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Monthly CDI Discussion – Complex Pneumonia

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.