The purpose of this literature review is to assess and appraise research studies in the last five years, investigating the latest management of community acquired pneumonia in immunocompromised adults patients. A literature search was performed using CINAHL Plus, Google Scholar, MEDLINE, EBSCOhost, UpToDate and PubMed databases. Boolean terms included: community acquired pneumonia, pneumonia, immunocompromised, adults, management, treatments, preventions, effectiveness, antibiotics, promotion, and outcomes. For each database, advance search was used and then limitations included systematic reviews, retrospective analysis, randomized control trial studies that were published, peer reviewed, full text, year of publication between 2010-2015, and English language, were applied.
Over the years, there has been an increase in diagnosis of immunosuppressive disease in the elderly in the community. Almost one third of hospital diagnosis in patients older than 6 years of age or older is community-acquired pneumonia and it is considered the sixth leading cause of death in developed countries according to Sousa, Justo, Dominguex, Manzur, Izquierdo, et al., 2012. In a prospective, observational study done in five public hospitals, where patients were diagnosed with CAP after seen in the emergency room three hundred and twenty cases were studied. Of those cases one hundred and fifteen occurred in immunocompromised patients. At all five hospitals, all patients had basic laboratory work completed such as basic metabolic panel, complete blood count, arterial blood gas, and a chest x-ray. However, after the initial laboratory tests, the administration of empirical antibiotics therapy based according to each hospital guidelines and policy, including microbiology studies. Patients were diagnosed with CAP if the chest X-ray showed new infiltrate and if a patient presents with one or more symptoms of the acute lower respiratory tract infections. These symptoms include cough, chest pain, fever > 100.4 F, temperature < 95 F and dyspnea within the last 24-hours. Patients were also considered immunosuppressed if they have one or more of these condition in their medical history “ underlying solid or hematological malignancy, solid organ or stem cell transplant, seropositivity for human immunodeficiency virus (HIV), splenectomy, radiotherapy, administration of corticosteroids and other immunosuppressive drugs, and congenital or acquired immune deficiency disorder”. The researchers were able to conclude that there has been increases in admission on elderly hospitalized for CAP and increasing number of them were secondary to their underlying immunocompromised health condition. However, the spread of microorganisms is the same for both immunocompromised and non-immunocompromised patients (Sousa et al., 2012).
One of the options available to treat CAP is the use of macrolide antibiotics. The United States National Library of Medicine define macrolides as antibiotics that contains bacteriostatic agents meaning it contains either biological or chemical agent that stops bacteria from either reproducing if not killing. Its is a broad spectrum antibiotics that works against gram-positive bacteria. Currently there are four macrolide antibiotics available in the United States: erythromycin, clarithromycin, azithromycin and telithromycin. In a systematic review and meta-analysis performed by Asadi, Sligl, Eurich, Colmers, Tjosvoild. et al., 2012, the researcher assess the effects of macrolide in the treatment of community acquired pneumonia compared to use of non-macrolide. Macrolide are considered to be effective against infection because of its its ability to modify the response of the immune system and anti-inflammatory properties. Prior research have shown that the use macrolide have been beneficial in treating inflammatory pulmonary diseases such as chronic inflammatory pulmonary disease such as chronic obstructive pulmonary disease (COPD). Nonetheless, a systematic review specifically assessing the effects of the use macrolide antibiotics on patients diagnosed with CAP has not been documented. The researchers used all randomized control trials (RCTs) and observational studies to compare the use of macrolide and non macrolide. Based on twenty three studies and 137,574 patients, it was reported that a 22% decrease in mortality is seen with the use of macrolide antibiotics compared with the use of non-macrolide antibiotics. Yet, when compared with the guideline-concordant regimens such as macrolide/beta-lactam combination therapies vs respiratory fluoroquinolone monotherapy instead of a non-macrolide antibiotic, results revealed that there was no significant difference in the mortality rate. The researchers concluded that the use macrolide antibiotic as empiric treatment does present with small advantages but more importantly, it demonstrated that adherence with antibiotics is key in treating patients diagnosed with CAP (Asadi et al ., 2012).
The American Thoracic Society and the Infectious Disease Society of America developed guideline-concordant regimens for pneumonias. The main focus is to improve the outcome of patients diagnosed with pneumonia including community acquired pneumonia. The guideline which consist of diagnostic tools, management and treatment is based on the initially assessment of the severity. Moran, Rothman, & Volturo., (2013) stated that Severity-of-illness scores, such as the “ CURB-65 criteria which consist of confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater, or prognostic models, such as the Pneumonia Severity Index (PSI), can be used to identify patients with CAP who may be candidates for outpatient treatment”. This is to prevent hospitalizing patients for CAP that can be treated as an outpatients. The CURB-65 criteria or the PSI provides objective scores that can help providers determine which patient is safe to be treated as an outpatients, and also assist in determining which level of care is required for patient that requires admission into the hospital. The guideline-concordant regimens for CAP stated that in order to diagnosis CAP, a chest x-ray must be obtained to confirm infiltrates. Additional supportive diagnostic tools such as confirmation by the microbiological data is optional, not required. It is however recommended that the pathogen should be determined once it is confirmed by chest X-ray, to help determine treatment option. The goals of empirical antibiotics therapy is to eliminate the causative organism by using appropriate antibiotics and completing the recommended course, to help prevent complications, and to improve the quality of life. See appendix A(WILL add the chart) for recommended antibiotics for inpatients as well as outpatients (Moran et al., 2013).
In a retrospective study by Chen, Slater, Kurdgelashvili, Husain, and Gentry (2013), the guideline–concordant antibiotic regimens of the use of empiric antibiotic in initial treatment of patients diagnosed with hospital acquired pneumonia (HCAPS) with community acquired pneumonia guideline–concordant antibiotic regimens were compared. Out of 228 diagnosed with HCAP, 122 patients was treated with CAP regimens and 106 was treated using HCAP regimens. HCAP regimens included “ 1 or more antibiotics with microbiologic activity against P. aeruginosa” organism and “Levofloxacin, gatifloxacin, and moxifloxacin therapies were classified as CAP regimens unless a second antipseudomonal agent was present”. Thirty days after discharge, patients were assessed to see if they meet all the clinical cure criteria which consist of “ no change in antibiotics because of therapy failure; no readmission, regardless of reason; no death, regardless of cause; and no antibiotics prescribed for pneumonia postdischarge”. It was considered clinical failure if the patients did not meet one or more of these criteria. The researchers also collected data to determine the hospital length of stay in both regimens. It was concluded that patients were more likely to achieve clinical cure using CAP guideline–concordant antibiotic regimens, whether it was for CAP or HCAP. Patients that were treated with CAP regimens was noted to have decreased in the number of days required for intravenous therapy, decrease length of stay as well as achieve higher clinical cure (Chen et al., 2013).
Over and Forrest (2011), conducted a retrospective cohort study of to evaluate the effectiveness of initial dual antibiotic therapy compared with single antibiotic therapy on mortality. Both groups of treatment received the first dose of antibiotic therapy within eight hours of admission. In the single antibiotic therapy group, patient received cefuroxime and for the dual antibiotic therapy group patients either received a Beta-lactam such as ceftriaxone or cefuroxime and macrolide. In the single antibiotic group 21% of the participants were considered immunocompromised whereas 17% of the participants were considered immunocompromised in the dual antibiotic group. The researchers were able to conclude that the single antibiotic therapy group had increase in mortality than the dual therapy group. It was concluded that initial empiric dual therapy with Beta lactam antibiotic and a macrolide decreases mortality in immunocompromised patients diagnosed with CAP.