Volume 186 - Issue 2
Conundrums in community-acquired pneumonia
Authors: Patrick G P Charles, Paul D R Johnson and M Lindsay Grayson
Med J Aust 2007; 186 (2): 102-103. || doi: 10.5694/j.1326-5377.2007.tb00824.x
Published online: 15 January 2007
Published online: 15 January 2007
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.
References
- Campbell SG, Murray DD, Hawass A, et al. Agreement between emergency physician diagnosis and radiologist reports in patients discharged from an emergency department with community-acquired pneumonia. Emerg Radiol 2005; 11: 242-246.
- Malcolm C, Marrie TJ. Antibiotic therapy for ambulatory patients with community-acquired pneumonia in an emergency department setting. Arch Intern Med 2003; 163: 797-802. 0_pgfId-1151268
- Novack V, Avnon LS, Smolyakov A, et al. Disagreement in the interpretation of chest radiographs among specialists and clinical outcomes of patients hospitalized with suspected pneumonia. Eur J Intern Med 2006; 17: 43-47. 0_i1091788
- Waterer GW. Monotherapy versus combination antimicrobial therapy for pneumococcal pneumonia. Curr Opin Infect Dis 2005; 18: 157-163. 0_CBBDGADF
- Antibiotic Writing Group. Therapeutic guidelines: antibiotic. 13th ed. Melbourne: Therapeutic Guidelines Limited, 2006. 0_CBBEBAEC