Preventing and Treating Community-Acquired Pneumonia

Full update January 2019

--The toolbox 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; IV = intravenous; MRSA = methicillin-resistant Staphylococcus aureus; PCR = Polymerase Chain Reaction

Goal

Suggested Strategies or Resources

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.

Choose the right flu vaccine for the patient. Get our chart, Flu Vaccines for 2018-2019 (U.S. Subscribers)(Canadian Subscribers) for help sorting out the available vaccines. Pharmacists can also get our continuing education course, A Guide to the 2018-2019 Influenza Season Recommendations.

The CDC provides flu prevention, diagnosis, and treatment information for healthcare professionals, and surveillance data, at https://www.cdc.gov/flu/professionals/index.htm.

Canadian healthcare professionals can get information on flu prevention, diagnosis, treatment, and updated surveillance data from the Public Health Agency of Canada at https://www.canada.ca/en/public-health/services/diseases/flu-influenza/health-professionals.html.

Provide immunization in your clinic, hospital, or pharmacy.

Encourage use of influenza vaccine standing orders. For help, see http://www.immunize.org/catg.d/p3067.pdf.

Educate patients about flu prevention.

Get materials to educate patients about flu vaccination and other preventive actions from the CDC at http://www.cdc.gov/flu/freeresources/index.htm. Includes posters, fact sheets, educational materials for children, sample posts for social media, and more.

Patient education handouts, What to Do If You Get the Flu and No More Excuses…You Need a Flu Vaccine, can be downloaded from our website.

Canadians can get information and materials to educate patients about flu vaccination and other preventive actions from the Public Health Agency of Canada at http://www.fightflu.ca.

Vaccinate eligible patients against pneumonia.

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, Pneumovax 23 is recommended for routine use. Prevnar 13 can be provided for additional protection on an individual basis.)5

Check for adults UNDER 65 who need one or both pneumococcal vaccines.3

  • Those who smoke (CDC), have certain chronic conditions (CDC, Health Canada), or live under certain conditions (Health Canada) will need Pneumovax 23.3,5
  • Immunocompromised patients will need both vaccines.3,5

To find out who gets what and when, see our charts of adult (U.S.)(Canada) pneumococcal vaccination recommendations.

Screen for pneumonia vaccine eligibility when adults 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. See http://www.immunize.org/catg.d/p3066.pdf for help.

Educate patients about pneumonia and pneumonia vaccination.

Get information for patients about pneumonia and pneumonia vaccination from the CDC at https://www.cdc.gov/pneumococcal/index.html, and from the Public Health Agency of Canada at https://www.canada.ca/en/public-health/services/immunization/vaccine-preventable-diseases/invasive-pneumococcal-disease.html.

Get a pneumococcal vaccine waiting room poster and fact sheets about pneumococcal disease and vaccination for patients and parents from the CDC at http://www.cdc.gov/pneumococcal/resources/print.html.

Help patients quit smoking.

For practical tips and resources to help your patients successfully quit smoking see our toolbox, Smoking Cessation: Helping Patients Who Use Tobacco.

Control high-risk chronic diseases that put patients at risk for pneumonia.

Asthma

Dose asthma medications correctly. Get our chart, Comparison of Inhaled Asthma Meds (U.S. Subscribers)(Canadian Subscribers), for help.

Our 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 NHLBI’s National Asthma Education and Prevention Program available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.

Canadian asthma guidelines are available from the Canadian Thoracic Society at http://www.respiratoryguidelines.ca/sites/all/files/cts_asthma_consensus_summary_2010.pdf, http://www.respiratoryguidelines.ca/sites/all/files/2012_CTS_Guideline_Asthma.pdf, and http://www.respiratoryguidelines.ca/2015-diagnosis-and-management-of-asthma-in-preschoolers-a-canadian-thoracic-society-and-canadian-pae.

The Global Initiative for Asthma Management and Prevention is available at http://www.ginasthma.org.

COPD

Get our 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 http://www.goldcopd.org.

Guidelines for prevention of acute COPD exacerbations from the American College of Chest Physicians and the Canadian Thoracic Society are available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388124/pdf/chest_147_4_894.pdf.

Diabetes

See our toolbox, Improving Diabetes Outcomes, for practical tips and resources to help care for your diabetes patients.

Get our algorithm, Initiation and Adjustment of Insulin Regimens for Type 2 Diabetes (U.S. Subscribers)(Canadian Subscribers).

Get our chart, Comparison of Insulins (U.S. Subscribers)(Canadian Subscribers).

Heart Failure

Get our toolbox, 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 self-care, help them identify when to seek additional care, and help them prevent future episodes.

Give patients our customizable 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 http://www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/goinghome/index.html.

Get patient information about pneumococcal disease from the CDC at http://www.cdc.gov/pneumococcal/about/index.html.

Get patient information about community-acquired pneumonia from the National Library of Medicine at http://www.nlm.nih.gov/medlineplus/ency/article/000145.htm.

Triage patients for possible hospital admission.

Utilize pneumonia severity tools to help determine if outpatient treatment is appropriate:

Consider admission for children with respiratory compromise, poor oral intake, complicated pneumonia, or age less than six months, unreliable home circumstances, or a particularly virulent pathogen is suspected.17,18

Get Community-Acquired Pneumonia Clinical Decision Support Implementation Toolkit from the Agency for Healthcare Research and Quality at https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-care/cap-toolkit.html

Choose appropriate antibiotics.

Get our chart, Outpatient Treatment of Community-Acquired Pneumonia in Adults, for a review of the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines.

Adult outpatients, choose:4,6

  • Levofloxacin for patients with comorbidities (e.g., COPD), immunosuppression, age >65 years, or exposure to child in daycare. Alternatives: moxifloxacin, OR azithromycin or clarithromycin plus a beta-lactam (high-dose amoxicillin, high-dose amoxicillin-clavulanate, cefdinir, cefpodoxime, or cefprozil).
  • Azithromycin or clarithromycin if no comorbidities, no immunosuppression, age <65 years, no exposure to child in daycare, and macrolide resistance ≤25%. Doxycycline is an alternative.
  • If antibiotics within the past three months, treat as for comorbidities, using different antibiotic class.

For adult inpatients NOT in the ICU, choose:4

  • Ceftriaxone or ceftaroline (U.S.) plus azithromycin (or doxycycline [alternative]) IV
  • OR
  • Levofloxacin IV (or moxifloxacin [alternative]) IV
  • PLUS
  • Vancomycin for MRSA coverage if IV drug user or influenza-associated pneumonia

For adult ICU patients, choose:4

  • Ceftriaxone plus azithromycin IV
  • OR
  • Levofloxacin IV or moxifloxacin IV
  • OR
  • Pseudomonas aeruginosa coverage if appropriate (e.g., chronic or structural lung disease, known colonization): cefepime, piperacillin/tazobactam, ceftazidime, or meropenem PLUS (levofloxacin or ciprofloxacin) or (tobramycin plus azithromycin)
  • PLUS
  • Oseltamivir for influenza infection
  • PLUS
  • Vancomycin IV or linezolid IV for MRSA coverage if influenza-associated pneumonia, IV drug user, or gram-positive cocci in clusters on gram stain.

In otherwise healthy pediatric patients, amoxicillin is recommended first-line in outpatients to cover S. pneumoniae, the most common bacterial pathogen.17 Our 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 4,000 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 chart, Beta-Lactam Allergy: FAQs, for a review of treatment considerations in penicillin-allergic patients.

Fine-tune the treatment spectrum as soon as possible.

Check a urinary antigen test and culture a lower respiratory specimen for Legionella in patients who: have failed outpatient treatment, have severe pneumonia, have traveled in the previous ten days, are immunocompromised, or who present with pneumonia in the setting of a legionellosis outbreak.14

  • Urinary antigen test 95% to 100% specific for L. pneumophila serogroup 1 (Lp1), which may account for over 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 response to treatment 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) and other reasons for poor response.17

Prevent interactions with antibiotics.

See our chart, Antimicrobial Drug Interactions and Warfarin, for help preventing and managing warfarin interactions.

Our 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 chart, Drug-Induced Long QT Interval.

Ensure patients stay on their medications.

See our toolbox, Medication Adherence Strategies.

See our patient education handout, Tips for Sticking With Your Meds.

Restrict use of meds associated with increased pneumonia risk.

Use medications associated with increased pneumonia risk (e.g., proton pump inhibitors, inhaled corticosteroids, benzodiazepines, antipsychotics, anticholinergics) only when clearly needed.7-10,12

Prevent avoidable hospital readmissions.

See our 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.

Project Leader in preparation of this clinical resource (350108): Melanie Cupp, Pharm.D., BCPS

References

  1. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2018–19 Influenza Season. MMWR Recomm Rep 2018;67(RR-3):1–20.
  2. Public Health Agency of Canada. An Advisory Committee Statement (ACS). National Advisory Committee on Immunization (NACI). Canadian immunization guide chapter on influenza and statement on seasonal influenza vaccine for 2018-2019. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/healthy-living/canadian-immunization-guide-statement-seasonal-influenza-vaccine-2018-2019/canadian-immunization-guide-statement-seasonal-influenza-vaccine-2018-2019.pdf. (Accessed November 30, 2018).
  3. CDC. Pneumococcal vaccine timing for adults. November 30, 2015. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf. (Accessed November 30, 2018).
  4. Chambers C. The Sanford Guide to Antimicrobial Therapy. Web Edition. Sperryville, VA: Antimicrobial Therapy, Inc., 2018. http://webedition.sanfordguide.com/. (Accessed December 2, 2018).
  5. Public Health Agency of Canada. Canadian Immunization Guide. Pneumococcal vaccine. Last modified December 22, 2016. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-16-pneumococcal-vaccine.html. (Accessed November 30, 2018).
  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):S27-72.
  7. 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 population-based cohort. Thorax 2013;68:163-70.
  8. Clinical Resource, Proton Pump Inhibitors: Appropriate Use and Safety Concerns. Pharmacist’s Letter/Prescriber’s Letter. April 2016.
  9. Suissa S, Patenaude V, Lapi F, Ernst P. Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax 2013;68:1029-36.
  10. Aparasu RR, Chatterjee S, Chen H. Risk of pneumonia in elderly nursing home residents using typical versus atypical antipsychotics. Ann Pharmacother 2013;47:464-74.
  11. CDC. Pneumococcal vaccination: what everyone should know Last reviewed/updated December 6, 2017. https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html. (Accessed November 30, 2018).
  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;63:476-85.
  13. CDC. Rapid influenza diagnostic tests. Updated January 18, 2017. http://www.cdc.gov/flu/professionals/diagnosis/clinician_guidance_ridt.htm. (Accessed December 2, 2018).
  14. CDC. What clinicians needs to know about Legionnaire’s disease. May 15, 2015. https://www.cdc.gov/legionella/downloads/fs-legionella-clinicians.pdf. (Accessed December 2, 2018).
  15. CDC. Legionella (Legionnaire’s disease and Pontiac fever). Last reviewed/updated April 30, 2018. https://www.cdc.gov/legionella/clinicians/diagnostic-testing.html. (Accessed December 2, 2018).
  16. Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med 2014;371:1619-28.
  17. 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. Updated October 31, 2018. https://www.cps.ca/en/documents/position/pneumonia-management-children-youth. (Accessed December 2, 2018).
  18. 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:e25-76.

Cite this document as follows: Clinical Resource, Preventing and Treating Community-Acquired Pneumonia. Pharmacist’s Letter/Prescriber’s Letter. January 2019.

Related Articles