To the Editor: A seminal 1997 article by Fine et al described the pneumonia severity score from the Pneumonia Patient Outcomes Research Team study and raised the role for Hospital in the Home (HIH):

A recent article in the Journal by Charles et al2 omitted a role for HIH in managing community-acquired pneumonia (CAP). Where their protocol mentions outpatient care, readers are led to interpret this as oral therapy only, managed by a general practitioner. Similarly, it is implied that inpatient therapy relates to traditional treatment in a hospital ward. No further clarification is given. This is a surprising omission, given that one of the authors has written extensively in support of HIH in the past.3

HIH administers hospital-level therapy (intravenous antibiotics, oximetry, rehydration, medical and nursing attendance, with 24-hour cover) to a clinical subgroup of CAP patients who can be defined and included within any protocol.

Evidence suggests that HIH can offer effective and safe treatment of patients with acute CAP referred directly from hospital emergency departments after diagnosis.4-6 Many patients with pneumonia appreciate the option of well organised, acute, home-based care. An important and growing subgroup of patients living in residential nursing care facilities can also receive acute CAP treatment in facilities with HIH involvement.7 A significant proportion of patients receiving HIH care have failed oral therapy.4-7

Why the omission of HIH? Protocols are tools of influence to be tussled over. This sometimes conflicts with their general aim of organising science into process and progress. Fine and colleagues’ intent in investigating the use of pneumonia severity scores was to help address the question of where and how to treat acute pneumonia. One of the aims of developing scores was to broaden the treatment options, not to narrow them.

To the Editor: The recent editorial on community-acquired pneumonia (CAP) stated that “even in an era in which penicillin resistance appears to be increasing among some Streptococcus pneumoniae isolates, there have been no documented failures of high-dose penicillin in treating pneumococcal pneumonia or bacteraemia”.1

The medical literature suggests otherwise.

Firstly, North American guidelines do not mention penicillin at all, and, in one analysis of 25 996 hospitalised patients who received monotherapy, mortality was about 50% higher with penicillin monotherapy than with monotherapy with ceftriaxone, another cephalosporin, a macrolide or a quinolone.2

More importantly, however, the same study found that the mortality rate in patients (even low-risk patients) treated with two antibiotics, one of which was a macrolide, was half the mortality rate of patients treated with one antibiotic. Dual therapies used were a macrolide agent in combination with ceftriaxone, another cephalosporin, a penicillin or a quinolone. Best outcomes were achieved with a ceftriaxone–macrolide combination.

In a review of seven studies, Waterer3 found that patients with severe pneumococcal pneumonia or bacteraemic pneumococcal disease who were treated with two antibiotics had a significantly lower mortality rate than patients treated with a single antibiotic. This was despite the fact that the patients treated with a single antibiotic were not as ill initially as those treated with two antibiotics.

Research by Waterer and colleagues4 showed that the benefit of taking two antibiotics was most apparent in the highest risk hospitalised patients, in whom mortality was five times higher in those receiving one antibiotic than in those receiving two.

Thus, it is imperative that all patients with severe pneumococcal CAP be treated with two antibiotics, one of which should be a macrolide.

In reply: Whether Hospital in the Home (HIH) care is suitable for managing patients with community-acquired pneumonia (CAP) depends on what is considered an appropriate use of resources. Overall, we see relatively few indications for treating CAP patients with parenteral antibiotics via HIH, as, in our experience, most patients who do not need supplemental oxygen and are well enough to be treated at home are usually also well enough to be treated with oral antibiotics. If they are not well enough to take oral antibiotics, then admission to hospital as an inpatient is generally appropriate. The occasional exceptions to this are selected patients in nursing homes (where around-the-clock supervision is available if required) and some patients with CAP caused by pathogens like Pseudomonas or Acinetobacter who benefit from longer treatment courses and may not have the option of oral antibiotics.

Furthermore, a report submitted to the Victorian Department of Human Services regarding HIH care of CAP patients at a number of Melbourne HIH units identified significantly worse outcomes at some centres, mainly related to inappropriate patient selection. Notable, but fortunately rare, cases included some patients with pulmonary embolism incorrectly diagnosed as CAP. Given that between 20% and 50% of patients given a diagnosis of CAP in the emergency department do not have pneumonia confirmed by a radiologist,1-3 the ability of busy emergency department doctors to select patients appropriately is definitely a concern. Thus, HIH treatment of CAP patients may be appropriate occasionally, but very careful patient selection is vital.

In response to Bradley, the statement that there have not been any failures in treating pneumococcal CAP with penicillins refers to microbiological failures due to antibiotic resistance. Although several studies have suggested that combination therapy may reduce mortality from bacteraemic pneumoccocal infections, all of these have been retrospective observational studies. Thus, they lack the ability to control accurately for potential confounding variables such as disease severity, patient or family wishes, pre-morbid quality of life, or “not for resuscitation” status. Data are also lacking on co-infection with “atypical” pathogens such as Legionella. The immunomodulatory effects of macrolides, quinolones and tetracyclines on treatment response are also still being elucidated.4 We agree with the CAP treatment recommendations in the Australian antibiotic guidelines,5 which recommend dual therapy with a β-lactam antiobiotic plus either a macrolide or doxycycline for all patients who are not allergic to these drugs.