What is the best initial treatment of an adult patient with healthcare-associated pneumonia?

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Of all the patients with HCAP criteria, residents in nursing homes have been studied the best. Loeb et al, while looking for a way to decrease hospitalizations for nursing-home residents, showed that patients who get pneumonia (by guideline definition HCAP) can be effectively treated as outpatients with a single antibiotic agent.10 This randomized controlled trial of 680 patients, all with HCAP, were treated with oral levofloxacin at the nursing home or admitted to the hospital. There were no significant differences between mortality (8% vs. 9%) and quality-of-life measures between the two groups. Furthermore, analysis of data from the 1980s showed that nursing-home-acquired pneumonia could be treated effectively with single agents.11,12

To address some of the questions regarding HCAP, national infectious-disease leaders were brought together to respond to a number of HCAP questions.13 One of the questions centered on the recommended empiric coverage for HCAP. Given the above noted studies in nursing-home patients, disagreement emerged about the need to empirically treat all HCAP patients with broad-spectrum antibiotics. Therefore, another assessment of risk factors for MDR infections was proposed (see Table 2, p. 20) and a consensus was reached, resulting in the current recommendations. The current guidelines state that once a patient has met HCAP criteria, if they have additional MDR risk factors, then broad antibiotic coverage is recommended; however, if no additional MDR risk is found, then more conservative, narrower coverage could be given (see Table 3, p. 31).13

Additional considerations

More studies are needed to refine and validate the specific diagnostic criteria for HCAP, as well as the MDR infectious risk factors. Moreover, current recommendations are for lower respiratory cultures to be obtained on all patients with pneumonia and antibiotic coverage to be titrated according to these results. This practice, however, appears to be uncommon. More data are needed to further guide treatment following initiation of empiric antibiotic coverage without the guidance of culture data, with reliance upon clinical parameters instead.

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Back to the Case

This patient met initial criteria for HCAP because he was a nursing home resident, and was found to have additional MDR risk factors (poor functional status and a recent course of antibiotics). Therefore, lower respiratory cultures were obtained, supplemental oxygen was started, and piperacillin/tazobactam plus levofloxacin and vancomycin (with consideration made for local resistance patterns) was administered. He clinically improved over the next two days. His sputum cultures grew Pseudomonas aeuroginosa, which was sensitive to piperacillin/tazobactam but resistant to levofloxacin.

The vancomycin and levofloxacin were discontinued, and he was treated with a seven-day course of piperacillin/tazobactam.

Bottom Line

For adults who present with pneumonia from the community, special attention must be paid to certain parts of the patient’s history to determine if they have HCAP.

Patients who have HCAP can benefit from broad-spectrum empiric antibiotic coverage, which current expert consensus believes is dependent upon further MDR infection risk factors. TH

Dr. Rohde is medicine faculty hospitalist at the University of Michigan in Ann Arbor.

References

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