Tackling Pneumonia in the Pharmacy

As cold and flu season approaches, another respiratory infection should be top of mind for health care providers. In the United States, approximately 1 million adults require hospital care due to pneumonia each year, of whom 50,000 die, according to the American Thoracic Society (ATS).¹ Pneumonia is also the most common cause of sepsis and septic shock, accounting for 50% of all episodes, and the rate of pneumonia-associated deaths has not improved, even with widespread introduction of antibiotic therapies.¹

Joan Kapusnik-Uner, PharmD, FCSHP, FASHP, vice president of clinical content at First Databank, began her clinical training and practice in infectious diseases, including oversight of inpatient hospital antibiotic stewardship and ambulatory clinic follow-up visits. She noted that community-acquired pneumonia (CAP) causes significant morbidity and mortality, and requires quick action when symptoms appear. Risk mitigation or prevention strategies also are important. “Even a small amount of continuing education coursework or reading can go a long way for staying informed about pneumonia management,” she noted.

The Society of Infectious Diseases Pharmacists gives members opportunities to stay informed. The Infectious Diseases Society of America (IDSA) also provides treatment guidelines and the latest updates.

Ramzan Judge, PharmD, BCCCP, clinical coordinator, pharmacy at Deborah Heart and Lung Center, Browns Mills, New Jersey, has spent the past 7 years working in an inpatient setting with providers to discern appropriate treatment, duration, and monitoring of outcomes, with most patients having either an active case or a past medical history of pneumonia.

According to Judge, pharmacists have become more involved in pneumonia management over the years and—as with many areas in health care—their role continues to evolve. “In an inpatient setting, pharmacists play an invaluable role in helping treat and monitor patients on various antimicrobial therapies,” he explained. “From renal dose adjustments to de-escalating [or] escalating therapies as needed, [these] are some of the valuable insights pharmacists offer daily. This is very telling in today’s climate. Similarly, as pharmacists, we are sought after for our ability to be meticulous in identifying drug-drug or drug-disease interactions.”

Rashmi Phumatia, senior health care analyst at Market Research Future, has been tracking the market for diagnosing and managing pneumonia for the past 6 years. Throughout the project’s duration, researchers have created connections with key opinion leaders including within the supply chain, in research, and in professional associations, as well as independent consultants who are significant stakeholders in the pneumonia management industry. Reports are released on a quarterly, half-yearly, or yearly basis depending on the kind of developments in the market.

“[Pneumonia management] has been steady over the past few years,” Phumatia said. “Depending on the severity of the pneumonia, the patient’s comorbid conditions, and any potential risk factors for drug-resistant bacteria, pharmacists advise several treatment plans, whether the patient is receiving care in a hospital or a home care setting.”

Health care providers depend heavily on antibiotic therapy as a sole means of management. Respiratory fluoroquinolones were introduced as an alternative to a combination of β-lactam and macrolide therapy in the 2000s based on the results of randomized controlled trials showing efficacy.^2,3 “However, owing to worries about the overuse of these broader-spectrum antibiotics, respiratory fluoroquinolones are still only prescribed to patients with severe β-lactam allergies in some countries,” Phumatia said. “Still, they are routinely used in the United States and in many European nations.”

The Latest Updates

The concept of pneumonia as an acute disease is slowly changing. Judge said pneumonia can accelerate overt chronic diseases, resulting in readmissions. Therefore, it is important to have predictive tools for pneumonia available to apply in the outpatient setting. These validated tools, he said, “will allow pharmacists and other providers to better [treat] patients.”

Shifting antibiotic sensitivities for the microorganisms that cause CAP is always an issue that pushes empiric use of broader spectrum antibiotics, such as third-generation cephalosporins. “There are efforts to restrict prescribing to narrower spectrum and less costly antibiotics such as azithromycin, levofloxacin, amoxicillin/clavulanate, and doxycycline,” Kapusnik-Uner said. “Antibiotics, though commonly prescribed, do not come without risk such as QT prolongation risk in elderly patients taking azithromycin or levofloxacin… even a short course of these antibiotics [posed] a risk in elderly patients.”

Kapusnik-Uner also noted that morbidity and mortality from influenza infection is of greater concern this fall and winter, because the Southern hemisphere has experienced a very difficult season. Experts recommend testing for influenza with a rapid molecular assay (ie, influenza nucleic acid amplification test), which is preferred over a rapid influenza diagnostic test (ie, antigen test).

Phumatia believes awareness of current management protocols, regulatory guidelines, and published treatment and management information is key to a pharmacist being up-to-date on pneumonia management. “In conditions such as CAP, this becomes more important as there is no gold standard of treatment,” she added. For example, according to the latest guidelines from ATS and IDSA, released in 2019,⁴ the therapeutic recommendation for patients with CAP is a minimum of 5 days’ antibiotic therapy.

Although there is constant demand for and use of macrolide antibiotics for adults and amoxicillin for children, there is a slow, continuous influx of newly approved drugs and therapy in the market, which helps grow market capital.

“As parallel therapy to antibiotics, demand for [nonsteroidal anti-inflammatory drugs] such as ibuprofen and painkillers such as [acetaminophen] also witness high consumption,” Phumatia said. “We think the market-wide consumption of these products is far from saturation and will experience consistent growth over the next few years, fueled by the growing prevalence of pneumonia.”

Still, there are concerns related to the management of certain types of pneumonia, such as CAP, viral pneumonia caused by respiratory syncytial virus, and pneumonia caused by Pneumocystis jirovecii, which is common and responsible for 25% to 30% of all pneumonia deaths in infants with HIV.

“There is significantly less medical knowledge and, by extension, standard treatment and management protocols, for these conditions,” Phumatia said. “Most of the new industry advances have been focused on the same.”

Pneumonia Vaccines

Pneumococcal vaccines are another integral preventive health care measure. There are several types of these vaccines that help prevent lung infections, especially those infections serious enough to be considered pneumonia where there may be compromised blood oxygenation, changes in mental status, and breathing difficulties.

The 2 main pneumonia categories for which pharmacists have ready access to preventive vaccines are bacterial pneumonia—caused by the aggressive pneumococcus microorganism Streptococcus pneumoniae—and viral pneumonia. Vaccines for bacterial pneumonia, Kapusnik-Uner noted, are extremely important; there are several types of pneumococcal vaccines given in a series or on a special schedule.

“Pharmacists are well poised to communicate the optimal regimen to patients based on new CDC guidelines and communicate that information electronically to [a patient’s] health care provider,” she said. “This year, 2 new pneumococcal conjugate vaccines [PCVs]: PCV15 [Vaxneuvance] and PCV20 [Prevnar 20] are recommended,” a change from previous guideline recommendations of PCV13 [Prevnar 13] and PPSV23 [Pneumovax 23]. “Pharmacists can sort through a patient’s vaccine history to help guide future vaccine scheduling.”

The pneumococcal vaccine has been a significant factor in the management of pneumonia caused by S pneumoniae. Although PCV13 and PPSV23 are most beneficial to only a subset of the population, including adults older than 65 years and some individuals aged 19 to 65 years, there have been immense benefits from these vaccinations.

Pharmacists can also educate patients that COVID-19 and annual influenza vaccines can be administered during the same visit and have wide availability for adults.

“Pharmacists who have ongoing dialogue in the community retail pharmacy setting with their high-risk patients can encourage individual conversations about concerns and highlight benefits to administration,” Kapusnik-Uner said. “Many [individuals] do not understand, for example, the great benefits of the new bivalent COVID-19 booster that should be given to all.”

Proper Pneumonia Management

Staying up-to-date on pneumonia management starts with regular review of core guidelines and recommendations from IDSA, the CDC, and the National Institutes of Health, Judge noted. “A pneumonia diagnosis requires the quick recognition of serious symptoms, especially in high-risk patients such as those with chronic obstructive pulmonary disease [or] asthma and in elderly or immunocompromised patients,” Kapusnik-Uner said. “Pharmacists are well positioned in the community to know when patients may have pneumonia with a chronic lung disease exacerbation.”

In the future, pharmacists may play a bigger role in identification and triage of these patients, thereby achieving earlier diagnosis—which could facilitate quicker initiation of antimicrobial therapy that improves morbidity and mortality outcomes.

Key Challenges

Judge agreed that being near patients will provide pharmacists with opportunities to administer vaccines for prevention and to prescribe therapies to treat mild pneumonia. “The biggest challenge is finding the balance,” he explained. “Pharmacists working in a retail setting are already inundated with responsibilities, with minimal help. To increase the reach of the pharmacists, there needs to be dedicated time for [these] valuable services.” The second challenge, he added, is buy-in from pharmacists.

“Pharmacist and pharmacy technician roles and responsibilities may need reevaluation to achieve new and emerging goals,” Kapusnik-Uner said, adding that reimbursement for services is “a key factor to consider that will make a difference.”

References

1. Top 20 pneumonia facts—2019. American Thoracic Society. Accessed October 17, 2022. https://www.thoracic.org/patients/patient-resources/resources/top-pneumonia-facts.pdf

2. Vardakas KZ, Siempos II, Grammatikos A, Athanassa Z, Korbila IP, Falagas ME. Respiratory fluoroquinolones for the treatment of community-acquired pneumonia: a meta-analysis of randomized controlled trials. CMAJ. 2008;179(12):1269-1277.

3. Lui S, Tong X, Ma Y, et al. Respiratory fluoroquinolones monotherapy vs β-lactams with or without macrolides for hospitalized community-acquired pneumonia patients: a meta-analysis. Front Pharmacol. 2019;10:489. doi: 10.3389/fpharm.2019.00489

4. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. 2019;200(7):e45-e67. Doi:10.1164/rccm.201908-1581ST

5. Pneumonia. Johns Hopkins Medicine. Accessed October 24, 2022. https://www.hopkinsmedicine.org/health/conditions-and-diseases/pneumonia