Patients may be resistant to common antibiotics

Options for community-acquired pneumonia?

Rising resistance rates to commonly used antibiotics has complicated treatment of community-acquired pneumonia in the ED, says a new publication.1 "In the ED, it is important that we begin antibiotics in a timely fashion for those patients who are seriously ill," says Gregory Moran, MD, the study's lead author and ED physician at University of California-Los Angeles Olive View Medical Center in Sylmar, CA.

Since treatment must be started in the ED before culture results are available, the challenge is to predict the likelihood that the patient is resistant to antibiotics, says Moran. "We need to strike the balance between choosing antibiotics likely to cover the likely bugs, but not choosing antibiotics with coverage so broad that we will cause even more antibiotic resistance over time," he explains.

For patients with greater risk for resistance because of prior antibiotic use, or for more seriously ill patients, it's safest to err on the side of more broad coverage, says Moran. "This is because the consequences are greater and therapy can be narrowed later based on culture results," he says. "For those who are not so severely ill, we are willing to accept a greater chance that we may not cover every possible organism. Then therapy can be broadened in the event we find a resistant organism or the patient fails to improve."

Respiratory fluoroquinolones are commonly used because they cover the likely pathogens, including resistant Streptococcus pneumoniae, says Moran. "As we use these drugs more commonly, however, we are starting to see more resistance emerge among the gram negative organisms that cause other infections such as urinary tract infections," he notes.

Respiratory fluoroquinolones are appropriate for patients who have previously been exposed to other types of antibiotics and therefore have a higher likelihood of resistance, says Moran. "Other factors such as simplicity of dosing, allergy, and drug toxicities should also be considered," he says.

Standing orders at triage

In the ED, the diagnosis for pneumonia can be challenging, says Jane Hottinger, RN, MSN, ED clinical educator, Aurora Medical Center in Oshkosh, WI.

Nurses obtain a thorough history of all patients who present with flu-like symptoms, especially the elderly and very young who have a natural diminished physiological reserve and possibly comorbid illness, says Hottinger.

"Their presenting complaint may be recent flu-like symptoms or pneumonia, both treated and untreated," says Hottinger. "We are alerted to potential pneumonia by presenting complaints of new onset of high fever, chills, myalgia, tachypnea, tachycardia, and productive or nonproductive cough."

At triage, nurses listen to lung sounds and note rales, rhonchi, or any bronchial breath sounds in the lung fields. The triage assessment also includes oxygen saturation, and nurses trend for progressive hypoxemia. Standing orders allow nurses to initiate a saline lock; draw blood, which includes blood cultures for pathogen identification; and obtain sputum specimen and urine for analysis and culture.

"Based on the ATS [American Thoracic Society] guidelines, we try very diligently to obtain both urine and sputum specimens prior to antibiotic treatment. However, antibiotics are not held if the sputum or urine are not obtained in the ED," says Hottinger. "When a pathogen is yet to be identified, we base our treatment on our triage assessment."

The goal is to initiate antibiotics for all suspected or known pneumonia within four hours of admission to the ED, because this approach has been shown to improve mortality, says Hottinger. "As a result, our assessment and triage treatment is extremely important," she says.

If patients are known to be resistant to commonly used antibiotics, it becomes important to obtain all culture specimens as quickly as possible, says Hottinger. "We obtain urine through straight catheterization, and we induce sputum specimens through inhalation treatment with saline and suctioning," she says.

The ATS guidelines recommend fluoroquinolone for high-risk patients with community-acquired pneumonia being managed as outpatients. These include patients with pre-existing chronic obstructive pulmonary disease, immunosuppression, a history of recent hospitalization, or residents of chronic care facilities. "It is also given to the rising number of patients who are allergic to macrolides and doxyclycline, as well as to those patients who were treated and failed to improve on other medications," says Hottinger.

Reference

  1. Moran G. Approaches to treatment of community-acquired pneumonia in the emergency department and the appropriate role of fluoroquinolones. J Emerg Med 2006; 30:377-387.

For more information, contact:

Sources

  • Jane Hottinger, RN, MSN, Clinical Educator, Emergency Department, Aurora Medical Center, 855 N. Westhaven Drive, Oshkosh, WI 54904. Telephone: (920) 456-7420. Fax: (920) 456-7421. E-mail: dhottinger@new.rr.com.
  • Gregory Moran, MD, Emergency Department, University of California-Los Angeles Olive View Medical Center, Box 951722, 14445 Olive View Drive, North Annex, Sylmar, CA 91342. Telephone: (818) 364-3107. Fax: (818) 364-3268. E-mail: gmoran@ucla.edu.