AANP: Vaccination Against Pneumonia Should Be a Patient-Education Focus

INDIANAPOLIS, June 21 -- Community Acquired Pneumonia (CAP) is the sixth leading cause of death in the U.S., yet health care professionals don't always offer immunization to their most vulnerable patients.

So said Sophia Chu Rodgers, A.C.N.P., NP-C, a critical care nurse practitioner at Loveless Health Systems in Albuquerque, N.M., at the American Academy of Nurse Practitioners meeting here.

"In a 2003 survey, a good percentage of patients said they'd never been asked if they wanted vaccinations against influenza or pneumonia,
she said, noting mortality rates of 1% to 5% outside the hospital and 12% in those who are hospitalized.

Streptococcus pneumoniae is the most common cause of Community Acquired Pneumonia, which would impact the choice of antibiotic. However, it is important that the physician knows what species of bacteria are common in their community, to better target treatment.

For an otherwise healthy outpatient, that would most likely be a macrolide antibiotic or doxycycline. For those with comorbidities, those who are immunosuppressed, or who've been on antibiotics within the previous three months, the choice is usually a fluoroquinolone or beta-lactam plus a macrolide.

Rodgers went on to review the three other types of pneumonia.

Hospital acquired pneumonia (HAP) occurs 48 hours or more following admission to the hospital. It is the second most common cause of hospital-acquired infections and can add between 7 and 9 days to a hospitalization and more than ,000 to the cost.

Ventilator-associated pneumonia (VAP) develops 48 - 72 hours after the patient has been placed on a ventilator. It occurs in up to 27% of all patients who are placed on a ventilator. The longer a person is on the ventilator, the more likely they are to become infected.

There are many modifiable risk factors for these two kinds of pneumonia. Intubation and especially reintubation should be avoided, Rodgers said. Nasal tubes should not be used because the bacteria in the nose can migrate to the lungs. Patients should be kept at a 30-45 degree angle. Feeding through the stomach is preferred to using the veins since normal bacteria in the gut can relocate when they are not active in digestion. Daily interruption or lightening of sedation to assess how well the patient breathes on his own, and intensive insulin therapy to maintain blood glucose between 80 and 100 mg/dL are also important interventions.

"Of these elevating the head of the bed, daily "sedation vacations," and prevention of peptic ulcers and deep vein thrombosis have been identified by the Institute of Healthcare Improvement as being the most important interventions," said Rodgers. "They call this the VAP bundle."

Healthcare Associated Pneumonia (HCAP) is seen where the person has been in contact with the health care system recently such as being admitted to the hospital, residing in a nurse home or other long term care facility, received antibiotics, chemotherapy, or kidney dialysis.

"This is a new category that takes into account those who had a recent, ongoing contact with a healthcare worker, but did not really fall into any of the other categories," said Rodgers.