New Directions in Antiinfective Therapy for Community‐Acquired Pneumonia in the Emergency Department

Abstract

The emergency department is becoming an increasingly important setting for the management of community-acquired pneumonia (CAP). This trend reflects the shortened hospital stays and decreased mortality among elderly hospitalized patients resulting from rapid administration of antimicrobials. In addition, decisions about the site of care (inpatient vs outpatient) and antimicrobial therapy frequently are made in the emergency department. Recent research and subsequent clinical guidelines may help with these decisions. For example, recently issued guidelines, such as those of the Infectious Diseases Society of America and the American Thoracic Society, suggest that selection of antimicrobials for CAP (which is typically empiric) should be based on the potential pathogens and likelihood of antimicrobial resistance. Macrolides and tetracyclines are recommended in younger patients with mild-to-moderate disease. Patients with more severe disease and those at risk for drug-resistant pathogens should be treated with broad-spectrum therapy, such as a newer fluoroquinolone or a cephalosporin plus a macrolide. When hospitalization is required, early switch from intravenous to oral therapy, followed by early discharge, can be a highly successful strategy. Antimicrobials that are available in both intravenous and oral formulations, such as the newer fluoroquinolones (e.g., levofloxacin and gatifloxacin), can simplify switch therapy For outpatients, an initial long-acting parenteral dose of azithromycin, ceftriaxone, or levofloxacin followed by oral therapy is an effective protocol. In addition, use of a prediction rule to identify low-risk patients with CAP may help guide decisions about the need for hospital admission.

National Study of Antibiotic Use in Emergency Department Visits for Pneumonia, 1993 Through 2008

“…Pneumonia accounts for a large proportion of ED visits in the United States and is associated with a high rate of morbidity and mortality 8–10 . We observed that rates of pneumonia were disproportionately higher among blacks and the elderly.…”

Reemergence of Established Pathogens in the 21st Century

“…In general, organisms considered resistant by microbiological standards increase the frequency of treatment failure, relapse, and mortality (examples are observed with Mycobacterium tuberculosis [O'Brien, 1994;Portaels et al, 1999], S. pneumoniae [Moran, 2001], Staphylococcus aureus , Pseudomonas aeruginosa [Carmeli et al, 1999;Olson et al, 1985], and Neisseria gonorrhoeae ). For a given patient, however, treatment may be successful even though the infection is caused by a pathogen deemed to be resistant by breakpoint criteria .…”

Use of intravenous antibiotics for the treatment of community-acquired pneumonia in the emergency department

“…A number of severity-related variables were associated with an increased probability of receipt of IV agents, however, differences between hospital sites persisted despite controlling for differences in case mix. While an initial dose of IV antibiotics in the ED has been suggested as part of an outpatient management strategy (Moran 2001), further study is required to determine the extent to which such use may prevent unnecessary hospitalization, and improve outcomes.…”

“…However, patients at low risk treated on an outpatient basis receive predominantly oral antibiotics, while the majority of higher risk hospitalized subjects initially receive intravenously administered antibiotics (Gilbert et al 1998). While oral treatment is the norm among nonhospitalized patients, there is some support for initial treatment with parenteral antibiotics in the emergency department (ED) followed by oral administration (Moran 2001). The extent of this practice is unknown.…”