Pneumonia Challenges Hospitalists on Multiple Fronts
Pneumonia is one of the most common diagnoses encountered by hospitalists, if not the most common, and its presentation continues to become more complicated, says Scott Flanders, MD, SFHM, professor of medicine and director of the hospitalist program at the University of Michigan Health System in Ann Arbor. Dr. Flanders has published on pneumonia (J Hosp Med. 2006;1(3):177-190), and this past fall he gave presentations on the subject at hospitalist conferences in San Francisco and Chicago—with a particular emphasis on how to prevent its recurrence in hospitalized patients at risk.
“The causative agents for community-acquired pneumonia (CAP) evolve over time,” even though the actual source of a hospitalized patient’s pneumonia may never be known, says Dr. Flanders, past president of SHM. The swine flu (H1N1) and community-acquired MRSA “are two examples of etiologic agents that were not even a consideration five years ago—and now are something hospitalists have to be aware of, understand, and recognize that they can cause pneumonia in patients who are admitted to the hospital from the community,” he says. “They need to be considered as potential etiologic agents first and foremost, because the treatments for them differ from usual empiric pneumonia treatments.
There is a subset of patients with bad reflux disease, history of GI bleeds, on anticoagulants, who have more potential benefit than harm from PPIs. Hospitalists should see if their patients fall into these categories and, if they don’t, consider discontinuing these medications.
—Scott Flanders, MD, SFHM, professor of medicine and director of the hospitalist program at the University of Michigan Health System, Ann Arbor, SHM past president
“As hospitalists, we spend a lot of time trying to think what we can do to prevent recurrent pneumonia episodes in our patients and looking for what could have caused the initial incident,” Dr. Flanders says. “Pneumococcal vaccination is not as good as we’d like it to be in preventing recurrent pneumonia. We have to look to see if there’s anything else we can do to help prevent it.”
One simple step is to review the patient’s medication list, see if proton pump inhibitors (PPI) for reducing gastric acid or antipsychotic medications are on the list, then ask whether they can be discontinued; both treatments are associated in the medical literature with higher rates of pneumonia recurrence. Patients often receive PPIs for empiric prevention of gastrointestinal bleeding in the ICU, a risk that might have ceased.
“There is a subset of patients with bad reflux disease, history of GI bleeds, on anticoagulants, who have more potential benefit than harm from PPIs,” Dr. Flanders explains. “Hospitalists should see if their patients fall into these categories and, if they don’t, consider discontinuing these medications.”
Dr. Flanders also points out hospitalists should keep an eye out for antipsychotic medications. “Many patients absolutely need these medications and are functional because they are on them,” he says. “We’d never consider stopping them for those patients. But some patients get them started for episodes of delirium in the hospital that have resolved or to enhance their sleep. I’d strongly recommend considering stopping them in that case.”
By contrast, statin use might improve outcomes associated with pneumonia.
Antibiotic selection is another big issue, and Dr. Flanders says hospitalists will be judged by how closely they stick to the recommended treatment guidelines. “They should be familiar with what the guidelines recommend, and recognize the types of variables they need to document if they are going to deviate from the recommendations,” he says. The evidence also says to stop routinely treating pneumonia with antibiotics beyond seven days, he adds.
