Nosocomial pneumonia: Hit it hard from start

Management strategies for nosocomial pneumonia are changing. The American Thoracic Society and the Infectious Diseases Society of America just issued the first new guidelines for the treatment of hospital and healthcare-related pneumonia in nine years. They appeared in the February issue of American Journal of Respiratory and Critical Care Medicine.

"This document represents an overall change in hospital practice," said Marianne Billeter, clinical pharmacist and infectious disease specialist at the Ochsner Clinic Foundation in New Orleans. "We used to treat pneumonia with 21 days of antibiotics without even thinking twice. There is a growing body of literature that says giving antibiotics for that long is doing more harm than good. The overall concept now is a shorter duration of therapy. That is going to be good for hospital practice."

The change in thinking is also going to present a battle in some institutions. Lead guideline author Michael Neiderman, M.D., chairman of the department of medicine at Winthrop-University Hospital, SUNY at Stony Brook, predicted that pharmacists, physicians, and patients would not see significant changes in day-to-day practice for several months.

The guidelines cover adults with hospital-acquired and ventilator and healthcare-associated pneumonias. Most evidence relates to ventilator-associated disease, the guidelines noted, but disease in patients who have not been intubated should be assessed and treated using the same approaches.

The goal, Neiderman said, is very aggressive empiric antibiotic therapy from the outset with regular reassessment and de-escalation of drug therapy as early as possible. Every patient with any respiratory infection that could be pneumonia should immediately be treated for pneumonia, he explained. Every patient who is treated should also have a lower respiratory tract culture to identify both the pathogen and susceptibility profile.

Once the culture is returned, therapy should be evaluated and adjusted or halted. Rather than the familiar 21 days of drug therapy, he said, three to four days should be sufficient for some patients. Most patients can be treated successfully in eight to 10 days.

What if the culture cannot be taken immediately? Start empiric therapy anyway, Neiderman advised. "You never want to delay therapy for the purpose of obtaining a culture," he explained. "We do not expect pharmacy to delay therapy in the name of getting a culture."

The new rush to treat is designed to improve patient outcomes, Billeter said. Even a 24-hour delay in initiation of antibiotic treatment is associated with significant increases in morbidity, mortality, length of stay, and treatment cost. Early, aggressive antibiotic use and less long-term therapy should help slow the development of drug resistance. And because long-term antibiotic therapy is associated with higher mortality, she added, treatment outcomes should also improve.

The new management strategies separate nosocomial pneumonia patients into one of two broad categories. The largest group has what could be early-onset pneumonia, any pneumonia-like disease that occurs within the first four days of hospitalization, and no risk factors for multidrug-resistant (MDR) pathogens. These patients should be treated with limited-spectrum antibiotics. All other patients with respiratory infections that could be pneumonia are at risk for MDR organisms and should be treated with broad-spectrum antibiotic combinations.

Risk factors for MDR organisms include any antimicrobial treatment within the preceding 90 days, current hospitalization of five days or longer, high frequency of antibiotic resistance in the community or the patient's hospital unit, exposure to any healthcare setting within the prior 90 days, home infusion therapy, home wound care, a family member with MDR pathogen, or any immunosuppressive disease or therapy.