What gaps have been identified in the transition of care for pneumonia patients, particularly those with underlying comorbidities like Chronic Obstructive Pulmonary Disease (COPD) or asthma?

Identified Gaps in Transition of Care for Pneumonia Patients

Multiple critical gaps exist in the transition of care for pneumonia patients, particularly affecting those with underlying comorbidities like COPD or asthma, including inadequate recognition of macrolide-resistant pathogens in patients on long-term macrolide therapy, insufficient microbiologic diagnostics to guide de-escalation, and failure to address the substantially elevated long-term mortality and readmission risks that persist for years after hospitalization. 1, 2

Antibiotic Selection Gaps in Comorbid Populations

Macrolide Resistance in Chronic Respiratory Disease Patients

• The increasing use of long-term macrolides in patients with chronic comorbidities (bronchiectasis, COPD, asthma) increases the risk for macrolide-resistant pneumococci in these patients who are especially prone to CAP. 1
• This creates a dangerous treatment gap, as these patients may receive empiric macrolide therapy despite harboring resistant organisms, potentially leading to treatment failure. 1
• The guideline's suggested 25% cutoff for macrolide resistance was criticized by half of experts as "too liberal" and a "dangerous approach that could demand lives," given the clear association between macrolide resistance and treatment failure. 1

Inadequate Pathogen Coverage

• Haemophilus influenzae exhibits intrinsic resistance to macrolides, and macrolide use in patients with H. influenzae has been associated with treatment failure. 1
• In outpatients, pneumococci and H. influenzae are often the leading pathogens and are not well targeted with a macrolide monotherapy approach. 1

Diagnostic Testing Gaps

Insufficient Microbiologic Diagnostics

• Testing practices for adults hospitalized with CAP varied significantly by geography and disease severity, with wide discordance between real-life testing practices and international guideline recommendations. 1
• The 2019 ATS/IDSA guideline expanded indications for blood and sputum cultures to all inpatients empirically treated for MRSA or P. aeruginosa, but 50% of experts suggested this did not go far enough compared to usual practice in the UK, Germany, or Japan where cultures are required for all inpatients. 1
• Decisions about diagnostic tests are often made before antibiotic and ICU admission decisions, making recommendations logistically impractical due to their conditional nature on other management decisions. 1
• There was concern that conditional testing requirements may result in poor-quality specimens due to ED workflow changes. 1

Risk Stratification Gaps in Comorbid Populations

COPD Patients with Pneumonia

• COPD patients with severe CAP are more likely to need mechanical ventilation and carry increased risk for mortality, with ICU mortality rates of 39% in COPD patients versus lower rates in non-COPD patients. 1
• COPD proved to be an important risk factor for mortality, with mechanical ventilation odds ratio of 2.78 (95% CI 1.63-4.74) and ICU mortality odds ratio of 1.58 (95% CI 1.01-1.43) compared to non-COPD patients. 1
• Patients with COPD have a more than 4-fold increase in pneumonia versus reference controls (HR 4.76,95% CI 4.48-5.06). 3

Asthma-COPD Overlap Patients

• Approximately 20% of patients with obstructive airway disease have asthma-COPD overlap, which leads to significant health status impairment, increased exacerbations, and increased hospitalizations. 1
• This group had the highest risk of mortality (HR 1.45,95% CI 1.06 to 1.98), followed by COPD alone (HR 1.28) and asthma alone (HR 1.04). 1
• When asthma is not recognized in overlap patients, there is potential for increased adverse events and drug toxicity from long-acting β2 agonist use without concurrent inhaled corticosteroids. 1
• Asthma was identified as an independent risk factor for pneumonia in the COPD population. 3

ICS-Related Pneumonia Risk

• ICS use increased the risk of pneumonia by 20-30% in patients with COPD with FEV1 ≥50% versus patients not using ICS, with the highest risk associated with high-dose ICS (HR 1.41,95% CI 1.23-1.62). 3
• This creates a treatment paradox where patients with asthma-COPD overlap require ICS for disease control but face increased pneumonia risk. 3

Long-Term Outcomes and Follow-Up Gaps

Persistent Elevated Mortality Risk

• For patients with selected underlying comorbidities, the odds ratio for mortality was significantly higher for at least 3 years after CAP, ranging from 4.76 (95% CI 4.12 to 5.51) for chronic liver disease to 7.50 (95% CI 4.71 to 11.92) for post-bone marrow transplant. 2
• This prolonged mortality risk is not adequately addressed in current transition of care protocols. 2

Increased Readmission Risk

• The relative risk of hospital admissions increased after CAP, ranging from 1.08 (95% CI 1.04 to 1.12) for chronic kidney disease to 1.38 (95% CI 1.35 to 1.40) for chronic respiratory disease, and this increase was maintained for at least 2 years. 2
• Pneumonia was frequent in first-time COPD exacerbations (36.1%), but declined in successive exacerbations to 25.6% by the seventh or greater exacerbation. 4
• Thirty-day mortality was 12.1% in first-time pneumonic COPD exacerbations versus 8.3% in first-time nonpneumonic cases (adjusted HR 1.20,95% CI 1.17-1.24). 4

Financial Burden

• Mean difference in hospital healthcare costs remained higher for CAP patients for at least 2 years in 4 of 6 comorbidity groups, ranging from £1,907 (95% CI £1,573 to £2,240) for diabetes to £11,167 (95% CI £10,847 to £11,486) for chronic respiratory disease. 2
• This sustained financial impact is not reflected in current care transition planning or resource allocation. 2

Comorbidity Assessment Gaps

Baseline Comorbidity Burden

• Among incident COPD patients, frequencies >1% within the first year after diagnosis were observed for angina (4.0%), cataracts, bone fractures, osteoporosis, pneumonia, and respiratory infections. 5
• COPD patients were at increased risk for pneumonia (RR 16.0), osteoporosis (RR 3.1), respiratory infection (RR 2.2), myocardial infarction (RR 1.7), angina (RR 1.7), fractures (RR 1.6), and glaucoma (RR 1.3). 5
• The comorbidity spectrum in asthma-COPD overlap remains an area requiring investigation, with inconsistent findings across studies regarding whether comorbidity burden is increased compared to COPD alone. 1

Historical Risk Factors

• Physicians should account for history of COPD, renal insufficiency/dialysis, chronic heart failure, coronary artery disease, diabetes mellitus, malignancy, chronic neurologic disease, and chronic liver disease/alcohol abuse when determining patient management. 1
• In patients older than 60 years, risk is further increased in the presence of asthma, alcoholism, or immunosuppression, and in institutionalized patients. 1
• The majority of patients with severe pneumonia have underlying comorbid illnesses, with COPD, alcoholism, chronic heart disease, and diabetes mellitus being the most frequent. 6

Common Pitfalls to Avoid

• Failing to obtain adequate microbiologic diagnostics before initiating antibiotics, which prevents appropriate de-escalation and antimicrobial stewardship. 1
• Using macrolide monotherapy in patients with chronic respiratory diseases who may be on long-term macrolide therapy for their underlying condition. 1
• Not recognizing asthma features in COPD patients, leading to inappropriate treatment without ICS and increased adverse events from LABA monotherapy. 1
• Inadequate long-term follow-up planning that fails to address the 2-3 year elevated risk of readmission and mortality after pneumonia hospitalization. 2
• Underestimating pneumonia risk in patients on high-dose ICS therapy for asthma-COPD overlap. 3