Hospital Medicine

Healthcare-Associated Pneumonia

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I. What every physician needs to know.

Hospital-acquired bacterial pneumonia (HAP) refers to pneumonias occurring after a patient has been hospitalized for 48 hours or more, which was not clinically suspected to be present on admission. The diagnosis of HAP implies that the patient is at risk for organisms more likely to be resistant to antibiotics typically given for community-acquired bacterial pneumonia (CAP). However, the vast majority of HAP cases occur in patients who are receiving mechanical ventilation. Such cases, more appropriately termed ventilator associated pneumonia (VAP), are covered elsewhere.

Healthcare-associated bacterial pneumonia (HCAP) represents the majority of cases in this category, and this terminology acknowledges the fact that many patients who acquire pneumonia outside the hospital are at risk for the more virulent organisms traditionally attributed to HAP and VAP.

Specifically, patients with HAP/HCAP are at risk for drug resistant or multidrug-resistant organisms (MDRO) such as methicillin-resistant staphylococcus aureus (MRSA), pseudomonas aeruginosa, gram-negative rods which produce extended-spectrum beta-lactamases (ESBL), and other gram-negative rods (see Table I). Of course, the usual spectrum of pathogens that cause CAP may be pathogens in patients with HCAP risk factors as well.

Table I.

Organisms associated with HAP/HCAP

For practical purposes, both HAP and HCAP will be considered together in this chapter, as their diagnosis and treatment are essentially the same. When important differences in the clinical approach exist, they will be explicitly stated.

II. Diagnostic Confirmation: Are you sure your patient has hospital-acquired bacterial pneumonia or healthcare-associated bacterial pneumonia?

As with other forms of pneumonia, the diagnosis of HAP/HCAP requires documentation of a new or progressive pulmonary infiltrate, as well as a clinical suspicion of infection. Fever, purulent sputum, and leukocytosis or leukopenia are common features of infection.

In addition, for patients who did not acquire their pneumonia during a hospitalization, presence of risk factors for HCAP should be documented (See IIb for risk factors).

A. History Part I: Pattern Recognition:

The key symptoms of HAP/HCAP include:

1. Dyspnea

2. Cough

3. Purulent sputum

4. Fever/chills/rigors

5. Pleuritic chest pain

The key signs of HAP/HCAP include:

1. Fever

2. Tachypnea

3. Tachycardia

4. Focal pulmonary crackles

5. Leukocytosis

6. New or progressive pulmonary infiltration

B. History Part 2: Prevalence:

As noted above, HAP is most common in ventilated patients; up to 90% of intensive care unit (ICU) HAP occurs during mechanical ventilation (VAP). HAP outside of the ICU is most commonly associated with patients at risk for aspiration pneumonia, such as those with altered sensorium due to acute delirium, chronic dysphagia, or perioperative anesthesia and other sedatives.

Original criteria for HCAP are as follows:

1. Hospitalized for 2 days or more within the past 90 days

2. Residence in a nursing home or extended care facility

3. Chronic dialysis within the past 30 days

4. Home infusion therapy (including antibiotics)

5. Home wound care

6. Family member with a known MDRO

Recently, the following criteria have been developed and are considered more specific to HCAP. They are considered "pneumonia specific criteria":

  • Hospitalized for 2 days or more within the past 90 days

  • Antibiotic use during the previous 90 days

  • Nonambulatory status

  • Tube Feedings

  • Immunocompromised status

  • Use of gastric acid suppressive agents

Other factors that increase the risk that a patient with pneumonia is infected with a resistant pathogen include:

1. Immunosuppression

2. Recent antibiotic therapy (within 90 days)

3. Current hospitalization of at least 5 days duration

4. Known high frequency of resistant pathogens in the community or hospital unit

C. History Part 3: Competing diagnoses that can mimic HAP and HCAP.

Other diagnoses that can mimic HAP/HCAP include viral pneumonia, community-acquired pneumonia, fungal pneumonia, chemical aspiration pneumonitis, or interstitial pneumonitis. It can be difficult to distinguish the etiology of the pneumonia at the time of presentation, and so initial empiric antibiotic therapy should be targeted based on patient risk factors. Those with risks for HCAP should be treated accordingly; patients with severe immunosuppression should have therapy to cover fungal organisms when appropriate.

D. Physical Examination Findings.

Typically patients will have fever over 100°F/38°C, tachypnea, tachycardia, and focal rales on physical examination. Older patients may have an atypical presentation, and often present with new onset delirium. Fevers may be absent in elderly and immunosuppressed patients.

E. What diagnostic tests should be performed?

Though these findings are present in many patients with HAP/HCAP, in general there is no reliable constellation of clinical findings to predict the presence of pneumonia with enough accuracy to preclude confirmatory radiographic imaging.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Initial laboratory studies should include a complete blood count (CBC), blood cultures and sputum sample for gram stain and culture. Everyone who is producing sputum should have a sample sent to facilitate antibiotic de-escalation, though yield is low. Additional studies that can be helpful include serum creatinine, electrolytes, liver function tests, and arterial blood gas (ABG).

When available, more advanced rapid diagnostic tests such as polymerase chain reaction (PCR) of respiratory specimens and urinary antigen testing for pneumococcus and legionella may be useful. During times when influenza is prevalent, rapid influenza testing as well as confirmatory PCR testing is appropriate. Finally, the use of serum procalcitonin when available may be useful. The utility of the above tests is discussed in detail below.

Complete blood count

Leukocytosis or leukopenia are supportive of a bacterial etiology of the pneumonia. Hematocrit below 30% is a predictor of increased mortality based on the pneumonia severity index. See discussion below in IIa.

Blood cultures

Although the yield remains relatively low, patients with severe pneumonia benefit from blood cultures to improve the likelihood of identifying the causative organism. All patients going to the ICU should have blood cultures. Given the increased likelihood that multidrug resistant organisms are the causative agents in HAP/HCAP, they should be strongly considered. If ordered, blood cultures should be obtained prior to antibiotic administration. However, significant delays in antibiotic delivery are inappropriate, and antibiotic administration should not be delayed unnecessarily in the pursuit of cultures.

Sputum gram stain and culture

Although it is often difficult to obtain sputum samples from non-ventilated patients, attempts should be made to collect sputum when possible to help in tailoring the antibiotic regimen.

Serum creatinine

Useful to help in appropriate antibiotic dosing when renal insufficiency exists.

Electrolytes

Based on the pneumonia severity index (PSI), blood urea nitrogen (BUN) greater than 30, glucose greater than 250 and sodium less than 130 are independent predictors of increased mortality.

Liver function tests

Useful to help identify patients with hepatic dysfunction in who antibiotic dose adjustment may be necessary. In addition, serum albumin levels are used to calculate the SMART-COP score (see IIIa), a risk stratification tool used to predict severity of illness.

Arterial blood gas (ABG)

Useful to identify hypoxic and hypercarbic respiratory failure, which will help determine level of care and need for ventilatory support. Arterial pH less than 7.35 and pO2 less than 60 are independent predictors of mortality based on the PSI.

Influenza testing

Important to help identify patients who might benefit from antiviral therapy, as well as to ensure adequate isolation precautions.

Sputum polymerase chain reaction testing

Limited availability in clinical laboratories, but can be helpful in providing more rapid etiologic diagnoses than cultures, particularly for viruses. Problems with this test include the potential for false positives due to specimen contamination via the oropharynx and upper airway.

Urinary antigen testing

For legionella, the antigen tests only for serogroup 1, which represents 80% of community-acquired legionella. For pneumococcus, the specificity and sensitivity are limited in patients who are not bacteremic. Combined with the fact that antibiotic susceptibility results are not available for positive tests, blood cultures remain a better test for identifying pneumococcus.

Procalcitonin

Serum procalcitonin levels below 0.25 mcg/L suggest the absence of a bacterial infection, and can be useful in the decision to discontinue antibiotics. Rapid procalcitonin assays have limited availability in most U.S. laboratories; most experience with this assay is in Europe.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Obtaining the best quality chest radiographs (CXR) possible for the clinical situation is imperative. Ideally, posterior-anterior and lateral films will be obtained.

The presence of a new or progressive pulmonary infiltrate and a clinical syndrome consistent with infection helps to confirm the diagnosis. In cases where the clinical suspicion of pneumonia is high but the initial radiographs are unremarkable, noncontrast chest computed tomography (CT) can be used to increase the sensitivity. Alternatively, pneumonia treatment can be initiated and plain radiographs can be repeated in 48 hours; in one study, 55% of patients with clinical suspicion of pneumonia and negative initial CXR showed an infiltrate on repeat imaging.

If a pleural effusion is suggested, decubitus films, ultrasound or chest CT is important to assess the practical considerations involved in drainage.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

In cases where the diagnosis is clear on admission and the patient is stable or improving, there is minimal benefit to routine follow-up radiographs in the inpatient setting. Similarly, advanced imaging such as chest CT does not change management when the diagnosis is clear from the CXR.

A. Immediate management.

Initial management of the patient with HAP/HCAP should be similar to that of other patients with pneumonia. Specifically, supportive care measures to improve oxygenation and ensure hemodynamic stability should remain the initial priority. Obtaining cultures of blood and sputum prior to administration of antibiotics is desirable, but the administration of appropriate initial empiric antibiotic therapy should not be significantly delayed to achieve this goal.

The intervention most likely to reduce inpatient and long-term mortality rates is the prompt administration of appropriate empiric antibiotic therapy. For patients with HAP/HCAP risks, the antibiotics should cover organisms that are present in patients with CAP, as well as MRSA and pseudomonas aeruginosa.

A list of appropriate initial empiric antibiotic regimens follows:

  • Antipseudomonal cephalosporin

or

  • Antipseudomonal carbapenem

or

  • B-lactam/B-lactamase inhibitor

plus

  • Antipseudomonal fluoroquinolone

or

  • Aminoglycoside

plus

  • Agent active against MRSA

Administration of antibiotics as soon as possible after the diagnosis is made is critical; studies show that significant delays in appropriate antibiotic therapy correlate with increased mortality. The evidence for this is strongest in patients with sepsis. Efforts to obtain cultures should be made, but antibiotics should be started within 6 hours of presentation. The first dose of antibiotics should be given in the emergency department or in the clinic whenever possible.

The current literature suggests that the guidelines may have overreached in recommending broad-spectrum antibiotic therapy for all patients with HCAP risk factors regardless of illness severity. It remains unclear which risks are the best predictors of MDRO, but certainly patients with septic shock or severe pneumonia, or those with multiple HCAP risk factors, are the most appropriate candidates for broad spectrum therapy. Stable patients with only 1 risk factor may be more appropriately treated for CAP. Recommendations for broad-spectrum therapy are intended to apply to inpatients only; outpatients with HCAP risk factors do not automatically require parenteral therapy or hospitalization.

There is increasing evidence to suggest that the use of short-term corticosteroid therapy reduces time to clinical stability and length of stay for hospitalized patients with pneumonia. An effect on mortality has not yet been definitively shown. A regimen of prednisone 50 mg daily for 7 days has been effective and should be considered in patients without contraindications.

Determination of the appropriate level of care is also an important step in the initial management of patients with HAP/HCAP. Early admission of patients with sepsis and/or respiratory failure to the intensive care unit (ICU) is of critical importance. Although there have been multiple risk prediction models proposed in the literature, the most widely accepted are the pneumonia severity index (PSI) and the CURB-65 scores. Each of these is useful in predicting pneumonia-related mortality.

Although these risk prediction models were developed prior to the description of HCAP as a concept, neither excluded patients with HCAP risk factors in their derivation models. As such, they likely remain relevant predictors of severity of illness.

The PSI is a clinical prediction tool that involves a point system based on the presence of factors correlating with increased mortality; higher scores correlate with increased 30-day mortality. The PSI classifies patients into 5 distinct risk classes. Any patient below 50 years old, without a history of cancer, congestive heart failure, cerebrovascular, renal or liver disease, with normal mental status and normal vital signs, is in the lowest risk category. To determine risk for all other patients, a more complex point system must be used. See Table II for details.

Table II.

Calculation of the PSI Score

As evidenced by Table II, patients with PSI class I-III pneumonia are at low mortality risk and studies have shown that outpatient management is safe and appropriate, barring other reasons that would warrant hospitalization. Patients with class IV-V disease should be hospitalized, with consideration to a higher level of care (step-down unit or ICU) for those with class V. It is also evident from the Table that the PSI is a fairly cumbersome tool, which limits its utility at the site of care. Web based PSI calculators and smartphone applications do exist to facilitate its use. However, simpler risk assessment tools have been sought.

The most widely recognized of the simpler tools is the CURB-65, an acronym for a scoring system that also predicts 30-day mortality. Each letter stands for a risk factor (C = Confusion, U = Uremia [BUN > 20], R = Respirations > 30, B = Blood pressure < 90/60, 65 = age > or = 65), and each is weighted equally at 1 point. Mortality rates increase with higher scores, as follows: 0 points = 0.7%, 1 point = 2.1%, 2 points = 9.2%, 3 points = 14.5%, 4 points = 40%, 5 points = 57%. Some suggest ICU admission for patients with CURB-65 scores above 3.

It is evident from comparing the 2 rating scales that the PSI is more sensitive for identifying patients at low risk, and the CURB-65 is superior for identifying patients at high risk. Therefore, utilization of one or the other may depend on the clinical scenario. Of course, no risk stratification tool should replace clinical judgment.

In addition to mortality prediction tools, the SMART-COP score (systolic BP, multilobar chest pneumonia on chest radiography, albumin, respiratory rate, tachycardia, confusion, oxygen level, arterial pH) is a method to identify patients who will likely require intensive care. A score of ≥3 has sensitivity of 92% to predict the need for vasopressors or invasive ventilation. Electronic SMART-COP calculators are available to facilitate its use.

B. Physical Examination Tips to Guide Management.

Resolution of fevers, improvement in oxygenation, and improvement of abnormal findings on chest auscultation are physical findings that suggest improvement. For patients with delirium, mental status should improve as well.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

The most important laboratory tests to monitor are the microbiologic studies, as treatment should be narrowed if the patient is clinically improving and cultures show no evidence of MDRO. Treatment should be adjusted when cultures are positive as well, with antibiotic therapy targeted to match the organisms identified.

As noted above, measurement of serum procalcitonin levels, if available with same-day results reporting, can be very useful to guide the length of antibiotic therapy. Several studies support discontinuation of antibiotic therapy in patients whose procalcitonin level has fallen below 0.25mcg/mL if the patient is otherwise clinically improving. Although HCAP patients have not been specifically included in such studies, this practice has been validated in patients in the ICU, so it is clinically reasonable to assume it would extrapolate. However, the use of procalcitonin guidance has not yet achieved widespread adoption in clinical practice.

D. Long-term management.

As noted above, antibiotic treatment should be adjusted according to culture results. In patients without evidence of MDRO who are clinically improving, narrowing antibiotics to match treatment recommendations for CAP should be strongly considered. Patients with positive cultures should similarly have therapy narrowed to match the results. Specifically, double-coverage for pseudomonas pneumonia need not be continued in most patients once sensitivities are available.

Due to increasing concerns about selecting for antibiotic resistant organisms, extended antibiotic treatment courses are not appropriate in most cases. A meta-analysis has concluded that there was no advantage in clinical cure or survival for patients receiving antibiotic regimens longer than 7 days in mild to moderate community-acquired pneumonia. Again there have been no specific studies of the subject specific to HCAP, but patients who are clinically improving should be treated similarly in absence of contradictory data.

For patients with VAP, a study of over 400 patients found no difference in mortality, recurrent pneumonia or time to clinical cure when comparing 8 days to 15 days of antibiotics. The subgroup of patients with pseudomonas who received short-course therapy had a higher rate of recurrent pneumonia but no worsening in mortality, time of mechanical ventilation or ICU length of stay.

Therefore, other than the subgroup of patients with documented pseudomonas infection, physicians should avoid extended courses of antibiotics (>7 days) for patients with pneumonia who are clinically improving.

A. Renal Insufficiency.

Antibiotics should be appropriately adjusted for renal insufficiency, with particular attention to monitoring of trough levels when aminoglycosides and vancomycin are used. The vancomycin trough is generally targeted at 15-20 mcg/mL in patients with pneumonia. Consultation with hospital pharmacists may be appropriate in such patients.

Careful attention to fluid management to avoid volume overload is warranted.

B. Liver Insufficiency.

No change in standard management.

C. Systolic and Diastolic Heart Failure

Careful attention to fluid administration to avoid volume overload is warranted.

D. Coronary Artery Disease or Peripheral Vascular Disease

No change in standard management.

E. Diabetes or other Endocrine issues

As with other infections, glycemic control is often more difficult during the acute phase of pneumonia. Using supplemental insulin, or increasing the total insulin dose during the hospitalization, is frequently necessary.

Respiratory fluoroquinolones, mainly gatifloxacin, have been linked to both hypo- and hyperglycemic events. As a result, gatifloxacin is no longer on the market in the US and Canada. Levofloxacin has been linked to a lesser extent, so diabetic patients taking this medication should have close monitoring of their blood sugars. Alternative choices should be sought for diabetics who demonstrate worsened glycemic control on levofloxacin.

F. Malignancy

Patients with underlying lung cancer may be at increased risk for bronchial obstruction and post-obstructive pneumonia. Antibiotics to cover anaerobic organisms, and consultation with interventional pulmonologists to consider stenting an obstructed airway to improve resolution of pneumonia may be appropriate.

G. Immunosuppression (HIV, chronic steroids, etc).

Patients with immunosuppression are considered to be at risk for MDRO's and should be treated according to HCAP guidelines. Of course, consideration should be given to non-bacterial causes of pneumonia syndromes in such patients, including mycobacteria, pneumocystis, invasive aspergillosis, cytomegalovirus, and others.

H. Primary Lung Disease (COPD, Asthma, ILD)

Oxygenation is often compromised at baseline with primary lung disease, so more careful monitoring of oxygenation and ventilatory status in such patients is critical. Consideration should be given to earlier utilization of noninvasive ventilatory support such as biPAP in patients who show signs of early respiratory insufficiency. Similarly, more aggressive treatment of the underlying disease to maximize lung function is important.

I. Gastrointestinal or Nutrition Issues

If there is concern for gastrointestinal malabsorption, a delay in transition to oral antibiotics may be appropriate. As above, in most cases prolonged antimicrobial treatment offers little advantage in most patients once they achieve clinical stability.

J. Hematologic or Coagulation Issues

Patients with coagulopathy may be at increased risk for hemoptysis in the setting of acute bacterial pneumonia. Appropriate measures to monitor and manage hemoptysis if it occurs, including temporary reversal of the coagulopathy, should be applied.

K. Dementia or Psychiatric Illness/Treatment

Patients with dementia and altered mentation are at increased risk for dysphagia and aspiration pneumonia. Testing of swallowing function may be appropriate in such patients who present with acute pneumonia, if it will change the ultimate decisions about how to manage long-term nutritional issues. In patients with end-stage dementia in whom enteral feeding tubes are inappropriate, dietary modification and aspiration precautions may be the best options.

These patients are also at increased risk of delirium in the setting of infection; in some patients this is the first manifesting sign of pneumonia.

The utilization of both conventional and antipsychotics to manage dementia-related psychosis is contraindicated according to an FDA advisory issued in 2005, due to increased mortality that was mostly attributable to cardiac events and pneumonia. Several studies suggest that among the elderly, active users of antipsychotics have a significantly increased risk of fatal and nonfatal pneumonias. Care should be undertaken administering these medications, though there are no clearly superior options for treatment of acute delirium in this population.

A. Sign-out considerations While Hospitalized.

Sign-out should include information about the patient's baseline and current oxygenation status, including the risk for CO2 retention. Suggestions for transition to noninvasive ventilation based on clinical parameters should be mentioned.

Status of blood and sputum cultures and the current antibiotic regimen should be mentioned. This will assist the covering clinician in decisions about broadening or narrowing coverage based on clinical changes.

B. Anticipated Length of Stay.

According to estimates from the National Hospital Discharge Survey, the mean length of hospitalization for patients with pneumonia is 5 days. For patients with HAP and HCAP in whom respiratory and/or blood cultures have been obtained and broad-spectrum antibiotics instituted, it will most likely require 48-72 hours before results are available that will allow narrowing of antibiotics to an oral regimen to facilitate discharge. There is no evidence to support ongoing inpatient observation of clinically stable patients with pneumonia following a switch from IV to oral antibiotics.

C. When is the Patient Ready for Discharge.

Most studies define clinical stability for pneumonia patients as follows:

  • Temperature less than 100°F

  • Respiratory rate less than 24 breaths/minute

  • Heart rate less than 100 beats/minute

  • Systolic blood pressure 90 mmHg or greater

  • Oxygen saturation greater than 90%

  • Mental status at baseline

  • Ability to tolerate oral intake

Readmission rates and adverse events are lowest in the group of patients who fulfill all of the above criteria prior to discharge.

Transition to oral antibiotics prior to or on the day of discharge should be considered, though occasionally treatment with outpatient parenteral antibiotics is more appropriate.

1. When should clinic follow up be arranged and with whom.

For most patients with HAP/HCAP, follow-up with the primary care physician near the end of the antibiotic course is appropriate. Those with comorbidities such as underlying primary lung disease or immunosuppression may require follow-up with a pulmonologist or infectious diseases specialist within 1-2 weeks following discharge.

2. What tests should be conducted prior to discharge to enable best clinic first visit.

None

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

Clinical improvement is the most important early parameter to monitor. If any laboratories (e.g., white blood cell count, creatinine, glucose) remained particularly abnormal at discharge, a repeat evaluation is warranted. Follow up chest radiographs to document clearing of the infiltrates should be done, but not until 4-6 weeks following clinical improvement.

E. Placement Considerations.

In a patient with identified MDRO who requires extended out of hospital parenteral antibiotics, placement of a PICC line or other central venous catheter should be pursued early to facilitate transition to SNF. Patients with significant deconditioning as a result of prolonged hospitalization or severe infection should have a functional assessment by a physical and/or occupational therapist to help guide decisions about outpatient safety and SNF placement. The need for ongoing speech therapy in patients with dysphagia and aspiration pneumonia should prompt placement of an enteral feeding tube in appropriate candidates prior to discharge.

F. Prognosis and Patient Counseling.

Hospitalization with pneumonia in patients aged 65 and above is a predictor of excess inpatient and long-term mortality. Risk-adjusted odds of inpatient mortality are 1.5 when compared with patients hospitalized for other common inpatient conditions, and 1.4 for overall mortality followed out for 5 years or more. Note, these numbers are based on studies of CAP; similar numbers are not available for HAP/HCAP. For unclear reasons, pneumonia seems to be a surrogate marker for poor outcomes in the elderly; however, this information is not typically useful in counseling patients, as there are few concrete steps that can be taken to intervene.

Studies of HCAP consistently show short-term mortality rates about twice that of CAP. Although estimates from existing studies vary widely due to heterogeneous patient selection, the average estimated 30-day mortality rates are as high as 30%. Current evidence suggests that comorbid conditions and severity of illness are the most significant contributors to mortality.

A. Core Indicator Standards and Documentation.

Although The Joint Commission (TJC) currently excludes cases of HAP and HCAP from core measures data, it is useful to review the indicators for CAP, as the clinical benefits are likely the same in both populations. Of note, many of the original CAP quality indicators have been retired. Current publicly reported measures tied to hospital reimbursement via the CMS Hospital Value-Based Purchasing Program include appropriate initial antibiotic selection, 30-day mortality rate, and 30-day readmission rate.

Although the following processes are no longer tied to public reporting, they remain good practice for all inpatients, especially those with pneumonia:

  • Providing pneumococcal vaccination to eligible patients prior to discharge.

  • Providing influenza vaccination to eligible patients during flu season.

  • Providing smoking cessation counseling for smokers.

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

Patients hospitalized with pneumonia are at increased risk of deep vein thrombosis (DVT), and appropriate prophylaxis should be administered when absent from any contraindications.

Vaccination rates among the elderly remain suboptimal; estimates suggest rates of pneumococcal vaccination to be 60%. Although a meta-analysis by the Cochrane Review found no clear reduction in all-cause mortality or pneumonia from the 23-valent pneumococcal vaccine (PPSV23, commonly known as Pneumovax), it was effective in reducing invasive pneumococcal disease (bacteremia, meningitis and joint disease) (OR 0.26, CI 0.15-0.46). Since the development of the 13-valent pneumococcal conjugate vaccine (PCV13, or Prevnar 13), vaccination trials have demonstrated significant reductions in both pneumonia and invasive pneumococcal disease. Given that there are many missed opportunities in the community setting, vaccination should be offered prior to discharge to all eligible patients.

ACIP recommends routine vaccination with both PCV13 and PPSV23 in all adults ≥ 65 years. CDC also recommends PCV13 in younger adults with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leak, or cochlear implant, in addition to PPSV 23. Patients < 65 with additional risk factors detailed in Table III should also receive PPSV23. In immunocompetent adults ≥ 65 years, administer PCV13 first, and then PPSV 23 ≥ 1 year later.

Table III.

Indications for PPSV23 in patients < 65

Annual influenza vaccination has been shown to reduce hospitalizations as well as mortality for pneumonia in the elderly. As with pneumococcus, rates are well below targets, estimated at 65% in the elderly in 2009. Vaccination should be offered to eligible patients prior to discharge. Current CDC recommendations state that all persons aged 6 months and over should receive annual influenza vaccination.

VII. What's the Evidence?

Am J Resp Crit Care Med.. vol. 171. 2005. pp. 388-416.

(The definitive guidelines on approach to the care of patients with HCAP, somewhat out of date at this point with revisions expected in 2016.)

Rothberg, MB,. "Association of guideline-based antimicrobial therapy and outcomes in healthcare-associated pneumonia.". J Antimicrob Chemotherapy.. vol. 70. 2015. pp. 1573-9.

Webb, BJ,. "Predicting risk of drug-resistant organisms in pneumonia: moving beyond the HCAP model.". Respir Med.. vol. 109. 2015. pp. 1-10.

(The above studies and many that precede them in the medical literature suggest the HCAP criteria are not specific enough to identify the subgroup of patients who benefit from the broad-spectrum antibiotic therapy suggested in the guidelines.)

Fine, JM,. "A prediction rule to identify low-risk patients with community-acquired pneumonia.". NEJM. vol. 336. 2007. pp. 243-50.

Charles, PG,, Wolfe, R,, Whitby, M,, Fine, MJ,, Fuller, AJ,, Stirling, R,. "SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia.". Clin Infect Dis. vol. 47. 2008. pp. 375-84.

Lim, WS,. "Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study.". Thorax. vol. 58. 2003. pp. 377.

(The above 3 studies review the various risk-stratification tools referenced in this article.)

Shindo, Y,. "Risk factors for drug-resistant pathogens in community-acquired and healthcare-acquired pneumonia.". Americal Journal of Respiratory Critical Care Medicine. vol. 188. 2013. pp. 985-95.

Blum, C,. Lancet. vol. 385. 2015. pp. 1511-8.

(One of several meta-analyses from 2015 demonstrating the benefit of corticosteroids on pneumonia outcomes.)

Moberley, S,. "Vaccines for preventing pneumococcal infection in adults.". Cochrane Database of Systematic Reviews.. 2013,.

Tomczyk, S,, Bennett, NM,, Stoecker, C,, Gierke, R,, Moore, MR,, Whitney, CG,. "Use of PCV-13 and PPSV-23 vaccine among adults aged 65 and older: recommendations of the ACIP.". MMWR.. vol. 63. 2014. pp. 822-5.

Grijalva, CG. "Association between hospitalization with community-acquired laboratory-confirmed influenza pneumonia and prior receipt of influenza vaccination.". JAMA.. vol. 314. 2015. pp. 1488-97.

(The above 3 articles review the evidence for current vaccination strategies for pneumococcal disease and influenza.)
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