o Ceftriaxone + Metronidazole +/- Azithromycin o Cefoxitin +/- Azithromycin o Clindamycin (only if beta-lactam allergy and not septic) +/- Azithromycin MRSA Risk o Vancomycin o Linezolid CURB 65 and CRB-65 Severity Scores for Community Acquired Pneumonia Clinical Factor Points Confusion 1 Page 2 of 8 Care of the Adult Pneumonia Patient Care Guideline

3 Blood urea nitrogen > 19 mg per dl 1 Respiratory rate 30 breathes per minute 1 Systolic blood pressure < 90 mm Hg Or Diastolic blood pressure 60 mm Hg Age 65 years 1 Total Points: 1 CURB Score> 2, Then Recommend Admission Community-Acquired Pneumonia with Drug Resistant Pathogen Risks (formerly HCAP) 0 1 Multi-drug resistant (MDR) (no sepsis or o Ceftriaxone + (Azithromycin OR Doxycycline) non-severe sepsis) 0 1 MDR Risk Factor (severe sepsis and/or immunosuppression) o Levofloxacin o Ceftriaxone + (Azithromycin OR Doxycycline OR Levofloxacin) If Immunosuppressed: o (Zosyn OR Cefepime OR Meropenem) + (Azithromycin or Doxycycline) 2 MDR risk factors (non-severe sepsis * o (Zosyn OR Cefepime OR Meropenem) + (Azithromycin OR Ciprofloxacin) 2 MDR risk factors (severe sepsis) * o (Zosyn OR Cefepime OR Meropenem) + (Ciprofloxacin OR IV Tobramycin) High or Known MRSA Risk o Vancomycin o Linezolid * Reserve double gram negative coverage for patients with history of MDR gram negative infection, and/or severe structural lung disease with immunosuppression MDR Pathogen Risk Factors IV or broad-spectrum antibiotics in past 90 days Poor functional status (i.e. significant debilitation and/or inability to perform ADLs) in a non-skilled nursing facility (SNF) resident Hospitalized > 2 days in past 90 days SNF resident Immunosuppression (ANC <1,000, asplenia, hematologic malignancy, prednisone equivalent >10 mg daily for 2+ weeks, congenital immunodeficiency, HIV, other immunosuppressive medication therapy) Colonization with known MDR pathogen (outside of the urinary tract) Structural lung disease in combination with any of the above Page 3 of 8 Care of the Adult Pneumonia Patient Care Guideline

4 Hospital-acquired pneumonia (HAP) and Ventilator-associated pneumonia (VAP) Early Onset HAP (day 0-4 of o Ceftriaxone admission, no high risk o Levofloxacin criteria, see below) Late onset HAP (day 5+ of o (Cefepime OR Zosyn OR Meropenem) admission) +/- (Ciprofloxacin OR IV Tobramycin) Decision to double cover gram negatives should be based on clinical judgement, considering the patient s severity of illness, duration of hospitalization, recent antibiotic exposure, and comorbities. HAP High Risk Criteria Mechanical ventilation Septic shock Structural lung disease IV antibiotics within 90 days One or more MDR risk factors Discharge Criteria Do not routinely discharge patients with communityacquired pneumonia if in the past 24 hours they have had 2 or more of the following findings: temperature higher than 37.5 C respiratory rate 24 breaths per minute or more heart rate over 100 beats per minute systolic blood pressure 90 mmhg or less oxygen saturation under 90% on room air upon ambulation abnormal mental status inability to eat without assistance Chronic co-morbid conditions are stabilized e.g. heart failure patient provider may consider BNP prior to discharge to ensure exacerbation has not occurred due to pneumonia treatments Unable to obtain transportation to follow-up provider after discharge or prescriptions, inhalers or oxygen where appropriate. Algorithm: Appendix A Evidence: Reference Document: 1. IDSA and ATS Consensus Guideline on Community Acquired Pneumonia 2. IDSA and ATS Consensus Guideline on Hospital Acquired and Ventilator-associated Pneumonia Other References: Page 4 of 8 Care of the Adult Pneumonia Patient Care Guideline

5 1. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults with Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis Sep 1;63(5):e61-e Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and metaanalysis. Clin Infect Dis Feb;58(3): Ewig S, Welte T, Torres A. Is healthcare-associated pneumonia a distinct entity needing specific therapy? Curr Opin Infect Dis Apr;25(2): Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Disease Society of American/American Thoracic Society consensus guidelines for the management of community acquired pneumonia in adults. Clin. Infect Dis 2007; 44:S Maruyama T, Fujisawa T, Okuno M, et al. A new strategy for healthcare-associated pneumonia: a 2-year prospective multicenter cohort study using risk factors for Multidrugresistant pathogens to select initial empiric therapy. Clin Infect Dis.2013 Nov;57 (10): Park SC, Kim EY, Kang YA, Park MS, Kim YS, Kim SK, Chang J, Jung JY. Validation of a scoring tool to predict drug-resistant pathogens in hospitalized pneumonia patients. Int J Tuberc Lung Dis May;17(5): Infectious Disease Society of America (IDSA); American Thoracic Society (ATS) List of Implementation Items and Patient Education: 1. SmartText Pneumonia discharge instructions and tip sheet a. MHS IP PNEUMONIA DISCHARGE INSTRUCTIONS 2. MHS IP PNEUMONIA CARE PLAN 3. MHS Pneumonia Admission Order Set # Patient Handout: Red/Yellow/Green Patient Action Plan form # (11/14) is available from MHS print shop. Page 5 of 8 Care of the Adult Pneumonia Patient Care Guideline

6 Metrics Plan: 1. Increase the composite index score of the Pneumonia NOREADMITS bundle to 70% by end of year Reduce Pneumonia Readmissions to less than or equal to 11.78% by end of year PDCA Plan: This Care Guideline will be reviewed by the Medicine Collaborative on a bi-annual review cycle. Point of Contact: Medical Lead of the Medicine Collaborative Approval By: MMA Clinical Quality & Compliance Committee Urgent Care Collaborative Emergency Department Provider Meeting MultiCare Inpatient Specialist Meeting Sound Inpatient Providers Medical Imaging Northwest Date of Approval: 08/ / / / / /2014 Page 6 of 8 Care of the Adult Pneumonia Patient Care Guideline

7 Pharmacy and Therapeutic Committee MHS Nurse Executive Committee ESOC Auburn Medical Executive Committee TG/AH Medical Executive Committee Good Samaritan Medical Executive Committee Medicine Collaborative Tacoma MEC Ops Committee Original Date: Revision Dates: Reviewed with no Changes Dates: 09/ / / / / / / / / /2017 X/XX Distribution: MultiCare Connected Care + MultiCare Health System Page 7 of 8 Care of the Adult Pneumonia Patient Care Guideline

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Care Guideline DRAFT for review cycle 08/02/17 CARE OF THE ADULT PNEUMONIA PATIENT

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