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Pneumonia – Treatment and Strategy

Rob Orman, MD and Cameron Berg, MD FAAEM
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EM:RAP 2016 December Written Summary 910 KB - PDF

Pneumonia isn’t just one illness. There are multiple factors to consider including  aspiration, multidrug resistance, and disposition. Cam Berg walks us through a pathway that makes order out of the pneumonia chaos.

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Ryan C. -

I think there was a significant point you all failed to touch on regarding the PO vs IV antibiotics for floor patients. I think that at this point, most practicing ER physicians know that PO antibiotics work just as well as IV. The issue with starting oral antibiotic therapy versus IV on many of these pneumonia admissions (or any admission for infectious pathology) is that it makes it more difficult for our hospitalist colleagues to get reimbursed for the admission. I know PO clindamycin has 90% bioavailability as does the hospitalist; however, if it makes it easier for the hospitalist to get reimbursed for the job they provided, I'm going to give IV clindamycin for the ill appearing cellulitis patient in order to help them out.

Now obviously if evidence comes out demonstrating that we are harming patients by starting patients on IV antibiotics versus PO, or if insurance companies make it easier to get reimbursed for admissions (which will never happen) I will change my practice.

Patrick B. -

According to McKesson, since at least 2014 they have recommended any antibiotics for pneumonia, not just IV. Hence, "the need IV antibiotics for reimbursement" myth is, well, just that.

There's also reasonable data that IV antibiotics have more risk than their PO counterparts:

https://www.ncbi.nlm.nih.gov/pubmed/25149599

Ryan C. -

To your first point, I'd like to see how McKesson came to that conclusion because I've witnessed hospitalist colleagues arguing with insurance companies over whether the patient required admission based almost solely on the fact that they never received IV antibiotics. I'm not sure how they can claim it's a myth when it's a very real issue.

To your second point, I'm not sure how that study demonstrates IV antibiotics have more risk than PO when there is no PO antibiotic group. It stands to reason that if PO antibiotics are just as effective as IV, they should also have very similar side effect profiles, as well.

c. berg -

Sorry for my slow reply. I've spent quite a while digging through the regulations and discussing this issue with Case Management. The payor landscape can differ substantially between locations and contracting potentially matters (not everything that I say can be extrapolated to your environment). That said, route of antibiotic administration has no bearing, locally, on patient status or payment. This, apparently, used to be a case in the past, but was twilighted by local payors 5-10 years ago.

In the end, we should do the right thing. Our language and decision making change patient status; we should articulate the other reasons why patients may or may note need hospitalization.

Best,
C Berg

Ian L., Dr -

Doxycycline ought be taken sitting and with water there is the danger of esophagitis .
With double dose GI side effects and also photo sensitivity are dangers .
Del Russo JQ in J Clin Aesthet Dermatol 2015 reports use of a new double scored 150 mg tablet Doxycycline hyclate used in acne vulgaris with less GI effects .

c. berg -

True true. Doxy certainly can irritating the GI tract when not taken with food.

C Berg

Erik D. -

Cam, have you had any issues with meeting CMS severe sepsis criteria for IV vs. PO antibiotics? Many patients who look well and would do just fine with PO abx, wind up meeting criteria for "severe sepsis" as defined by CMS (e.g. a lactate of 2.1), and therefore require an IV abx such as levofloxacin or ceftriaxone to satisfy the measure. I think many of my clinicians will go crazy trying to figure it out!

Thanks,
Erik Deede

c. berg -

entirely correct...this is a serious issue. we have opted to take care of the patient and understand that we will "miss" on these cases.

caleb b. -

Do you have a copy of your actual pathway posted somewhere to review in entirety? I've tried piecing it together from the conversation and written summary, but don't want to miss any pieces as we try to bring something like this to our department.

c. berg -

send me an email - cameron.berg@northmemorial.com, and i'll reply with everything we have

Sean G., M.D. -

Cam running into the same thing here in AZ, payors not paying for admissions if iv antibiotics not given. This is no myth it is happening...and as much as I want to do the right thing for the patient, I have to work with hospitalists who need to get paid in order to stay in business. Any thoughts on that? Its hard to do things that you know may hurt patients, but we do it all the time due to CMS constraints thru out history.

Rob O -

Hey Sean, See Cam's response to Ryan C above...

Sean G., M.D. -

lol Rob of course I read it! He was suggesting there are local variations in payor response... I believe... my point was to show that it is probably more widespread than he realized... and the true cunundrum... yes I very much want to do what is right for my patients but at the same time I can not force another doctor to practice in a certain way and I don't walk in his shoes... if he( and it's one guy I work in a small hospital) does not feel he has the time to battle out payment for simple cases like med floor pneumonias I am not going to judge him for that. It should be something recognized nationally if the research is so robust... meaning it's apparently not ready for prime time or it would be more universally accepted. Perhaps we just need s couple of more studies because if this is true the insurance companies should be on our side as it would mean less expense for them in the long run. On my iPhone so excuse typos please I can't see %%^* at age 50

Rob O -

Sean, I feel your pain! It's so hard fighting every little battle when you're just trying to keep the ED afloat. Which ones do you pick? Is this one worth it?

Geoff M. -

I know this is late in the game as this segment came out a long time ago, but this is coming up again as we are hitting cough and cold season, and trying to convince my colleagues to avoid monotherapy with azithro and shift towards Doxy. My Sanford's guide says doxy 100mg bid x7 days. Uptodate also says 100mg bid. where is this high dose doxy regimen coming from??

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Pneumonia in the Hotseat Full episode audio for MD edition 227:49 min - 317 MB - M4AEM:RAP 2016 December Aussie Edition Australian 31:23 min - 43 MB - MP3EM:RAP 2016 December Spanish Edition Español 79:39 min - 109 MB - MP3EM:RAP 2016 December Canadian Edition Canadian 16:00 min - 18 MB - MP3EM:RAP 2016 December French Edition Français 30:18 min - 42 MB - MP3EM:RAP 2016 December German Edition Deutsche 94:18 min - 129 MB - MP3EM:RAP 2016 December Written Summary 910 KB - PDFEMRAP 2016 December MP3 Files 183 MB - ZIPEM:RAP 2016 December Board Review Answers 201 KB - PDFEM:RAP 2016 December Board Review Questions 193 KB - PDF

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