Skip to content

Monthly CDI Discussion – Complex Pneumonia

Topic: Complex Pneumonia


  • 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?

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.