Topic: Complex Pneumonia
Scenario:
- 82 yr. old female admitted from her skilled nursing facility with complaints of chest pain, SOB and cough with yellow mucus.
- Hx of COPD, on continuous O2 at 2L with recent hospital discharge for exacerbation, CVA with dysphagia.
- Assessment, patient noted with wheezing, rhonchi with mild dyspnea.
- VS: temp 99.2, HR 90, RR 20, BP 132/85, O2 Sat 93% on room air.
- WBC: 7.8, CXR: “right basilar infiltrate consistent with pneumonia”
- Admitting diagnosis: Suspected HCAP
- Orders:
- 2 gm Cefepime IV q 12h
- Duonebs
- O2 to keep SaO2 above 90%
- Sputum and blood cultures
- Infectious Disease consult
- Infectious Disease consult indicates, “at risk for Healthcare associated pneumonia”. Sputum culture noted with moderate growth of pseudomonas aeruginosa. IV Zosyn added.
- Swallow evaluation showed aspiration with thin liquids, recommended thickened liquids.
- Discharge summary noted “HCAP due to recent hospitalization”.
Principal diagnosis assigned: Healthcare associated pneumonia (J18.9); Nosocomial condition (Y95)
Secondary diagnosis assigned: COPD with Acute lower respiratory infection (J44.0)
Dependence on supplemental oxygen (Z99.81)
DRG: Simple Pneumonia & pleurisy with cc (DRG 194)
Question: Are there query opportunities based on the scenario stated above?
Discussion:
Patient presents with indicators of targeted pneumonia treatment. However, the diagnoses from the attending physician and by the Infectious Disease consult are both non-specific.
The patient exhibited risk factors for a complex pneumonia such as:
- Skilled nursing facility resident
- Cough with yellow mucus
- COPD on home O2 at night
- Recent hospital stay for COPD exacerbation
- CXR with right basilar infiltrate
- Failed swallow evaluation
- Treated with Cefepime with addition of Zosyn following sputum culture growth of pseudomonas aeruginosa
UASI Recommends:
Query for specificity of pneumonia: Pseudomonas and/or Aspiration Pneumonia
Also possible query for chronic respiratory failure since the patient has COPD with continuous O2 use.
Potential DRG change from Simple Pneumonia & pleurisy with cc (DRG 194) to Respiratory Infections & inflammation with cc (DRG 178)
CDI Education Tips:
There are indicators to be on alert for that pose as risk factors for complex pneumonias:
- Debilitated/Aged patients (i.e., Skilled Nursing residents or recent Rehabilitation care)
- Immunocompromised patients (i.e., long-term steroid treatment, s/p organ transplant, chemotherapy patients)
- COPD/Chronic Disease (i.e., lung diseases like Bronchiectasis with Cystic Fibrosis, DM, CHF, CKD, Alcoholism)
- Recent hospitalization
- Recent antibiotic treatment (i.e., inpatient or outpatient treatment (failed or not))
- O2 dependencies (i.e., contaminated oxygen equipment and devices)
Be on the look out for treatment and monitoring for additional indicators of complex vs. a simple pneumonia being treated:
- WBC with left shift
- Two or more antibiotics/switching antibiotics two or more times/use of organism specific antibiotics
- Worsening status despite treatment
- Infectious Disease consult
- Sputum and blood cultures
- Speech evaluations
Possible Antibiotic Coverage | |
Zosyn (Piperacillin + Tazobactam) | Aspiration, gram neg rods |
Gentamycin, Tobramycin, Amikacin | gram neg rods |
Aztreonam, Cefazoline, Cefepime, Cefotaxime, Ceftazidime, Ertapenem, Meropenem, Primaxin | pseudomonas and gram neg rods |
Ciprofloxacin | pseudomonas |
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.