Preventing and Treating Community-Acquired Pneumonia

Transcription

1 PL Detail-Document # This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER June 2015 Preventing and Treating Community-Acquired Pneumonia --The chart below provides practical tips and resources to help prevent and treat pneumonia, and prevent hospital admission and readmission.-- Abbreviations: CDC = Centers for Disease Control and Prevention; COPD = Chronic Obstructive Pulmonary Disease; PCR = Polymerase Chain Reaction Prevent and treat influenza. Vaccinate all patients six months and older, including pregnant women, yearly. 1,2 Get vaccinated yourself, to set a good example for patients and coworkers. Get mobile apps to help you easily find the CDC s latest recommendations regarding flu prevention, treatment, and diagnosis, and national flu activity at Choose the right flu vaccine for the patient. Get our PL Special Report, Influenza Immunization Update for 2014 (U.S.). Get our PL Charts, Influenza Vaccines for (U.S.); Flu Vaccines (Canada), for help sorting out the available vaccines. Canadians can get information and materials to educate health care professionals about flu vaccination and other preventive actions from the Public Health Agency of Canada at Provide immunization in your pharmacy. U.S. subscribers can get our PL Detail-Document, Pharmacy Immunization Clinics: Making It Happen, for help getting started. Encourage use of influenza vaccine standing orders. An example is available at Educate patients about flu prevention. Get materials to educate patients about flu vaccination and other preventive actions from the CDC at Includes posters, fact sheets, stickers, brochures, ecard reminders, and more. Canadians can get information and materials to educate patients about flu vaccination and other preventive actions from the Public Health Agency of Canada at Vaccinate eligible patients against pneumonia. Continued Routinely vaccinate healthy infants and children against pneumonia per the childhood vaccination schedule. Immunocompromised children or children with certain chronic conditions may need both Prevnar 13 and Pneumovax 23. 5,11 Give people 65 and over Pneumovax 23 AND Prevnar 13 vaccines (CDC). 3 (In Canada, only Pneumovax 23 recommended.) 4

2 (PL Detail-Document #310618: Page 2 of 7) Vaccinate against pneumonia, continued Check for adults UNDER 65 who need one or both pneumococcal vaccines. Those who smoke (CDC) or have certain chronic conditions (CDC, Health Canada) will need Pneumovax 23. 3,4 Immunocompromised patients will need both vaccines. 3,4 To find out who gets what and when, see our PL Charts of adult (U.S.)(Canada) and pediatric (Canada) pneumococcal vaccination recommendations. Screen for pneumonia vaccine eligibility when patients present for their flu shot. They can be given at the same visit. 1,2 Encourage adults to document their pneumonia vaccination history on their med list to prevent duplication. Encourage use of pneumonia vaccine standing orders. An example is available at Educate patients about pneumonia and pneumonia vaccination. Get information for patients about pneumonia and pneumonia vaccination from the CDC at and from the Public Health Agency of Canada at Get a pneumococcal vaccine waiting room poster and fact sheets about pneumococcal disease and vaccination for patients and parents from the CDC at Help patients quit smoking. Get our PL Special Report, Clearing the Air: How to Help Patients Quit Smoking. Get our PL Chart, Smoking Cessation Drug Therapy, for help choosing smoking cessation pharmacotherapy. Includes the Fagerstrom Nicotine Tolerance Scale. Control high-risk chronic diseases that put patients at risk for pneumonia. Asthma Dose asthma medications correctly. Get our PL Chart, Comparison of Inhaled Asthma Meds (U.S. Subscribers)(Canadian Subscribers), for help. Our PL Toolbox, Improving Asthma Care, suggests strategies and resources to educate patients, ensure patients are on the right medications for their disease severity, treat exacerbations, and meet other therapeutic goals. Get the National Heart, Lung, and Blood Institute s National Asthma Education and Prevention Program at Canadian asthma guidelines are available from the Canadian Thoracic Society at and The Global Initiative for Asthma Management and Prevention is available at

3 (PL Detail-Document #310618: Page 3 of 7) COPD Get our PL Toolbox, Improving COPD Care, for suggested strategies or resources to educate patients, ensure patients are on the best medications for their disease severity, treat exacerbations, and meet other therapeutic goals. Get COPD guidelines from the Global Initiative for Chronic Obstructive Lung Disease at Guidelines for prevention of acute COPD exacerbations from the American College of Chest Physicians and the Canadian Thoracic Society are available at Diabetes See our PL Toolbox for Improving Diabetes Outcomes, for practical tips and resources to help care for your diabetes patients. Get our PL Algorithm, Initiation and Adjustment of Insulin Regimens for Type 2 Diabetes (U.S. Subscribers)(Canadian Subscribers). Get our PL Chart, Comparison of Insulins and Injectable Diabetes Meds (U.S. Subscribers)(Canadian Subscribers). Heart Failure Get our PL Toolbox for Improving Heart Failure Care, for target doses of heart failure meds, tools to help educate patients, and other resources to improve patient care and prevent readmissions. Empower pneumonia patients for outpatient selfcare, help them identify when to seek additional care, and help them prevent future episodes. Give patients our customizable PL Patient Education Handout, What I Need to Know About Pneumonia. Give inpatients, at hospital discharge, a customizable patient handout Taking Care of Myself, a Guide for When I Leave the Hospital, from the Agency for Healthcare Research and Quality at Get patient information about pneumococcal disease from the CDC at Get patient information about community-acquired pneumonia from the National Library of Medicine at Triage patients for possible hospital admission. Continued Utilize pneumonia severity tools to help determine if outpatient treatment is appropriate: Get the Pneumonia Severity Index calculator at Get the CURB-65 and CRB-65 Severity Scores at Consider admission for children with respiratory compromise, poor oral intake, unreliable home

4 (PL Detail-Document #310618: Page 4 of 7) Triage patients, continued circumstances, complicated pneumonia, a particularly virulent suspected pathogen, or age less than six months. 17,18 Get Improving Treatment Decisions for Patients with Community-Acquired Pneumonia from the Agency for Healthcare Research and Quality at Choose appropriate antibiotics. Continued Get our PL Chart, Outpatient Treatment of Community-Acquired Pneumonia in Adults. For adult inpatients, not in the ICU, choose: 6 A respiratory quinolone (e.g., moxifloxacin, levofloxacin) OR Beta-lactam (cefotaxime, ceftriaxone, ampicillin, or ertapenem) PLUS either a macrolide or doxycycline for atypical coverage For adult intensive care patients, choose: 6 A beta-lactam (cefotaxime, ceftriaxone, or ampicillin/sulbactam) PLUS either a respiratory quinolone (e.g., moxifloxacin, levofloxacin) or azithromycin for atypical coverage If beta-lactam allergic, use aztreonam PLUS a respiratory quinolone (e.g., moxifloxacin, levofloxacin) OR If Pseudomonas is a concern, an antipneumococcal/antipseudomonal beta-lactam (piperacillin/tazobactam, cefepime, imipenem, or meropenem) PLUS either ciprofloxacin or levofloxacin; OR the above beta-lactam PLUS an aminoglycoside PLUS azithromycin; OR the above beta-lactam PLUS an aminoglycoside PLUS a respiratory quinolone. If beta-lactam-allergic, substitute aztreonam. ADD vancomycin or linezolid if community-acquired methicillin-resistant Staph is of concern In otherwise healthy pediatric patients, amoxicillin is recommended first-line in outpatients to cover S. pneumoniae, the most common bacterial pathogen. 17,18 Our PL Chart, Empiric Treatment for Pediatric Community-Acquired Pneumonia, provides dosing for amoxicillin and other recommendations from the Infectious Diseases Society of America. The Canadian Paediatric Society recommends an amoxicillin dose of 40 to 90 mg/kg/day divided three times daily (max total daily dose 4000 mg). 17 Use beta-lactams when appropriate. Most penicillin-allergic patients can take cephalosporins. The Canadian Paediatric Society suggests that cefprozil, cefuroxime, or ceftriaxone can be used in penicillin-allergic patients; however, if the reaction was urticaria, angioedema, bronchospasm, or hypotension, the patient should be observed for 30 min after the first dose, with epinephrine available. 17 Get our PL Chart, Beta-Lactam Allergy: FAQs, for a review of treatment considerations in penicillin-allergic patients.

5 (PL Detail-Document #310618: Page 5 of 7) Choose appropriate antibiotics, continued Fine-tune the treatment spectrum as soon as possible. Use macrolides only when indicated, due to the growing incidence of macrolide-resistant Streptococcus pneumoniae. Use a beta-lactam plus a macrolide, or a respiratory quinolone (e.g., levofloxacin): In areas where S. pneumoniae macrolide resistance is over 25%. 6 If the patient has comorbidity or risk factor for resistance: use of a broad spectrum antibiotic in the previous three months, age over 65, alcoholism, chronic disease, exposure to a child in day care, or immunosuppression. 6 For a review of the role of macrolides in respiratory infections, get our PL Detail-Document, Should Macrolides Be Used for Respiratory Tract Infections? If available, perform urinary antigen test for Legionella in patients who: have failed outpatient treatment, have severe pneumonia, have traveled in the previous two weeks, abuse alcohol, have a pleural effusion, are immunocompromised, or who present with pneumonia in the setting of a legionellosis outbreak. 6,14 100% specific for L. pneumophila serogroup 1 (Lp1), which may account for 80% of cases. 15 Test for flu if suspected in hospitalized patients. 13 In outpatients, flu can be diagnosed based on symptoms if flu is circulating. 13 If available, use the pneumococcal urinary antigen test in hospitalized patients who: have failed outpatient treatment, have severe pneumonia, are leukopenic, abuse alcohol, have severe chronic liver disease, are asplenic, or have a pleural effusion. 6 Consider PCR assays (e.g., for Mycoplasma pneumoniae, Chlamydia pneumoniae, and respiratory viruses), keeping in mind that detection of a virus does not exclude bacterial pneumonia; patients may be co-infected. 16 Consider checking a procalcitonin level. A level of 0.25 mcg/l or higher suggests typical bacteria or Legionella. 16 Note that these rapid tests are not a substitute for blood and sputum cultures, when indicated. 6 Expect improvement in children with bacterial pneumonia within 48 hrs (e.g., increased appetite, decreased fever, improved breathing, etc). If there is no improvement, or the patient worsens, look for complications (e.g., get a chest x-ray or ultrasound to look for an abscess, etc) or other reason for poor response. 17 Prevent interactions with antibiotics. See our PL Chart, Antimicrobial Drug Interactions and Warfarin, for help preventing and managing warfarin interactions. Our PL Charts, Cytochrome P450 Drug Interactions and P-glycoprotein Drug Interactions, can help you check for interactions. For help identifying drugs or combos that may increase torsades risk, see our PL Chart, Drug-Induced Long QT Interval.

6 (PL Detail-Document #310618: Page 6 of 7) Ensure patients stay on their medications. See our PL Chart, Medication Adherence Toolbox. See our PL Patient Education Handout, Tips for Sticking With Your Meds. Restrict use of meds associated with increased pneumonia risk. Prevent avoidable hospital readmissions. Use medications associated with increased pneumonia risk (e.g., proton pump inhibitors, inhaled corticosteroids, benzodiazepines, antipsychotics, anticholinergics) only when clearly needed. 7-10,12 See our PL Toolbox, Reducing Hospital Readmissions. This document includes information about providing and billing for transitional care and chronic care management services. Call the patient within two business days of discharge, and see patient within a week of discharge from the hospital. Ensure patient s chronic illnesses are tuned up. Review current med list and assess adherence. Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and internet links in this article were current as of the date of publication.

7 (PL Detail-Document #310618: Page 7 of 7) Project Leader in preparation of this PL Detail- Document: Melanie Cupp, Pharm.D., BCPS References 1. Centers for Disease Control and Prevention (CDC). Influenza vaccination: a summary for clinicians. September 9, (Accessed April 30, 2015). 2. Public Health Agency of Canada. National Advisory Committee on Immunization (NACI). Statement on seasonal influenza vaccine for An Advisory Committee Statement (ACS). (Accessed April 30, 2015). 3. CDC. PCV13 (pneumococcal conjugate) vaccine. Recommendations, scenarios and Q&A for healthcare professionals about PCV13 for adults. Last reviewed/updated December 10, PCV13-adults.htm. (Accessed April 30, 2015). 4. Public Health Agency of Canada. An Advisory Committee Statement (ACS). National Advisory Committee on Immunization (NACI). Statement on the use of conjugate pneumococcal vaccine-13 valent in adults (PNEU-C-13). Can Commun Dis Rep 2013;39(ACS-5): Public Health Agency of Canada. Canadian Immunization Guide. Pneumococcal vaccine. March 24, (Accessed April 30, 2015). 6. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S Obiora E, Hubbard R, Sanders RD, Myles PR. The impact of benzodiazepines on occurrence of pneumonia and mortality from pneumonia: a nested case-control and survival analysis in a populationbased cohort. Thorax 2013;68: PL Detail-Document, Proton Pump Inhibitors: Appropriate Use and Safety Concerns. Pharmacist s Letter/Prescriber s Letter. May Suissa S, Patenaude V, Lapi F, Ernst P. Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax 2013;68: Aparasu RR, Chatterjee S, Chen H. Risk of pneumonia in elderly nursing home residents using typical versus atypical antipsychotics. Ann Pharmacother 2013;47: CDC. Pneumococcal vaccination who needs it? February 2, (Accessed April 30, 2015). 12. Paul KJ, Walker RL, Dublin S. Anticholinergic medications and risk of community-acquired pneumonia in elderly adults: a population-based case-control study. J Am Geriatr Soc 2015;63: CDC. Guidance for clinicians on the use of rapid influenza diagnostic tests. Updated November 13, an_guidance_ridt.htm. (Accessed May 13, 2015). 14. CDC. Top 10 things every clinician needs to know about legionellosis. February 5, (Accessed May 13, 2015). 15. CDC. Legionella (Legionnaires disease and Pontiac fever). Advantages and disadvantages of diagnostic tests. June 2, (Accessed May 13, 2015). 16. Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med 2014;371: Le Saux N, Robinson JL, Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Uncomplicated pneumonia in healthy Canadian children and youth: practice points for management. Paediatr Child Health 2015;20: Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and Infectious Diseases Society of America. Clin Infect Dis 2011;53:e Cite this document as follows: PL Detail-Document, Preventing and Treating Community-Acquired Pneumonia. Pharmacist s Letter/Prescriber s Letter. June Evidence and Recommendations You Can Trust 3120 West March Lane, Stockton, CA ~ TEL (209) ~ FAX (209) Copyright 2015 by Therapeutic Research Center Subscribers to the Letter can get PL Detail-Documents, like this one, on any topic covered in any issue by going to or