Management of community-acquired pneumonia in persons with spinal cord injury

Abstract

Study design: Retrospective case series. Objectives: Respiratory disorders are the leading cause of death in persons with spinal cord injury (SCI), but the epidemiology and medical management of pneumonia in persons with chronic SCI is not well characterized. We describe the clinical presentation of persons with SCI with community-acquired pneumonia (CAP), characterize its management and compare practice to recommendations for CAP in the general population. Setting: Three United States Veterans Affairs Medical Centers with specialized SCI services. Methods: Chart abstraction was performed for all persons with chronic SCI seen at participating centers for treatment of CAP during a 2-year period. Collected data included presenting signs and symptoms, laboratory and imaging results, initial antibiotic therapy, secretion mobilization techniques, in-patient vs outpatient management, length of stay, and mortality. Results: In all, 41 persons with SCI received treatment for CAP during the study period. A total of 32 (78.0%) patients were admitted for treatment; two (4.8%) required intubation and mechanical ventilation. Initial antibiotic coverage met guideline recommendations for only half of inpatients and infrequently provided adequate antipseudomonal coverage. Microbiologic testing was performed on 26 cases (63.4%) and demonstrated a specific pathogen in only five cases (12.2% of total). Three cases (7.3%) died during treatment for CAP, and 16 (42.1%) of 38 CAP survivors died within a median follow-up of 3 years. Conclusion: The majority of chronic SCI patients who present to specialized SCI centers with CAP are admitted for treatment. Short-term mortality is comparable to CAP in the general population.

Infections in the spinal cord-injured population: a systematic review

“…45,46 However, it is worth noting that symptoms of pneumonia may be more subtle in this population. Patients with SCI may present with weaker cough and consequently poor pulmonary hygiene, which could delay recognition, and conceivably delay recovery.…”

“…Five studies that addressed pneumonia were identified, including three retrospective cohort studies, 45 a retrospective case series 46 and one prospective study. 43 All were in adult populations, and four were in VA patient populations.…”

“…43 All were in adult populations, and four were in VA patient populations. [45][46][47] Sugarman et al conducted both a prospective and retrospective cohort analysis of SCI patients with fever. Pneumonia was found to be relatively rare in this study, with no definite cases in the prospective cohort (n = 72) and four cases in the retrospective cohort (n = 56).…”

“…Only five patients had organisms recovered for identification (Table 3). 46 Chang et al conducted a retrospective cohort study on 260 SCI patients with pneumonia admitted to a VA hospital between 1998 and 2000. No difference was found in mortality (overall rate 8.5%), but increased length of stay was observed in SCI cases.…”

Providers' beliefs and behaviors regarding antibiotic prescribing and antibiotic resistance in persons with spinal cord injury or disorder

“…9 The selection of azithromycin and fluoroquinolones for the treatment of CAP was consistent with another study showing that the most common outpatient treatments for veterans with SCI/D with CAP were macrolides and fluoroquinolones. 10 Wester and associates 3 showed that most clinicians felt antibiotic misuse was an important factor in resistance, but slightly under half were opposed to restricting broad-spectrum antibiotic use. Of the antibiotic choices we provided in the clinical scenario, levofloxacin, moxifloxacin, amoxicillin/clavulanate plus azithromycin, and cefpodoxime proxetil plus azithromycin are the regimens that are recommended by the IDSA guidelines for the CAP management of outpatients with comorbidities.…”