What is the recommended prophylactic therapy for pneumonia?

Recommended Prophylactic Therapy for Pneumonia

The most effective prophylactic therapy for pneumonia is pneumococcal vaccination, specifically the 23-valent pneumococcal polysaccharide vaccine for adults aged ≥65 years and those aged 5-64 years with risk factors, along with the appropriate pneumococcal conjugate vaccine based on age and risk factors. 1

Pneumococcal Vaccination Recommendations

Adults

• Administer the 23-valent pneumococcal polysaccharide vaccine to:
  • All persons aged >65 years 1
  • Persons aged 5-64 years with chronic cardiovascular disease (e.g., congestive heart failure, cardiomyopathy) 1
  • Persons aged 5-64 years with chronic pulmonary disease (e.g., COPD, emphysema, but not asthma) 1
  • Persons with diabetes mellitus, alcoholism, chronic liver disease, or cerebrospinal fluid leaks 1
  • Persons with functional or anatomic asplenia 1
  • Immunocompromised persons aged >5 years (HIV infection, leukemia, lymphoma, Hodgkin's disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome) 1
  • Persons receiving immunosuppressive therapy (including long-term systemic corticosteroids) 1
  • Residents of long-term care facilities 1

Children

• Administer the appropriate pneumococcal conjugate vaccine to:
  • All children aged <2 years 1
  • Children aged 24-59 months at increased risk for pneumococcal disease 1
  • Priority should be given to children aged 24-35 months, American Indians/Alaska Natives, Black children, and those attending group childcare centers 1

Implementation in Healthcare Settings

• Establish a standing order program for the administration of 23-valent vaccine to high-risk persons in nursing homes and long-term care facilities 1
• Recent evidence suggests expanding pneumococcal conjugate vaccine recommendations to include all adults aged ≥50 years 2

Prevention of Hospital-Acquired Pneumonia

Reducing Aspiration Risk

• Remove devices such as endotracheal, tracheostomy, and enteral tubes as soon as clinically indicated 1
• When feasible and not medically contraindicated, use noninvasive positive-pressure ventilation instead of endotracheal intubation in patients with respiratory failure 1
• Avoid repeat endotracheal intubation in patients who have received mechanical ventilation 1
• Perform orotracheal rather than nasotracheal intubation when possible 1

Postoperative Pneumonia Prevention

• Instruct high-risk preoperative patients about taking deep breaths and early ambulation postoperatively 1
• Encourage all postoperative patients to take deep breaths, move about the bed, and ambulate unless medically contraindicated 1
• Use incentive spirometry for postoperative patients at high risk for pneumonia 1

Special Considerations for Immunocompromised Patients

HIV-Infected Individuals

• For prevention of Pneumocystis carinii pneumonia (PCP), prophylaxis is recommended when CD4+ T-lymphocyte counts are less than 200 cells/μL or less than 20% of total circulating T-lymphocytes, or after a previous episode of PCP 1
• Oral trimethoprim-sulfamethoxazole is the preferred regimen for PCP prophylaxis, as it has shown superior efficacy compared to aerosol pentamidine 1

Treatment Response Monitoring and Follow-up

• Clinical review should be arranged for all patients at around 6 weeks after pneumonia, either with their general practitioner or in a hospital clinic 1, 3
• A chest radiograph should be arranged at follow-up for patients who have persistent symptoms or physical signs, or who are at higher risk of underlying malignancy (especially smokers and those over 50 years) 1, 3

Common Pitfalls and Caveats

• Pneumococcal vaccine effectiveness may be limited in those with underlying high-risk conditions, so additional preventive measures should be considered 4
• Prior administration of PPSV23 may diminish the response to subsequent administration of pneumococcal conjugate vaccines, so proper sequencing and timing of vaccines is important 5, 6
• When administering pneumococcal vaccines in series, the recommended intervals between PCV and PPSV23 differ by age and risk group 6
• Monitor for C. difficile-associated diarrhea when using broad-spectrum antibiotics for treatment of pneumonia 1, 3
• The chest radiograph need not be repeated prior to hospital discharge in patients who have made a satisfactory clinical recovery 1

Antibiotic Prophylaxis

• No recommendation can be made for the routine administration of systemic antimicrobial agents to prevent pneumonia in critically ill patients or those receiving mechanical ventilation 1
• No recommendation can be made for scheduled changes in the class of antimicrobial agents used routinely for empiric treatment of suspected infections 1