In 2003 the Centers for Disease Control and Prevision and the Healthcare Infection Control Practices Advisory Committee proposed several recommendations to prevent HAP and VAP, including staff education in preventing infection, infection and microbiologic surveillance, prevention of transmission of organisms (by sterilization or disinfection and by maintenance of equipment and devices), prevention of person to-person transmission of bacteria (through hand hygiene, gloving, wound care, and suctioning of respiratory secretions), modifying host risk for infection through vaccination (for influenza and pneumococcal disease), prevention of aspiration, and prevention of postoperative pneumonia. Recommendations for the prevention of VAP were published recently, and they support the CDC recommendations.

The use of prophylactic antibiotics or topical antibiotics to reduce oropharyngeal, tracheal, and gastric colonization or to selectively decontaminate these areas in at-risk patients has been investigated, but the interpretation of results is difficult because of methodological differences among studies. In a recent meta-analysis, the use of topical and systemic agents reduced the number of respiratory tract infections and deaths due to pneumonia in the ICU. Topical agents alone reduced the number of infections but did not change the mortality rate. The use of sucralfate, topical and systemic antibiotics, or topical antiseptics in the ICU setting remains controversial because of concerns about antibiotic resistance and cost-effectiveness. Recent guidelines from the Planning Group of the Canadian Critical Care Society and the Canadian Critical Care Trials Group do not support the use of sucralfate or intratracheal or topical antibiotics, although no recommendations were made regarding IV administration of antibiotics alone or in combination with topical antibiotics. The ATS-IDSA guidelines do not support the routine use of systemic or topical antibiotics to prevent HAP. Further investigations about the role of antibiotics in reducing HAP and VAP infections are required before these strategies can be used routinely.
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ROLE OF THE PHARMACIST

Various opportunities exist for pharmacists to participate in the management of CAP and HAP. Depending on practice setting, these activities may range from selecting an appropriate antibiotic to monitoring outcome and performing follow-up. In the community setting, pharmacists should encourage patients to complete the full course of antibiotic treatment to ensure clinical success as well as to minimize antibiotic resistance. Because many patients have one or more residual symptoms up to 30 days or more after antibiotic therapy ends, pharmacists should reassure patients if such symptoms persist. If patients indicate worsening symptoms (e.g., fever, chills, shortness of breath), they should seek appropriate medical attention. As previously mentioned, pharmacists should promote and encourage smoking cessation programs to decrease the risk of CAP.

Pharmacists should encourage patients at risk of influenza or pneumococcal disease to receive a pneu- mococcal vaccine and annual influenza vaccination. Informational materials such as patient brochures, posters, and reminders may be used in these efforts. Pharmacists may partner with public health authorities on a seasonal basis to offer “flu shot” clinics in local pharmacies to expand awareness and increase opportunities for the public to receive annual influenza vaccination.

Table 10. Role of the Pharmacist in the Treatment of Community-Acquired Pneumonia


Activity


Comments


Assess appropriateness of empiric therapy


Consider most likely pathogens and local resistance patterns.


Consider drug route of administration, drug dose, drug interactions,
patient allergy status,


and cost.


Follow up on patient’s progress


Monitor for improvement of
clinical signs and symptoms within
3
to 5
days.


If patient does not have some
indication of clinical response within
3
to
5 days
or


if patient deteriorates at any time, physician reassessment and
alternative drug therapy


may be recommended.


Assess medication tolerability and adherence.


For patients being managed as
outpatients, provide telephone follow-up within

48 to
72
h


of initiating antimicrobial therapy, to assess efficacy, tolerability,
and adherence


Streamlining: on day
2 or
3,
review culture and sensitivity
data; consider narrowing


spectrum of therapy if a pathogen is identified.


IV to PO step-down: on day
3 to
5,
consider switch to PO therapy if
patient is improving


clinically, is afebrile, is able to ingest oral therapy, and has a
normally functioning


gastrointestinal tract.


Duration: Usually
7 to
14
days, determined by patient’s
clinical response.


Prevention strategies


Vaccinate for influenza and
Streptococcus pneumoniae.


Encourage smoking cessation.


*Reproduced, with permission, from
Gin AS, Tailor SAN. Community-acquired pneumonia.
Can J Hosp Pharm
2001;54 Suppl

1:1-16. ©
Canadian


Society of Hospital Pharmacists.

To minimize antibiotic resistance, pharmacists can participate in educational activities to increase awareness about appropriate antibiotic use among prescribers, patients, insurers, and government. Pharmacists can also participate in programs to minimize antibiotic use and to educate the public that antibiotics should not be used for viral infections. In partnership with physicians, pharmacists can work to optimize the use of antibiotic therapy. More specific interventions are presented in Table 10.
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CONCLUSIONS

Pneumonia is a leading cause of morbidity and mortality in the community and in the hospital setting. Several risk factors may predispose a patient to CAP or HAP. S. pneumoniae is the most common cause of CAP, whereas gram-negative pathogens are often associated with nosocomial pneumonia. Antibiotics form part of the core management of CAP and HAP. Several guidelines have been published to assist clinicians in selecting an appropriate empiric regimen. Pharmacists have an important role to play, and they have various opportunities to participate in the prevention and management of pneumonia.