Policing and preventing pneumonia outbreaks
Elizabeth Cerceo, M.D.
Anyone involved in the care of the chronically ill and those in long-term care facilities is always vigilant in monitoring for the beginnings of pneumonia in this vulnerable population, many of whom have functional disabilities and underlying medical illnesses. Even though we know that pneumonia is the leading cause of morbidity and mortality in this group alone and despite decades of research and patient care, pneumonia has remained one of the top 10 causes of death in the US.
Pneumonia is getting tougher to treat
Part of the challenge of treating pneumonia is that antibiotics are among the most frequently prescribed medications in long-term care facilities. High rates of institutional antibiotic use are driving increased rates of antibiotic resistance, Clostridium difficile infection, antibiotic-related adverse events, and healthcare costs. In many areas of the country, more than 45% of pneumococci are resistant to currently available antibiotics. For example, many strains of Streptococcus pneumoniae, the primary community acquired bacterial pneumonia (CABP) pathogen, are resistant to currently-approved macrolides, a class of antibiotics that remains among the most commonly prescribed class for CABP both in the hospital and community settings. Antibiotic resistance conveys not only patient care issues with increased morbidity and mortality but also societal costs. The total cost of pneumonia was approximately $20 billion, including $14 billion in healthcare expenditures and $6 billion in lost productivity.
Guidelines for the initial treatment of pneumonia in the nursing home suggest a fluoroquinolone antibiotic suitable for respiratory infections (moxifloxacin or levofloxacin, for example), or amoxicillin with clavulanic acid plus a macrolide.
In a hospital setting, intravenous fluoroquinolones or a second- or third-generation cephalosporin plus a macrolide could be used.
Recently, during a meeting of the FDA's Antimicrobial Drugs Advisory Committee and the Drug Safety and Risk Management Advisory Committee, panelists voted to recommend label changes to reflect how fluoroquinolones are prescribed for acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis in patients with chronic obstructive pulmonary disease (ABECB-COPD) and uncomplicated urinary tract infections (uUTIs).
The panel called for clearer warnings about serious side effects and perhaps an antibacterial-wide risk evaluation and mitigation strategy (REMS) for this medication class. It follows that any subsequent FDA action may also impact the treatment of CABP if the regulating body takes the step to adjust labeling to provide a stronger warning in an effort to better educate providers regarding when to judiciously use these powerful antibiotics.
Effective, tailored treatment must take into account many patient factors such as their overall health status and immune status, receipt of recent antibiotics, prior infections with resistant organisms (such as MRSA or Pseudomonas aeruginosa), and whether or not they are ambulatory.
Providers should evaluate recent antibiotic therapy (because of possible resistance caused by recent exposure) and known carrier state or risk factors for resistant organisms, (e.g., known carrier of MRSA or presence of bronchiectasis predisposing to Pseudomonas, gram negative infections, Aspergillus, or Staphylococcus aureus). Additionally, if there is any suspicion for mycobacterial infections such as tuberculosis or Mycobacterium avium complex (MAC), fluoroquinolones can confer resistance to the class, making long-term treatment options more limited.
It is important that patients and health care professionals who meet existing guidelines get vaccinated to reduce the risk for pneumonia. Older adults have several pneumonia vaccine options based on their overall health and co-morbidities. Among adults younger than 65 years, improved vaccination has decreased incidence in invasive pneumococcal disease by 34% between 1997 and 2008, from 62 to 41 new cases per 100,000 population, exceeding the 2010 target of 42 per 100,000. However, despite preventative measures, nursing home residence is one of the most common risk factors for healthcare acquired pneumonia diagnosis.
Following diagnosis, follow-up is key after the start of antibiotic treatment. Management might include early shifts to oral antibiotics, stewardship according to the microbiological results, and short-duration antibiotic treatment that accounts for the clinical stability criteria. New approaches for fast clinical (lung ultrasound) and microbiological (molecular biology) diagnoses are promising.
Given the challenges of treating pneumonia and growing resistance, there is a need to develop new antibiotics for antibiotic resistant CABP. In fact, many are in the pipeline, stimulated in part by President Obama's National Action Plan to combat antibiotic resistant bacteria. The goals of the initiative include accelerating research into new therapeutics and diagnostics, improving surveillance, limiting antibiotic use in livestock, and slowly spread of resistant infections. Among the new candidates for treatment is solithromycin, a next-generation macrolide in development that has the potential to offer a first-line treatment for pneumococcal pneumonia that may be effective against macrolide-resistant pathogens, ease transition from IV to oral treatment, and reduce hospitalizations as a result of CABP.
Protecting patients and yourself
Pneumonia is an important problem with significant morbidity, mortality, and cost. In addition, the incidence of pneumonia has not decreased over the past few decades, despite advances in supportive care.v Two general strategies to reduce antibiotic resistance in long term care facilities are the implementation of infection control measures and antibiotic stewardship. But while we are mindful of sterilization techniques and hygiene to reduce the risk for all infections, simultaneously, we must promote a culture that fosters institutional and local efforts for thoughtful use of antibiotics.
Elizabeth Cerceo, M.D., FACP, is an assistant professor at the Division of Hospital Medicine, Associate Program Director of the Internal Medicine Residency, Cooper Medical School of Rowan University.