Healthcare-Associated Pneumonia in the Emergency Department

Healthcare-Associated Pneumonia in the Emergency Department Ellen M. Slaven, M.D., 1 Jairo I. Santanilla, M.D., 1,2 and Peter M. DeBlieux, M.D. 1 ABSTRACT Emergency medicine clinicians frequently diagnose and treat patients with pneumonia. The recent recognition of healthcare-associated pneumonia (HCAP) mandates that emergency medicine clinicians remain current and able to distinguish this from community-acquired pneumonia. This article reviews the diagnosis and management of HCAP from the perspective of the emergency medicine clinician. KEYWORDS: Healthcare-associated, pneumonia, emergency department The emergency department (ED) is often the initial point of contact for many patients presenting with community-acquired pneumonia (CAP), accounting for over 1.5 million visits annually. 1 The majority of these patients are managed with an outpatient regimen of oral antibiotics, and the use of prediction scores has helped identify those patients who may warrant inpatient care and possibly intensive care unit resources. With the recognition of healthcare-associated pneumonia (HCAP), emergency medicine clinicians have had to revolutionize their standard approach to patients presenting with CAP. The categorization of pneumonia is primarily based on historical data points, traditionally distinguishing CAP from hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) (Table 1). 2 Emergency medicine clinicians must now carefully screen their patients for previous healthcare contacts and prior antibiotic exposure (Table 1). 2 These historical data points, when positive for: healthcare admissions, clinic visits, recent antibiotic use, and dialysis, predispose patients to multidrug-resistant (MDR) pathogens. Patient presentations for CAP and HCAP may be similar, but their treatment and diagnostic choices may differ dramatically. The failure to recognize HCAP exposures and the associated MDR pathogen risks can lead directly to poor outcomes for these patients accessing the ED for pneumonia treatment. DEFINITIONS Traditionally, pneumonia has been categorized into CAP and the nosocomial pneumonias HAP and VAP. However, recently a fourth category, HCAP, has been introduced. This reflects the emerging understanding that patients presenting from the community who have been exposed to healthcare environments or antibiotics may have a pathogenesis that more closely resembles HAP than CAP. The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) have recently published guidelines for the diagnosis and management of HCAP. According to the 2005 ATS/ IDSA guidelines, HCAP is defined as a patient with pneumonia and any of the following historical features: (1) hospitalization for 2 or more days in an acute care facility within 90 days of infection, (2) resident of a nursing home or long-term care facility, (3) attended a hospital or hemodialysis clinic, (4) has received intravenous antibiotic, chemotherapy, or wound care within 30 days of infection. 3 46 1 Section of Emergency Medicine, Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana; 2 Section of Critical Care Medicine, Ochsner Medical Center, New Orleans, Louisiana. Address for correspondence and reprint requests: Ellen M. Slaven, M.D., Section of Emergency Medicine, Department of Medicine, Louisiana State University Health Sciences Center, 2021 Perdido St., 5th fl., New Orleans, LA 70112 (e-mail: eslave@lsuhsc.edu). Healthcare-Associated Pneumonia; Guest Editor, Marin H. Kollef, M.D. Semin Respir Crit Care Med 2009;30:46 51. Copyright # 2009 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. DOI 10.1055/s-0028-1119808. ISSN 1069-3424.

Table 1 Definitions: The American Thoracic Society/ Infectious Diseases Society of America Guidelines 2 Community-acquired pneumonia (CAP) Patients with pneumonia who do not meet HCAP, HAP, or VAP criteria Healthcare-associated pneumonia (HCAP) Hospitalized for > 2 days in an acute care facility within 90 days of infection, residing in a nursing home or long-term care facility Attending a hospital or hemodialysis clinic Receiving intravenous antibiotic therapy or immunosuppressive therapy or wound care within 30 days of infection Hospital-acquired pneumonia (HAP) Pneumonia occurring 48 hours post hospital admission Ventilator-associated pneumonia (VAP) Pneumonia occurring > 48 72 hours postintubation HAP is defined as a pneumonia that has developed 48 hours or more after hospital admission. VAP is defined as a pneumonia that has developed 48 hours or more after endotracheal intubation. CAP is defined as a patient presenting to the hospital or clinic from the community who does not meet any of the foregoing definitions (Table 1). It should be noted that, based on these definitions, CAP and HCAP will predominantly present to outpatient settings such as clinics and the ED. HAP and VAP diagnoses are traditionally made in the inpatient setting; however, a high level of suspicion should be used in patients that have recently been discharged or that present as transfers from other facilities. EPIDEMIOLOGY Kollef et al s recent retrospective epidemiological and outcome study of a multicenter database of 4543 patients with culture-positive pneumonia showed that 48.9% had CAP, 21.7% had HCAP, 18.4% had HAP, and 11% had VAP. Skilled nursing facilities accounted for nearly half of all patients with HCAP (49.6%). Demographic and clinical characteristics of patients with HCAP appeared to be more similar to those of patients with HAP than to those of patients with CAP. In addition, there were a statistically significant greater number of comorbidities in the HCAP group than in the CAP cohort. 4 PATHOGENS CAP is typically caused by Streptococcus pneumoniae, and atypical organisms such as Mycoplasma pneumoniae, Chlamydia pneumoniae, and respiratory viruses. Kollef et al found that the microbes most commonly found in HCAP IN THE EMERGENCY DEPARTMENT/SLAVEN ET AL 47 HCAP appear to be Staphylococcus aureus (46.7%), and Pseudomonas species (25.3%). Of the S. aureus species, 56.8% were found to be methicillin-resistant S. aureus (MRSA). In addition, HCAP was found to have significantly more Acinetobacter species than CAP (2.6% vs 1.6%; p < 0.05). The microbiological and resistance patterns found in HCAP were more similar to those of HAP and VAP than to those of CAP. 4 Emergency medicine (EM) physicians should be aware of resistance patterns found in their community and geographic area. Drug-resistance patterns and pathogens causing nosocomial and healthcare-related infections are in a continuous state of flux and directly impact community patients presenting to the ED. MORTALITY Kollef et al showed that HCAP has similar outcomes to that of HAP. Mortality rates in the HCAP and HAP groups were nearly identical (19.8% vs 18.8%; p > 0.05) and significantly higher than those of the CAP group (19.8% vs 10%; p < 0.0001). In addition, length of stay and cost were significantly higher with HCAP than with CAP. 4 IDENTIFYING PATIENTS AT RISK FOR HCAP History By definition, HCAP involves the recent exposure of the patient to healthcare environments. It is important to elucidate the historical features that define HCAP. The clinician should ask about recent hospitalizations, length of hospitalization, nursing home or long-term care facility admissions, attendance at hemodialysis clinics, recent intravenous antibiotics, chemotherapy, or wound care. Such information can change the management from one geared to CAP to one focused on HCAP (Table 2). Table 2 Questions for All Pneumonia Patients in the Emergency Department to Aid in Healthcare-Acquired Pneumonia Diagnosis 1. Have you been hospitalized within the past 90 days? 2. Do you reside in a nursing home or long-term care facility? 3. Do you receive hemodialysis? 4. Have you attended a healthcare setting for same-day procedures or sought care in an emergency department within the past 30 days? 5. Have you received antibiotics, chemotherapy, or wound care within the past 30 days? 6. Are you immunocompromised? 7. Have you had contact with someone who had been diagnosed with a multidrug-resistant infection?

48 SEMINARS IN RESPIRATORY AND CRITICAL CARE MEDICINE/VOLUME 30, NUMBER 1 2009 Physical Examination In patients presenting to the ED with pneumonia, there is no specific physical exam finding that differentiates HCAP from CAP. However, there are physical exam findings that can raise suspicion for HCAP. Patients who are bedridden, profoundly disabled, incontinent, or malnourished, or who have indwelling catheters, contractures, difficulty swallowing, or require feeding tubes are all likely to have had recent exposure to a healthcare environment and have an increased risk for HCAP. 5 Such findings are especially important in patients if the history is incomplete or difficult to obtain. In addition, the presence of these findings in patients presenting with pneumonia should trigger the clinician to add HCAP to the differential diagnosis and prompt further historical information. Management The initial ED management of the patient with HCAP is dictated by the severity of illness. Assessment of the airway, ventilation, and circulatory status are paramount, and intervention occurs as required. Supplemental oxygen is provided if the patient is hypoxic, intubation is indicated for respiratory failure and intravenous saline, and possible vasopressor agents are administered for septic shock. LABORATORY TESTING/DIAGNOSTIC STUDIES Laboratory Testing All patients with HCAP should have a complete blood count, basic serum chemistries, and liver function panel obtained. Serum lactate should be measured in those who have severe illness. Additional testing, such as D-dimer, B-type natriuretic protein, and cardiac enzymes, may be indicated. Abnormalities detected may alter treatment regimens and may assist in discharge planning. Pulse Oximetry Oxygen saturation should be measured by pulse oximetry in all patients with pneumonia, including HCAP. Additionally, arterial blood gas analysis should be obtained in patients with abnormally low oxygen saturation, with tachycardia, those that have underlying respiratory disease such as chronic obstructive pulmonary disease, and those requiring ventilator support. Chest Radiographs A chest radiograph must be acquired in all patients suspected of having any type of pneumonia, including HCAP. Ideally a posterioranterior and lateral radiograph is preferable to a portable image to increase accuracy. There is no evidence to suggest that radiographic findings differ between CAP and HCAP. A negative radiograph does not exclude the diagnosis of HCAP, particularly if the patient demonstrates symptoms and signs of pneumonia. Computed tomography of the chest is a more sensitive study and may be obtained in the presence of diagnostic uncertainty. 6 Microbiological Testing The recommendations for microbiological testing for patients with HCAP are distinctly different than those for patients with CAP. 3 The IDSA/ATS consensus guidelines published in 2007 acknowledge that microbiological testing for patients with CAP remains controversial. 2 Based upon the frequent low yield and the minimal impact regarding clinical care, routine testing for patients with CAP is now considered optional for patients without severe disease. Blood samples and expectorated sputum for culture are indicated for patients with CAP with more severe disease and in those where the results of the cultures are likely to change the clinical management, such as those with underlying comorbid diseases and those with cavitary lesions on chest radiographs. The reasoning behind the differing recommendations between CAP and HCAP is that early empirical therapy for patients with HCAP must be quite broad to ensure adequate activity against a rather large pool of potential pathogens, pathogens that more closely resemble those identified in patients with HAP and VAP as opposed to those identified for CAP. Early and appropriate antibiotic therapy has been shown to improve outcomes in patients with HCAP, in particular, improvements in mortality. 7 If microbiological testing yields a pathogen, or pathogens, then the initially broad antibiotic regimen may be narrowed or deescalated as quickly as possible to reduce the unnecessary exposure of antimicrobials. Thus the recommendations are to obtain cultures of both sputum and blood samples on all patients suspected of having HCAP, regardless of severity of disease. Preferably the samples should be collected prior to the administration of antibiotics. 3 However, delay of antibiotics to secure sputum or blood samples must be avoided. ANTIBIOTIC SELECTION The consensus guidelines from the ATS/IDSA for the management of patients with HAP, VAP, and HCAP delineate the need for early delivery, appropriate selection, and adequate dosing of antibiotics. The guidelines also highlight the distinction between recommendations for patients with HCAP, who should be treated more similarly to patients with HAP or VAP than those with CAP. Within the ED the selection of antibiotics is empirical and based upon likely pathogens and the likely antimicrobial resistance of those pathogens. It is imperative for emergency physicians to be familiar with the local susceptibility and resistance patterns of common pathogens because antimicrobial resistance patterns vary according to geographic regions and between hospitals. Current hospital-based antibiograms must be made available in the ED.

Table 3 Antibiotic Regimens for Healthcare-Acquired Pneumonia Antipseudomonal b-lactam PLUS Piperacillin/tazobactam Imipenem Meropenem Cefepime Ceftazidime Antipseudomonal fluoroquinolone PLUS Ciprofloxacin Levofloxacin Anti-MRSA* agent Vancomycin Linezolid *MRSA, methicillin-resistant Staphylococcus aureus. Recommendations for antibiotics for patients with HCAP include combination intravenous therapy with an antipseudomonal b-lactam (piperacillin/tazobactam, imipenem, meropenem, cefepime, or ceftazidime) plus an antipseudomonal fluoroquinolone (ciprofloxacin or high-dose levofloxacin) plus coverage for methicillin-resistant Staphylococcus aureus (vancomycin or linezolid). If a patient has been treated with an antibiotic within the previous 90 days avoid using an agent from the same class if possible (Table 3). If the patient has an allergy to penicillin gentamicin may be substituted for the b-lactam. In our institution commonly utilized combinations include piperacillin/ tazobactam, ciprofloxacin, and vancomycin. DISPOSITION The ATS/IDSA guidelines do not directly address the possibility of outpatient therapy for patients with HCAP, and the recommended antibiotic regimens include primarily intravenous agents. 3 The guidelines suggest that patients at risk for HCAP are a population that is previously ill. Because the precise description of the risk factors for HCAP remain dynamic it is likely that some patients with HCAP may not have underlying comorbid conditions. It is not difficult to imagine a scenario where a patient at risk for HCAP is not seriously ill. For example, a 25-year-old, normally healthy man presents to the ED with pneumonia. Upon questioning it is determined that he underwent an appendectomy 6 weeks ago. It was noted during surgery that his appendix had ruptured, and he subsequently received 3 days of intravenous antibiotics and was discharged home in good condition. His current symptoms of pneumonia are mild. He has normal vital signs. His pulse oximeter reads 99% oxygen saturation on room air. And the patient desires to be treated at home. The decision on whether to admit a patient with pneumonia is an important one and not always easy. HCAP IN THE EMERGENCY DEPARTMENT/SLAVEN ET AL 49 The pneumonia severity index (PSI) is a prognostic model used to assess the risk of mortality, and the possible need for hospitalization, in patients with CAP. The CURB-65 model, another tool used to assess the need for admission for patients with CAP, does not require as many data points and is easily recalled. Neither model has been validated, nor studied, in patients with HCAP. However, it seems these two measures of objective criteria may be useful in decision making regarding admission for patients with HCAP. Pneumonia Severity Index The PSI classifies patients with CAP into five risk categories from class I (associated mortality < 1%) up to class V (associated mortality 27%). 8 The first step of implementing the PSI integrates the age of the patient, comorbidities, and physical findings. Patients less than 50 years of age, without comorbid illnesses and no abnormalities on physical examination, are assigned to class I and may be strongly considered for outpatient therapy. The next step of the PSI includes data from laboratory testing and radiography to assign patients to the remaining four classes. Patients assigned to risk class III and above should be considered for admission to the hospital. CURB-65 CURB-65 is an illness severity measure based upon the presence of confusion, uremia, respiratory rate, blood pressure, and age. It is a much simpler measure than the PSI; 1 point is assigned for each of the following: confusion, uremia (BUN > 20 mg/dl), respiratory rate > 30/minute, blood pressure < 90 mm Hg systolic or 60 mm Hg diastolic, and age > 65 years. 9 The higher the score the greater the associated mortality, from < 1% with a score of 0 to 57% with a score of 5. Patients with scores of 0 or 1 may be considered for outpatient therapy, whereas those with a score of 2 or more should be hospitalized. Intensive Care Unit Admission to the intensive care unit (ICU) is required for patients requiring invasive mechanical ventilation due to respiratory failure and/or vasopressors for septic shock. The presence of three or more minor criteria also warrants admission to the ICU. These minor criteria include multilobar infiltrates, BUN > 20 mg/dl, confusion, PaO 2 :FiO 2 ratio 250, serum lactate > 4, asplenia, alcoholism/cirrhosis, and unexplained metabolic acidosis. Additionally, patients with a PSI risk class of V and/or a CURB-65 score of 3 or greater are often candidates for ICU admission. Outpatient Therapy Once a patient with HCAP has been determined to have mild disease and may be safely treated as an outpatient, microbiological testing should proceed with sputum Gram staining and culture of both sputum and blood. There is currently a lack of evidence to support the utility of this recommendation,

50 SEMINARS IN RESPIRATORY AND CRITICAL CARE MEDICINE/VOLUME 30, NUMBER 1 2009 and until such data demonstrate otherwise, we suggest to continue with aggressive microbiological investigation and to err on the side of caution in investigating potential pathogens. There is also no evidence to support which antimicrobial agent, or agents, are preferable in this scenario. Monotherapy with an oral fluoroquinolone (levofloxacin or moxifloxacin) has been proposed as a practical choice. 10 A study of 680 nursing home patients with HCAP compared usual care versus a clinical pathway that allowed for oral therapy with levofloxacin in the nursing home for patients with nonsevere disease. 11 Mortality and health-related quality of life were comparable between the two groups. Patients selected to be treated as outpatients should be instructed to follow up within 1 to 2 days for clinical reassessment and evaluation of culture results. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS MRSA is a well-known pathogen in HAP and VAP. Recently, MRSA has been identified as a pathogen in HCAP. A retrospective review of a large inpatient database revealed S. aureus, both MRSA and methicillin-sensitive S. aureus, to be the dominant pathogen in HCAP. 4 This report was limited by its retrospective design and inclusion of only culture-positive hospitalized patients. Therefore, the actual incidence of S. aureus, in particular MRSA, in HCAP remains unknown. Within the past decade the emergence of community-acquired MRSA (CA-MRSA) has dramatically demonstrated how antimicrobial resistance alters the management of common infectious diseases. CA- MRSA predominantly causes skin and soft tissue infections but reports of severe pneumonia continue to be published. 12 Pneumonia caused by CA-MRSA frequently afflicts previously healthy adults and children. This disease is characterized by a severe illness with necrotizing multilobar involvement, cavitary lesions, and hemoptysis. The mortality is high. Risk factors may include postinfluenza illness, prior infection or colonization with CA-MRSA, history of injection drug use, and perhaps close contact with another who is infected or colonized with CA-MRSA. Empirical treatment with either vancomycin or linezolid is a mandatory component of antibiotic therapy for patients suspected of MRSA pneumonia. CONCLUSION There is a need for EM clinicians to distinguish between CAP and HCAP in patients presenting to the hospital with pneumonia. There are discrete patient populations at risk for MDR pathogens, and HCAP is one of the diseases that alter clinicians traditional approach to patients presenting from the community. 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