Chief symptoms: Cough, fever, and shortness of breath
History: A 66-year-old woman with a history of type 2 diabetes and mild intermittent asthma was brought to the ED by her husband with a 3-day history of subjective fever, cough productive of thick yellow sputum, and worsening shortness of breath. She reported runny nose and a dry cough beginning 1 week ago, for which she took over-the-counter medication without significant improvement. She also reported a decrease in appetite, poor oral intake, and nausea. She reported no hemoptysis, chest pain, palpitations, headache, abdominal pain, vomiting, night sweats, or weight loss. She had no history of hospitalization in the last 6 months and reported no recent sick contacts or travel. Her last visit to a primary care physician was 3 months ago to refill her asthma and diabetes medications. Her home medications were metformin, 500 mg once daily, and albuterol inhaler, 2 puffs every 6 hours as needed.
The patient reported that she was adherent to her medications although she had no insurance. She reported no other medical or surgical history. She was allergic to cat dander but had no drug allergies. Her family history was positive for squamous-cell lung cancer in her father, who was a heavy smoker. She previously worked in the Coast Guard but she quit 5 years ago. She had been smoking 1 pack of cigarettes per day for about 25 years and reported binge drinking on weekends but no IV drug use.
Physical examination: Vital signs were as follows: temperature 101.5 °F, blood pressure 100/70 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 89% on room air that improved to 96% on 2 L of oxygen by nasal cannula. The patient was sitting in bed and appeared to be in mild to moderate respiratory distress, coughing and breathing using accessory muscles. She had tan skin with some hypo-pigmented patches on the upper back and many wrinkles on her face. Chest examination revealed crackles and bronchial breath sounds in the right lower lobe without wheeze, with diminished breath sounds and dullness to percussion on the right basilar region posteriorly. On cardiac examination, she had tachycardia with regular rhythm, normal S1 and S2 heart sounds, and no murmurs or S3. No jugular venous distension (JVD) or lower-extremity edema was seen. The rest of the exam was unremarkable.
Labs: A complete blood count showed a white blood cell count of 18,000 cells/mm3 with 68% neutrophils, 15% bands, 2% eosinophils, and 15% lymphocytes. Fasting glucose level was 140 mg/dL. Arterial blood gas showed a pH of 7.48, PaO2 of 59 mm Hg on room air, and PaCO2 of 25 mm Hg; bicarbonate level was 21 mg/dL. Sputum Gram stain showed gram-positive cocci in pairs and chains with 2+ white blood cells and some epithelial cells. Sputum culture grew pan-sensitive Streptococcus pneumoniae. The blood cultures were negative. B-type natriuretic peptide level was within normal limits. All other labs, including urinalysis, were within normal limits.
Imaging: Electrocardiogram (ECG) revealed regular rhythm and heart rate of 110 beats/min with no ST or T-wave changes. Posterior-anterior and lateral view chest X-ray revealed right-lower-lobe consolidation with air bronchograms and mild pleural effusion (<1 cm on the lateral X-ray, less than half of the hemithorax on upright X-ray) on the right. There was no cardiomegaly.
The patient was admitted to a medical floor with a diagnosis of “pneumonia” because her CURB-65 score was 2. The patient received a dose of azithromycin intravenously in the ED before being transferred to the medical floor. Sputum cultures/Gram stain and blood cultures were collected. Intravenous azithromycin, 500 mg daily, was continued for 3 days.
The patient started feeling better on day 2 and remained afebrile for 12 hours with improvement of her cough. She started eating well and was discharged on day 3 with 2 additional days of oral azithromycin, 500 mg once daily. She was advised to follow up at a free clinic in 3 weeks.
Ten days after discharge, the patient returned to the ED with severe dyspnea, productive cough, and hypoxia, requiring emergent endotracheal intubation and mechanical ventilation. She was found to have an empyema causing septic shock. The patient died on day 2 in the intensive care unit.
Q: Was our patient diagnosed correctly?
A: Yes, from a clinical perspective. However, the primary and secondary diagnosis should have been documented as “community-acquired pneumonia (CAP) due to Streptococcus pneumoniae” and “mild intermittent asthma” respectively. The improper documentation of “pneumonia” would have resulted in inappropriate coding of the diagnosis-related group (DRG), leading to lower-than-expected geometric mean length of stay (GMLOS) and lower reimbursement to the hospital.
Q: Was our patient managed and discharged appropriately?
A: No. While the CURB-65 score was used appropriately to determine need for admission, the patient was managed sub-optimally for the following reasons:
- Blood cultures and sputum cultures should have been taken in the ED before administration of antibiotics.
- The optimal antibiotic regimen for inpatient management of CAP is a respiratory fluoroquinolone or a beta-lactam antibiotic (ceftriaxone, cefotaxime, or ampicillin/sulbactam) plus a macrolide (azithromycin). Empiric therapy with a macrolide alone cannot be routinely recommended due to increasing resistance rate (1).
- The antibiotic regimen should have been tailored to the sputum culture results.
- The patient was discharged inappropriately early as she was afebrile for only 12 hours. The decision to discharge should be made only after the patient is afebrile for 48 to 72 hours (2).
- Influenza and pneumococcal vaccination should have been provided during the hospitalization.
- Smoking cessation assistance and education regarding avoidance of pets and alcohol should have been provided.
Q: Were care transitions handled appropriately at discharge?
A: No. The patient should have been advised to follow up within 1 week after discharge and to seek immediate medical attention if her symptoms worsened. Case managers and patient care coordinators should have been involved to facilitate outpatient care adherence and to decrease readmission risk, especially because the patient lacked insurance.
Pneumonia can be classified into 4 different types: 1) CAP, 2) health care-associated pneumonia (HCAP), 3) hospital-acquired pneumonia (HAP), and 4) ventilator-associated pneumonia (VAP).
CAP is defined as pneumonia in community-dwelling patients who have not had extensive health care contact in the last 30 days and were not hospitalized in the last 90 days (1). Inpatient treatment for CAP costs about $7.5 billion per year in the United States (3). Some of the predisposing factors for developing CAP are advanced age (>65 years), comorbidities (chronic obstructive pulmonary disease [COPD], cardiovascular disease, diabetes, neurologic illness, renal insufficiency, and malignancy), cigarette smoking, alcohol abuse, poor functional status, and immune suppression (4). Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Legionella pneumophila, Mycoplasma species, and Chlamydophila pneumoniae are a few of the commonly isolated organisms in CAP.
Common clinical features of CAP include cough, fever, chills, rigors, pleuritic chest pain, dyspnea, and sputum production. Although fever can be frequently absent in older patients (>65 years old) (5), a respiratory rate of 24 breaths/min or higher is noted in 45% to 70% of patients and may be the most sensitive sign in this group. Chest examination reveals crackles in most patients (6). The initial workup should include a complete blood count, a complete metabolic panel, and a chest X-ray with or without microbiological tests (blood and sputum cultures/Gram stain), and/or urinary antigen tests (Legionella pneumophila and Streptococcus pneumoniae) (1, 7).
Severity-of-illness scores such as the CURB-65 criteria (confusion, uremia, respiratory rate >30 breaths/min, systolic blood pressure <90 mmHg or diastolic ≤60 mmHg, age ≥65 years) and the Pneumonia Severity Index (PSI) are used to determine whether a patient should be treated in or out of the hospital. The PSI includes 20 different variables, limiting its practicality in a busy ED. In contrast, the CURB-65 criteria are easily remembered and widely used (8). Clinical judgment, however, should supersede any decision based on the PSI and/or CURB-65 score alone (9).
The goal of inpatient treatment is to attain resolution of symptoms, reduce mortality, and eradicate the causative organism (2). In a retrospective study of 13,771 Medicare patients, antibiotic administration within 4 hours of arrival at the hospital was associated with decreased mortality and length of stay in older patients with CAP (10). The recommended antibiotic therapy for an inpatient non-ICU case is either beta-lactam antibiotics (ceftriaxone, cefotaxime, or ampicillin/sulbactam) plus a macrolide (azithromycin) or, in case of penicillin allergy, a respiratory fluoroquinolone (levofloxacin, gemifloxacin, or moxifloxacin) (1). For ICU patients, the recommended antibiotic therapy includes a beta-lactam antibiotic plus a respiratory fluoroquinolone or macrolide.
If there are known risk factors for Pseudomonas, such as severe COPD, bronchiectasis, cystic fibrosis or aspiration (11), then the choices are a beta-lactam antibiotic (piperacillin/tazobactam, cefepime, imipenem/cilastatin, meropenem, or doripenem) plus respiratory fluoroquinolone or beta-lactam antibiotics plus an aminoglycoside and azithromycin, or a beta-lactam antibiotic plus an aminoglycoside and an antipneumococcal fluoroquinolone (1). If there is a risk of methicillin-resistant Staphylococcus aureus (MRSA) colonization such as hospitalization within the preceding year, oral antibiotics within the last 90 days, presence of skin and soft-tissue infection at the time of admission, and HIV-seropositive status (12), then vancomycin or linezolid should be added (1).
Patients with hypoxemia or respiratory distress can benefit from a trial of noninvasive ventilation (NIV), which can help reduce the need for intubation and prevent increased length of ICU stay and other ventilator-associated infections (13). A response to initial therapy should be seen in 48 to 72 hours, although overall, 6% to 15% of hospitalized patients with CAP do not respond to the initial antibiotic treatment. Thoracentesis followed by pleural fluid analysis should be performed if there is an effusion that meets specific characteristics on imaging studies (free-flowing but layers >25 mm on a lateral decubitus film (14), loculated and findings suggesting empyema). Bronchoalveolar lavage (BAL) and transbronchial biopsies can also yield a specific diagnosis if the previously mentioned investigations fail to pinpoint a cause or diagnosis in non-responders (2).
The decision to discharge should be made only if the patient is afebrile for 48 to 72 hours, is breathing without supplemental oxygen (unless required for pre-existing disease), and has no more than 1 clinical instability factor (defined as heart rate >100 beats/min, respiratory rate >24 breaths/min, and systolic blood pressure ≤90 mm Hg) (1).
Patients with CAP who show good clinical response within the first 2 to 3 days of therapy should be treated for a minimum of 5 to 7 days total (15). In patients who are treated with a combination of an IV beta-lactam and a macrolide and have risk factors for drug-resistant Streptococcus pneumoniae, an oral replacement option is amoxicillin, 1 g 3 times daily, to complete the course of therapy. When drug-resistant Streptococcus pneumoniae is not a concern, amoxicillin can be dosed at 500 mg 3 times daily or 875 mg twice daily. Patients who are treated initially with an IV respiratory fluoroquinolone can switch to the oral formulation of the same (levofloxacin, 750 mg/d, or moxifloxacin, 400 mg/d) to complete the course of therapy (1, 6).
Preventive care like vaccinating against pneumococci and influenza and counseling about smoking cessation have helped to reduce hospital admissions and mortality in CAP (16, 17). A patient's level of education, employment, and socioeconomic status have also been found to be associated with readmission risk (18). Strategies to reduce readmissions include combining clinical expertise with coordinated care, providing patient education, and maintaining close follow-up, including home monitoring and adjustment of medications (19). Patients who have been discharged from the hospital with CAP should have a follow-up visit, usually within 1 week (2).
Health care-associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP)
HCAP is defined as pneumonia that occurs in a non-hospitalized patient with extensive health care contact, as defined by 1 or more of the following: IV therapy, wound care, or IV chemotherapy within the prior 30 days; residence in a nursing home or other long-term care facility; and hospitalization in an acute care hospital for at least 2 days within the prior 90 days or attendance at a hospital or hemodialysis clinic within the prior 30 days. HAP is defined as pneumonia arising at least 48 hours after hospital admission (20). The presence of HAP can increase hospital stay by approximately 7 to 9 days per patient and has been reported to cost more than $40,000 per patient (21). VAP is pneumonia arising at least 48 to 72 hours after intubation (22). VAP occurs in between 9% and 27% of all intubated patients (23). Common pathogens for HCAP, HAP, and VAP include aerobic gram-negative bacteria such as Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Acinetobacter species, and MRSA (24, 25).
American Thoracic Society guidelines recommend ceftriaxone or levofloxacin/moxifloxacin or ampicillin/sulbactam or ertapenem as initial empiric antibiotic therapy for HAP or VAP in patients with no known risk factors for multidrug-resistant (MDR) pathogens (Pseudomonas aeruginosa, Acinetobacter species, and MRSA). For patients with late-onset disease or risk factors for MDR pathogens, the treatment should include: 1) an antipseudomonal cephalosporin (cefepime, ceftazidime) or antipseudomonal carbapenem (imipenem, meropenem) or beta-lactam/beta-lactamase inhibitor (piperacillin-tazobactam) plus 2) an antipseudomonal fluoroquinolone (levofloxacin, ciprofloxacin) or aminoglycoside (amikacin, gentamicin, tobramycin) plus 3) linezolid or vancomycin if MRSA is suspected (18).
Recommendations from the American Thoracic Society/Infectious Diseases Society of America guidelines have suggested that the duration of treatment should be guided by severity, time to clinical response, and the pathogenic organism. Shorter duration of HCAP, HAP, or VAP therapy (7 to 8 days of culture directed antibiotics) is preferred when good clinical response is evident. Longer-duration antibiotics (14 to 21 days) are indicated if there is fever greater than 38.3oC, if leukocyte count is greater than 10,000 cells/mm3, if chest radiograph shows no improvement, or if the patient is producing purulent sputum. Shorter courses of antibiotic therapy have been shown to result in better clinical outcomes than longer treatment (20, 25-27). Non-response (no clinical improvement after 48 to 72 hours of initial antibiotic therapy) should prompt a search for noninfectious mimics of pneumonia, unsuspected or drug-resistant organisms, extra-pulmonary sites of infection, and complications of pneumonia and its therapy (20).
CMS's performance indicators for pneumonia include a guideline-directed initial antibiotic regimen, blood cultures performed in the ED before initial inpatient antibiotic therapy, and 30-day mortality rate (6). It is also important to document the specific causative pathogen, as well as the severity of a patient's condition with comorbidities (Table). In our patient, the Medicare Value-Based Purchasing (VBP) program would have lowered reimbursements because pretreatment cultures were not taken, guideline-specified antibiotic therapy was not implemented, and the patient died within 30 days of admission.
In conclusion, this case demonstrates potential opportunities for better pneumonia care and outcomes, including adhering to guideline-directed medical therapy and improving transitions of care and documentation.