By Dorothy Brooks
While patients with community-acquired pneumonia (CAP) commonly present to the ED, obtaining a proper diagnosis and determining the best treatment course is not always clear-cut. For one thing, while there are many evidence-based guidelines for CAP, many of these tools are more than 50 pages long, making it difficult to integrate them into clinical practice, explains Steven Burdette, MD, a professor of internal medicine at Wright State University and the infectious disease program director at Miami Valley Hospital in Dayton, OH. Burdette also is one of the clinicians who was tasked by the Centers for Disease Control and Prevention (CDC) and the Infectious Diseases Society of America (IDSA) to create a more concise tool.
“Our group had emergency department clinicians, hospitalists, pharmacists, and infectious disease physicians, so it was a collaborative group,” Burdette explains. “Not everybody out there is an infectious disease physician, and so we tried to put something together that any physician or healthcare provider — whether you’re a PA [physician assistant], a nurse practitioner or what have you — has the ability to access and to go through.”
A second, equally important task of the developer group was to ensure that the resulting tool prioritizes antibiotic stewardship in its treatment recommendations. “The guidelines [that are out there] are not written about antibiotic stewardship. We tried to be consistent with the existing guidelines but still add in some of the things that have emerged in the literature over the last few years since [many of the CAP] guidelines came out,” Burdette says.
For example, Burdette notes that research in recent years has shown that CAP can be effectively treated in three to five days. “From an antimicrobial stewardship standpoint, the duration of therapy is as important, many times, as the antibiotic selection, so we have included guidance [on that aspect],” he says. “There is also a little bit better guidance, from a stewardship standpoint, on de-escalation [from IV] to oral therapy for culture-negative patients.”
Burdette notes that 80% to 90% of CAP will be culture-negative, so the new pathway includes a table providing practitioners with specific oral de-escalation options. This is important because many times patients can finish their antibiotics at home following discharge from the hospital or ED.
Explaining how an emergency provider might first apply the new tool, Burdette says that typically, respiratory symptoms and abnormal imaging results will lead emergency providers to suspect CAP in a patient. However, the task becomes determining whether there are any risk factors evident for a methicillin-resistant Staphylococcus aureus (MRSA) or pseudomonas infection — either of which would drive the need for a broader-spectrum antibiotic choice.
Burdette emphasizes that a patient’s recent medical history (generally from the past year) is clinically relevant to consider. Too often, practitioners see that a patient with CAP had a pseudomonas infection a decade earlier and consequently opt for broad-spectrum antibiotics when a narrower choice would have been more appropriate from an antibiotic stewardship standpoint, he notes.
“If a patient has been hospitalized [with either of these infections in the past year], you’re probably going to have to be broader with your antibiotics — but again, instead of having to read five pages to figure out where to go, [the CAP Clinical Pathway] is really now down to one page,” Burdette says. “Is the patient medically stable enough for a medical floor, or is he ICU material? Then select your antibiotics based on whether there are MRSA or pseudomonas risk factors.”
Once the collaborative group members put their final touches on the CAP Clinical Pathway, they sent it out for pilot testing. “There were large academic centers and small community hospitals that volunteered to take this algorithm and either roll it into their electronic medical records [EMR] or just do education and utilize it,” Burdette says. “We wanted to get feedback from hospitals of various sizes on whether the providers could utilize this and whether they found it helpful.”
It also was important to seek input from a wide range of clinicians, Burdette explains. “Emergency medicine physicians see things differently because what they [see and] have available in the ED is different than what I have as an infectious disease doctor who is seeing somebody on day three of hospitalization,” he says. “We tried to take as many perspectives into account as possible. This [tool] is meant to help somebody at a major academic center or somebody in a critical access hospital. There should be something for any level of healthcare provider that utilizes this.”
In addition to collecting input from a wide range of clinicians, the developers discovered that the various medical centers involved with pilot testing tended to reap value from the tool in different ways. For example, Burdette notes that for facilities that conduct grand rounds, the tool could be used as part of the education process. Other facilities were more interested in converting the tool into their own pathways.
“Every facility had one or two ideas on what they thought was the best way to roll this out, so making it available is the first step, and then letting sites decide how they can best utilize in it their facilities is step two,” Burdette says. “I think from a big picture standpoint, finding a way to incorporate this into the EMR would be the most beneficial.”
With all the pilot testing completed, the new CAP Clinical Pathway tool is available to frontline practitioners to integrate it in a way that fits with their available resources and practice settings. (Recently, the tool was added as an additional resource within the ATS/IDSA guidelines on the diagnosis and treatment of adults with CAP: https://www.idsociety.org/prac....)
“We tried to write this knowing that how you do things in the ED in one hospital may be different than the ED at another hospital,” Burdette explains. “We understand that a test in some hospitals will come back in an hour, and the same test in another facility may not come back for four days because [they have to] send it out.”
Similarly, different hospitals use different formularies that need to be considered. “What we would like people to do is take this template and then customize it to their formulary for antibiotics, their local resistance patterns, and the availability of testing [in their practice setting],” Burdette observes. “They can use this [pathway] as a foundation, and then customize it for their local patient needs and access to lab testing and medications.”
While patients with community-acquired pneumonia (CAP) commonly present to the ED, obtaining a proper diagnosis and determining the best treatment course is not always clear-cut. For one thing, while there are many evidence-based guidelines for CAP, many of these tools are more than 50 pages long, making it difficult to integrate them into clinical practice.
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