VA20 • Virginia Nurses 2020

Table of Contents

VA20 • Virginia Nurses 2020

How to Receive Credit

NetCE 10 Hour Course #94672 • Pneumonia

94672 • Pneumonia

1. HISTORICAL BACKGROUND

2. DEFINITIONS

3. EPIDEMIOLOGY AND SCOPE

4. GUIDELINE-DIRECTED MANAGEMENT AND PREVENTION OF PNEUMONIA

5. PATHOGENESIS AND CLASSIFICATION OF PNEUMONIA

6. COMMUNITY-ACQUIRED PNEUMONIA

7. PREVENTION OF PNEUMONIA

8. PNEUMONIA ASSOCIATED WITH HEALTHCARE FACILITIES

9. SUMMARY

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 5 Hour Course #31432 • Burnout: Impact on Nursing and Quality of Care

31432 • Burnout: Impact on Nursing and Quality of Care

1. INTRODUCTION

2. HISTORY AND DEFINITION OF BURNOUT

3. DEVELOPMENT OF BURNOUT

4. IDENTIFICATION AND MEASUREMENT OF BURNOUT

5. BURNOUT AMONG NURSES

6. CONSEQUENCES OF STRESS AND BURNOUT

7. STRATEGIES TO PREVENT AND COPE WITH STRESS AND BURNOUT

8. CASE STUDY: A TALE OF TWO NURSES

9. CONCLUSION

Works Cited

VA20 • Virginia Nurses 2020

Lori L. Alexander, MTPW, ELS, MWC

Carol Whelan, APRN

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

VA20 • Virginia Nurses 2020

Expiration Date: 01/31/2021

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

94672 • Pneumonia

Lori L. Alexander, MTPW, ELS, MWC

Carol Whelan, APRN

www.netce.com

Copyright © 2018 NetCE, All rights reserved.

Pneumonia is a substantial healthcare concern, ranking among the most common reasons for emergency department and outpatient visits, hospitalizations, and deaths among both adults and children. Decreasing the incidence of pneumonia and its associated morbidity and mortality requires a multifaceted approach and a strategy that includes: a concerted effort to improve rates of pneumococcal and influenza vaccinations, especially among high-risk populations; better adherence to guideline-recommended treatment; systems-level approaches to improve the appropriate use of antibiotics; and performance improvement initiatives to reduce healthcare-associated infections.

Table of Contents

94672 • Pneumonia

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

About the Sponsor

Disclosure Statement

1. HISTORICAL BACKGROUND

2. DEFINITIONS

3. EPIDEMIOLOGY AND SCOPE

4. GUIDELINE-DIRECTED MANAGEMENT AND PREVENTION OF PNEUMONIA

5. PATHOGENESIS AND CLASSIFICATION OF PNEUMONIA

6. COMMUNITY-ACQUIRED PNEUMONIA

EPIDEMIOLOGY

RISK FACTORS

ETIOLOGY

DIAGNOSIS IN ADULT PATIENTS

MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA IN ADULTS

ILLUSTRATIVE CASE

PNEUMONIA IN THE PEDIATRIC PATIENT

7. PREVENTION OF PNEUMONIA

IMMUNIZATION

8. PNEUMONIA ASSOCIATED WITH HEALTHCARE FACILITIES

EPIDEMIOLOGY

RISK FACTORS

ETIOLOGY

DIAGNOSIS

TREATMENT

PREVENTION

ILLUSTRATIVE CASE

9. SUMMARY

Works Cited

Evidence-Based Practice Recommendations Citations

94672 • Pneumonia

Education Category. Infection Control / Internal Medicine

Release Date. 09/01/2018

Expiration Date. 08/31/2021

Course Overview

Pneumonia is a substantial healthcare concern, ranking among the most common reasons for emergency department and outpatient visits, hospitalizations, and deaths among both adults and children. Decreasing the incidence of pneumonia and its associated morbidity and mortality requires a multifaceted approach and a strategy that includes: a concerted effort to improve rates of pneumococcal and influenza vaccinations, especially among high-risk populations; better adherence to guideline-recommended treatment; systems-level approaches to improve the appropriate use of antibiotics; and performance improvement initiatives to reduce healthcare-associated infections.

Audience

This course is designed for all physicians, physician assistants, and nurses, especially those working in the emergency department, outpatient settings, pediatrics, nursing homes, and intensive care units.

Course Objective

The purpose of this course is to provide primary care clinicians and other members of the healthcare team with the knowledge and skills necessary to appropriately diagnose, treat, and prevent pneumonia. It is designed to enhance clinical skills, improve outcomes, and foster an interprofessional collaborative practice consistent with published guidelines.

Learning Objectives

Upon completion of this course, you should be able to:

1. Discuss the epidemiology, scope, and classification of pneumonias.

2. Predict the likely etiology (pathogens) in a given case of pneumonia, based on epidemiologic features, clinical setting, and risk factor assessment

3. Assess the diagnostic probability of pneumonia in a given patient, using careful history and clinical examination findings.

4. Determine, by clinical criteria and severity of illness score, which patients with pneumonia require hospitalization or admission to an intensive care unit.

5. Develop a management plan for community-acquired pneumonia, including selection of initial antibiotic therapy appropriate to clinical context and site of care, in accordance with established guidelines.

6. Outline the diagnosis and management of community-acquired pneumonia in pediatric patients.

7. Devise a strategy for prevention of community-acquired pneumonia, including risk factor reduction and recommended immunization protocols.

8. Identify the epidemiology and risk factors of hospital-acquired, ventilator-associated, and nursing home-acquired pneumonia.

9. Anticipate the likely pathogens and antibiotic-sensitivity patterns associated with pneumonia that arises in healthcare facilities.

10. Initiate the management of patients with hospital-acquired or ventilator-associated pneumonia, including guideline-adherent selection of empiric antibiotic therapy.

11. Develop a strategy to reduce the risk of pneumonia for patients in healthcare facilities.

Faculty

Carol Whelan, APRN, has been working in nursing education since 2000. She received her Master's degree in psychiatric/mental health nursing from St. Joseph College in West Hartford, Connecticut, and completed post-graduate nurse practitioner training at Yale University. Ms. Whelan is an Associate Clinical Professor and Lecturer at Yale University and works as an APRN at the Department of Veterans' Affairs in Connecticut, where she also serves as the Vice President of Medical Staff. She has authored many articles, textbook chapters, and books.

Lori L. Alexander, MTPW, ELS, MWC, is President of Editorial Rx, Inc., which provides medical writing and editing services on a wide variety of clinical topics and in a range of media. A medical writer and editor for more than 30 years, Ms. Alexander has written for both professional and lay audiences, with a focus on continuing education materials, medical meeting coverage, and educational resources for patients. She is the Editor Emeritus of the American Medical Writers Association (AMWA) Journal, the peer-review journal representing the largest association of medical communicators in the United States. Ms. Alexander earned a Master’s degree in technical and professional writing, with a concentration in medical writing, at Northeastern University, Boston. She has also earned certification as a life sciences editor and as a medical writer.

Faculty Disclosure

Contributing faculty, Carol Whelan, APRN, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Contributing faculty, Lori L. Alexander, MTPW, ELS, MWC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

John V. Jurica, MD, MPH

John M. Leonard, MD

Jane C. Norman, RN, MSN, CNE, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

1. HISTORICAL BACKGROUND

Hippocrates first described the clinical picture of pneumonia in 400 B.C.E., including the presence of fever, chest pain, productive cough, rales, and dyspnea [1]. However, the disease was recognized even before Hippocrates' time. The disease has resulted in a serious public health and mortality burden over the years, with Osler referring to pneumonia as the "captain of the men of death" in the early 1900s. During this same period, pneumonia surpassed tuberculosis as a leading cause of death.

However, dramatic changes in the past century, namely the introduction of effective antibiotics and vaccinations and improved medical and surgical techniques, have changed the clinical picture of pneumonia dramatically. These developments have resulted in vast improvements in morbidity and mortality from pneumonia in developed countries. Despite these advances, pneumonia remains a major health concern, and the emergence of multidrug-resistant organisms has led to renewed interest and research on this ancient disease.

2. DEFINITIONS

Pneumonia is defined as a lower respiratory tract, parenchymal infection of the lung. The usual clinical presentation is that of acute- or subacute-onset fever, productive cough, pleuritic chest pain, localized rales and signs of consolidation, and a new pulmonary opacification on chest radiograph. For clinical purposes, acute pneumonia that develops in the nonhospitalized patient is designated as either community-acquired (CAP) or healthcare-associated (HCAP) depending on whether there has been significant exposure to a healthcare environment (e.g., hospital, nursing home, dialysis clinic) within the previous 90 days. Pneumonias that develop as a complication of hospitalization are termed "nosocomial" and are further divided into hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP). These are important distinctions, as HCAP and nosocomial pneumonias carry a greater risk for less common, multidrug-resistant bacterial infection.

The term "pneumonia" is sometimes used in reference to other inflammatory conditions of the lung when a component of infection is known or suspected. An example is "aspiration pneumonia," whereby a focal chemical pneumonitis (lung injury) is followed rapidly by bacterial overgrowth and incipient infection (pneumonia).

3. EPIDEMIOLOGY AND SCOPE

Pneumonia is a substantial healthcare concern, ranking among the most common reasons for emergency department and outpatient visits, hospitalizations, and deaths among both adults and children [2,3,4,5,6]. The World Health Organization (WHO) estimates that 57 million people die from pneumonia every year [228]. Collected data consistently demonstrate a bimodal distribution of mortality, with peaks in children younger than 5 years of age and adults older than 75 years of age. Worldwide, pneumonia was responsible for an estimated 920,000 deaths in children younger than 5 years of age in 2015, mainly in developing countries [228]. In the United States, pneumonia is the leading cause of death from infectious disease and the eighth most common cause of death overall. There is seasonal variation in the incidence of pneumonia, with most cases occurring in the winter months.

U.S. hospital discharge statistics show that the rate of hospitalization for pneumonia varies with age, being highest among adults 75 to 84 years of age. In recent decades, the rate of hospitalization for pneumonia has been relatively stable for adults younger than 65 years of age and has declined somewhat for adults older than 65 years (Table 1) [6]. In 2010, there were 1.1 million U.S. hospital discharges for which the leading discharge diagnosis was pneumonia, and the average length of stay for these patients was 5.2 days [2].

Table 1: DISCHARGES FROM HOSPITAL WITH A FIRST-LISTED DIAGNOSIS OF PNEUMONIA, BY AGE

Age

Rate (per 10,000)

1990

2000

2009–2010

18 to 44 years

12.5

10.9

9.5

45 to 64 years

33.5

35.3

32.6

65 to 74 years

98.1

121.3

83.8

75 to 84 years

224.6

263.5

179.3

85 years and older

501.0

514.9

355.3

Source: [6]

The mortality rate for pneumonia and influenza combined has decreased substantially in the United States over the past 20 years, falling from 36.8 per 100,000 in 1990 to 16.1 per 100,000 in 2016 [6]. Two important public health factors, which may account for this trend, are the increased utilization of pneumococcal and influenza vaccines among adults and children and the decline in cigarette smoking [220,221].

Despite advances made in prevention, treatment, and clinical outcomes, the impact on healthcare delivery systems and the aggregate cost of caring for patients with pneumonia are expected to increase in years to come. This is because of an aging U.S. population, the very group in whom the rate of pneumonia is highest. Using a decision analytic model that assumes no targeted intervention, a population medicine study group projected the incidence of pneumococcal pneumonia in the United States will increase by 38% between 2014 and 2040, with hospitalizations for pneumococcal pneumonia increasing by 96% (from 401,000 to 790,000) in that same period. As a result, healthcare costs associated with pneumonia are expected to increase by $2.5 billion and demand for healthcare services for pneumonia is expected to double [14].

4. GUIDELINE-DIRECTED MANAGEMENT AND PREVENTION OF PNEUMONIA

In the past two decades, clinical guidelines for the management of pneumonia have been developed by infectious disease and pulmonary medicine societies to improve outcomes and decrease the cost of care. Unfortunately, adherence to guideline-directed management protocols has been low, despite studies demonstrating that lack of adherence is associated with higher rates of adverse outcomes and inappropriate use of antimicrobials [15,16,17,18,20,21]. Attention to guidelines varies across hospitals, clinical settings, and specialty practices. Adherence rates tend to be lower among non-pulmonologists and in relation to patient variables such as presence or absence of comorbidities and recent use of antibiotics [20,22,23]. Several barriers to guideline adherence have been identified, including lack of familiarity, concern over the practicality and perceived cost of recommended antibiotics, limited documentation of improved outcomes, and potential conflict with other guidelines [23]. The time spent on continuing education activities appears to have a direct correlation with a positive attitude toward, and propensity to follow, published clinical guidelines.

Success in reducing the incidence of pneumonia relies on effective strategies to prevent disease. The primary preventive strategy for CAP is immunization with influenza and pneumococcal vaccines, especially for high-risk groups (i.e., young children, older individuals, and people with compromised immune systems). Targeted immunization has been shown to decrease the rate of hospitalization for pneumonia and influenza and to decrease the risk of long-term morbidity and mortality [7,9,10,218]. However, vaccine utilization rates are low, especially pneumococcal vaccination among high-risk groups and influenza vaccination among children [6,11].

Prevention of HCAP focuses on care measures to preserve healthy pulmonary defense mechanisms and to reduce transmission of healthcare-associated, often multidrug-resistant, bacterial pathogens. The adherence to guidelines for the prevention of pneumonia that arises in the hospital setting has also been low, with approximately 39% to 66% of hospitals reporting full compliance and up to one-half of nurses reporting that they do not routinely adhere to recommended prevention practices [12,13].

Decreasing the incidence of pneumonia and its associated morbidity and mortality requires a multifaceted approach and a strategy that includes a concerted effort to improve rates of pneumococcal and influenza vaccinations, especially among high-risk populations; better adherence to guideline-recommended treatment; systems-level approaches to improve the appropriate use of antibiotics; and performance improvement initiatives to reduce healthcare-associated infections. This course is designed to assist healthcare professionals provide better care to their patients by highlighting guideline-recommended diagnosis, treatment, and prevention of pneumonia.

5. PATHOGENESIS AND CLASSIFICATION OF PNEUMONIA

Pneumonia is an acute inflammatory condition within the parenchyma of the lung caused by infection that reaches the lower respiratory tract. In most cases, pneumonia develops as a consequence of bacterial colonization/infection of the upper respiratory tract, followed by microaspiration of infected secretions at a time of impaired host pulmonary defense mechanisms [217]. The prime host defenses against foreign particulate matter that reaches the lower respiratory tract are the cough reflex, tracheobronchial (mucociliary) clearance, and alveolar macrophage phagocytosis. Activation of the humeral (antibody) immune response provides augmentation of phagocytosis and the acute cellular response. One or more of these defense mechanisms may be impaired by a variety of factors, including underlying cardiopulmonary and neurologic disease, sedative medication, bronchial obstruction, concurrent active viral and mycoplasma bronchitis, and toxic/metabolic conditions such as alcohol excess, acidosis, and hypoxia. Individuals with an impaired immune system, such as occurs from immunosuppressive drugs, human immunodeficiency virus (HIV), chronic disease, or old age, are more susceptible to infection [4].

Clinically, pneumonia is often described in reference to suspected or established causative pathogens (i.e., viral, bacterial, fungal, or parasitic); however, the specific etiology cannot be identified in more than half of cases in which testing is done [9,24,25]. Classifying pneumonia according to the setting in which it develops is more useful for clinical purposes because the most common pathogens, as well as the outcomes, are similar within distinct clinical settings [26,27]. Pneumonia was once broadly classified as either community-acquired (developing outside of a hospital or other healthcare facility) or nosocomial (developing 48 hours or more after hospital admission, usually postoperatively). In its 2005 guideline, the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) noted three distinct categories within the broader classification of pneumonia associated with healthcare facilities: HAP, VAP, and HCAP (Table 2) [3,28]. These three categories of pneumonia are similar in that they often result from colonization, then infection, by resistant gram-negative bacilli and methicillin-resistant Staphylococcus aureus (MRSA), necessitating broader empiric antibiotic therapy than that commonly used for CAP [27].

Table 2: TYPES OF PNEUMONIA

Type

Definition

Community-acquired

New infection in a patient residing in the community, with no recent exposure to a healthcare setting or antibiotics

Hospital-acquired

New infection occurring more than 48 hours after hospital admission

Ventilator-associated

New infection occurring more than 48 to 72 hours after endotracheal intubation

Healthcare-associated

Infection developing within 90 days after hospitalization in an acute care facility for 2 days or more

Infection in a resident of a nursing home or long-term care facility

Infection after receiving care in an outpatient setting (e.g., hemodialysis or intravenous therapy clinic)

Infection occurring with 30 days after home care (e.g., intravenous antibiotic therapy, chemotherapy, or wound care)

Source: [28]

As noted, the cause of pneumonia varies according to setting and patient age. Viruses are the most common cause in young children, whereas bacteria are the more frequent cause among older children and adults [29,30,31]. Studies have shown that respiratory viral pathogens play a greater role in the pathogenesis of pneumonia than once thought; many cases of pneumonia, both pediatric and adult, involve a combination of bacterial and viral pathogens or two or more viral pathogens [9,24,30,32]. The increase in the number of viral infections is thought to be related, in part, to better diagnostic testing methods, most notably, polymerase chain reaction (PCR)-based techniques [24,33,34].

Pyogenic bacterial infection is the cause of nearly all cases of HAP and VAP, and the distribution of pathogens varies among institutions [26,28,29]. Mixed infection appears to be common, as more than one pathogen is frequently isolated from sputum cultures in these cases [28]. Bacteria isolated from cases of early-onset HAP (within four days after admission) are usually sensitive to available drugs [28]. In contrast, late-onset HAP (i.e., more than five days after admission) is likely to be caused by multidrug-resistant pathogens, such as Pseudomonas spp., MRSA, and Acinetobacter spp. [26,35]. Viral and fungal pathogens rarely cause HAP or VAP [28].

6. COMMUNITY-ACQUIRED PNEUMONIA

EPIDEMIOLOGY

Determining accurate incidence rates for CAP is challenging for a variety of reasons, including the facts that "pneumonia" is not a reportable disease, case definition varies across studies, and national databases often link pneumonia with influenza. The epidemiology relies primarily on estimates derived from community-based cohort studies and surveillance networks. Approximately 5 to 6 million cases of pneumonia are diagnosed annually, with about 1 million occurring in older adults [36]. Approximately 4.2 million adult outpatient visits are related to CAP every year, and the mortality rate is less than 1% for adults treated on an outpatient basis [37].

The burden of disease is considerably greater for patients hospitalized with pneumonia. A prospective cohort study of adult residents living in Louisville, Kentucky (population 587,000 adults), recorded 7,449 unique patients hospitalized with CAP between June 2014 and June 2016 [232]. The annual age-adjusted incidence was 649 patients hospitalized with CAP per 100,000 adults, which extrapolates to nearly 1.6 million annual adult CAP hospitalizations in the United States. The observed mortality during hospitalization was 6.5%. An earlier report placed the average overall mortality rate for hospitalized adults at 12%, but the rate is higher—about 30% to 40%—for adults who require admission to an intensive care unit (ICU) [37]. The estimated direct and indirect financial costs are $3.7 billion and $1.8 billion, respectively [38].

The burden of pneumonia is greatest among the elderly (65 years of age and older). In one study of 46,237 people 65 years of age and older, the overall rate of CAP was 18.2 cases per 1,000 person-years for people 65 to 69 years of age, increasing to 52.3 cases per 1,000 person-years for those 85 years of age or older [39].

The mortality rate for adults with pneumonia has decreased substantially over the past two decades. In a review of more than 2.6 million Medicare claims for pneumonia between 1987 and 2005, the age- and sex-adjusted mortality rate dropped from 13.5% to 9.7% [40].

The rate of pediatric outpatient visits for CAP has been reported to be 35 to 52 per 1,000 children 3 to 6 years of age and 74 to 92 per 1,000 children 2 years of age and younger [10]. The hospitalization rate for children up to 18 years of age is 201.1 per 100,000; the highest rate is for infants younger than 1 year of age (912.9 per 100,000) and lowest for teenagers (62.8 per 100,000) [4]. According to data from the Centers for Disease Control and Prevention (CDC), 525 infants and children (up to 15 years of age) in the United States died as a result of pneumonia (or another lower respiratory tract infection) in 2006 [30].

RISK FACTORS

The primary risk factors for CAP are age, smoking history, and chronic lung disease (e.g., chronic obstructive pulmonary disease [COPD]) and other comorbidities. Occupational dust exposure and history of childhood pneumonia have also been associated with an increased risk, as has male gender, unemployment, and single marital status [39,41]. As noted earlier, the risk for pneumonia is higher for individuals 65 years or older compared with younger adults, with the risk further increasing for those 85 years and older [39]. Alcoholism and chronic diseases, such as respiratory disease, cardiovascular disease, or kidney disease, also increase the risk for pneumonia, especially in the older population [3,42,43]. In the pediatric population, very young children are at increased risk because their immune systems have not fully developed. Conditions of frailty, dementia, alcohol use, and sedative medication all lead to diminished or ineffectual cough and the propensity for aspiration, thereby increasing the risk for pneumonia. Diseases or medications that suppress the immune system increase the risk among all ages [39,42].

The airways of normal lungs are sterile, and pulmonary defense mechanisms (e.g., mucociliary clearance, alveolar macrophage phagocytosis) work in concert to maintain this sterility. Smoking cigarettes eventually leads to bronchial inflammation and disrupts host defense mechanisms to such an extent that "colonization" of the airways by microbial pathogens is established early in the course of many persons with COPD [44]. The pathogens most commonly implicated are adenovirus, Chlamydophila pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae. Bacterial colonization in this setting represents low-grade chronic infection, which, in combination with clinical exacerbations, augments airway inflammation, and contributes to pathogenesis and disease progression.

Proton pump inhibitors (PPIs) may increase the risk of pneumonia, but the data are somewhat unclear. One study found that only treatment with PPIs within the past 30 days (and not long-term use) was associated with increased risk, but a later meta-analysis showed that the risk was increased among people taking PPIs or histamine2 receptor antagonists [44,45].

Among the nursing home population, older age and male gender are risk factors for pneumonia. Other risk factors for this population include swallowing difficulty, inability to take oral medications, profound disability, bedridden state, and urinary incontinence [42].

ETIOLOGY

Given the right conditions, a great many micro-organisms are capable of infecting the lung. In general, however, a relatively small collection of viruses and bacteria account for most cases of CAP in adults and children. For a given case, the clinical setting and the patient's age, comorbidity, and risk factors are useful predictors of causation. Viral pneumonia (e.g., influenza) is most commonly linked to community outbreaks.

The most common cause of CAP is S. pneumoniae, accounting for approximately one-third of all cases and 40% to 50% of all culture-confirmed bacterial pneumonia cases that require hospitalization [9,29,30,46]. The most common causative pathogen varies in relation to the patient's age, illness severity, and clinical context (Table 3) [29,30,47].

Table 3: MOST LIKELY ETIOLOGIES OF COMMUNITY-ACQUIRED PNEUMONIA ACCORDING TO PATIENT AGE AND SETTING

Age and/or Setting

Most Likely Pathogens

Adults

Outpatient

Streptococcus pneumoniae

Mycoplasma pneumoniae

Chlamydophila pneumoniae

Haemophilus influenzae

Respiratory viruses

Legionella spp.

Inpatient, not intensive care unit

S. pneumoniae

M. pneumoniae

C. pneumoniae

H. influenzae

Legionella spp.

Respiratory viruses

Intensive care unit

S. pneumoniae

Staphylococcus aureus

Legionella spp.

Gram-negative bacilli

H. influenzae

Children

Birth to 3 weeks

Group B streptococci

Listeria monocytogenes

Gram-negative bacilli

Cytomegalovirus

3 weeks to 3 months

S. pneumoniae

Respiratory viruses

Bordetella pertussis

S. aureus

Chlamydia trachomatis (transnatal exposure)

4 months to 4 years

S. pneumoniae

Respiratory viruses

M. pneumoniae (in older children)

Group A streptococci

5 to 15 years

S. pneumoniae

M. pneumoniae

C. pneumoniae

Source: [29,47]

Clues to the etiology of the pneumonia can often be found in the patient's past medical or social history (Table 4). Persons with chronic bronchitis/COPD frequently have tracheobronchial colonization with S. pneumoniae, H. influenzae, or M. catarrhalis, and when pneumonia supervenes, it is usually with one of these pathogens. Heavy alcohol use carries the risk for anaerobic pleuropulmonary infection (e.g., lung abscess, empyema) and pneumococcal or gram-negative bacillary (e.g., Klebsiella pneumoniae, Proteus spp.) pneumonia.

Table 4: COMORBIDITY AND EXPOSURE IN RELATION TO AT-RISK PATHOGENS

Patient Characteristic

Suspect Pathogen(s)

Alcoholism

Oral anaerobes

Streptococcus pneumoniae

Gram-negative bacilli

COPD, tobacco use

Haemophilus influenzae

S. pneumoniae

Moraxella catarrhalis

Nursing home resident

S. pneumoniae

Gram-negative bacilli

H. influenzae

Staphylococcus aureus

Poor dental hygiene

Oral anaerobes

Recent exposure to contaminated plumbing or water

Legionellaorganisms

Exposure to exotic birds and/or decaying bird nesting sites

Chlamydia psittaci

Histoplasma capsulatum (histoplasmosis)

HIV infection

Pneumocystis carinii

S. pneumoniae

H. influenzae

Mycobacterium tuberculosis

Exposure to excreta of wild rodents

Sin nombre virus (hantavirus pulmonary syndrome)

COPD = chronic obstructive pulmonary disease.

Source: Adapted with permission from File TM, Tan JS, Plouffe JF. Community-acquired pneumonia: what's needed for accurate diagnosis. Postgrad Med. 1996;99(1):102. ©1996 McGraw-Hill.

Other epidemiologic clues to the etiology of pneumonias include seasonal and geographic considerations. Influenza outbreaks are associated with a seasonal increase in secondary S. pneumoniae, S. aureus, and H. influenzae pneumonias. Legionellosis is acquired through inhalation of an aerosol arising from contaminated water; cases present sporadically or as cluster outbreaks related to a point source exposure such as a reservoir, water tower, or air conditioning system [229].

Bacterial Pathogens

Bacterial causes of CAP predominate, accounting for at least half of all adult cases, including older individuals [9,42]. S. pneumoniae is the leading cause of CAP in any adult age-group, with or without comorbid conditions [6,7,10]. It is estimated that pneumococcal infection accounts for 20% to 60% of all hospitalized patients with pneumonia [6]. Common bacterial pathogens other than S. pneumoniae include H. influenzae type b, S. aureus, and gram-negative bacilli [25,26,29,48]. H. influenzae type b is a small, pleomorphic gram-negative rod known for causing pneumonia in older adults and patients with underlying lung disease.

Atypical pneumonia (and the pathogens associated with this syndrome) is so labeled because the onset of illness tends to be subacute and the clinical exam and radiographic features lack the classical findings seen with typical cases of pneumonia. The most common atypical pathogens are Mycoplasma pneumoniae and C. pneumoniae, followed by Legionella spp. [9]. M. pneumoniae is a tiny bacterium that lacks a rigid cell wall. It is spread by droplet nuclei, and transmission within a community proceeds slowly over many weeks. Mycoplasma infection is a disease of adolescence and young adulthood, and it is the most common cause of atypical pneumonia in those younger than 40 years of age [66]. Small cluster outbreaks of pneumonia have been observed in large families, schools, nursing homes, and other closed population. There are about 60 different species of Legionella, but most disease is caused by Legionella pneumophila, a gram-negative rod usually transmitted via inhalation of aerosolized water contaminated with the bacteria [229].

The distribution of etiologic agents accounting for pneumonia varies in relation to illness severity and management setting. In cases of relatively mild illness that permit treatment as an outpatient, blood cultures are rarely positive and the diagnosis is usually made by sputum culture and/or serial serology. In a Canadian study of CAP in the ambulatory setting, designed to determine the frequency of usual and atypical bacterial pathogens, an etiologic diagnosis was established in 48% of patients examined [222]. Of the 419 patients who had blood cultures, 7 (1.4%) were positive, all for S. pneumoniae. The atypical pathogen group (M. pneumoniae or C. pneumoniae) accounted for 29% of cases, S. pneumoniae for 6%, and Haemophilus spp. for 5%. The etiologic role of viruses was not studied [222].

A similar distribution and frequency was observed in a well-studied series from Spain, comparing pneumonia microbial etiology in three clinical management settings: outpatient, inpatient on the general care ward, and inpatient admissions to the ICU [29]. Among outpatients with CAP, the most frequently identified etiology was the atypical pathogen group (36%), followed by S. pneumoniae (35%), viruses (9%), and mixed etiologies (9%). As the severity of illness increased, marked by admission to the hospital general ward and ICU, the likelihood of mycoplasma or chlamydia etiology decreased substantially (14%) and the frequency of S. pneumoniae (43%), mixed bacterial pathogens (22%), S. aureus, Pseudomonas, and other gram-negative bacteria infection increased.

In general, S. aureus is an uncommon cause of CAP but should be suspected during influenza outbreaks and in any patient with sepsis syndrome and multifocal pulmonary infiltrates. The role of S. aureus, and MRSA specifically, was examined in an observational study of 627 CAP cases admitted to 12 university-affiliated hospitals during the winter months (influenza season) of 2006–2007 [49]. Of the 595 patients from whom blood and sputum cultures were collected, a bacterial pathogen was identified in 107 (17%). The most common pathogen identified was S. pneumoniae (57 cases), followed by S. aureus (23 cases, 14 of which were MRSA). Thus, S. aureus accounted for 5% of the total and 22% of the cases in which the etiology was identified. Of the 23 patients with staphylococcal pneumonia, blood cultures were positive in 39% and sputum culture in 89%. Clinical features observed to be highly associated with S. aureus infection were multiple pulmonary infiltrates, altered mental status, illness severity requiring ICU admission, and intubation [49].

Viral Pathogens

Studies have indicated that 5% to 20% of adult CAP may be caused by a viral pathogen [50]. However, as noted earlier, the role of respiratory tract viral infection in pneumonia is complex and perhaps underestimated. Studies utilizing newer diagnostic methods such as PCR have demonstrated rates of viral infection as high as 39% in patients presenting with pneumonia [9,34]. Because these studies rely on specimens and washings taken from the nasopharynx, rather than directly from the lung, it is not clear to what extent viral isolates in this setting represent primary pneumonia pathogens or concomitant viral upper respiratory infection that may impair pulmonary defense mechanisms and thus predispose to bacterial pneumonia.

Clinical and pathologic studies of pneumonia during influenza seasons have demonstrated clearly that influenza virus (types A and B) is an important cause of primary viral CAP [25,47]. Other common respiratory viruses associated with pneumonia in adults are respiratory syncytial virus (RSV), rhinovirus, adenovirus, and parainfluenza virus [31,34,47]. RSV and rhinovirus are especially common among older adults and nursing home residents [31]. Clinical studies that utilize viral culture for case definition have demonstrated that RSV can be recovered from 3% to 10% of older adults with pneumonia [30]. The paramyxovirus hMPV, first isolated in 2001 from children hospitalized with acute respiratory infection, has now been reported in all age groups and with varying stages of disease, from asymptomatic carrier states to severe bronchitis and pneumonia [30].

Mixed Pathogens

Mixed viral-bacterial infection has been observed in 30% of adult cases of CAP in some studies [9,31,34]. Most commonly, S. pneumoniae is identified in combination with rhinovirus, influenza A, or RSV [34]. On rare occasions fungal and parasitic pathogens are isolated in association with CAP syndrome.

DIAGNOSIS IN ADULT PATIENTS

Clinical Features

The diagnosis of CAP in adults is challenging because its presentation is similar to other acute respiratory illnesses such as pulmonary embolism/infarction and congestive heart failure [3,51,52]. Diagnosis relies primarily on clinical features combined with radiographic findings; however, both the clinical presentation and chest x-ray abnormalities are variable and in part nonspecific, particularly in the elderly [3,29]. Common presenting symptoms and signs are:

- Productive cough, purulent sputum

- Fever with rigors (shaking chills)

- Dyspnea

- Pleuritic chest pain

- Tachypnea

- Tachycardia

- Hypoxemia

- Signs of consolidation (e.g., crackles, bronchial breath sounds, egophony)

- Signs of pleural effusion (e.g., absent fremitus, dullness to percussion, decreased breath sounds)

Pneumonia in the elderly may present without a history of chills or fever, little cough, and a paucity of findings on exam and chest x-ray. Often in such cases, some combination of tachypnea, tachycardia, and altered mental status is the only sign [31,42].

Physical examination should focus on the chest, with auscultation to detect localized crackles (rales), bronchial breath sounds, and other signs of consolidation or pleural effusion [47]. Pulse oximetry should also be done. The most clinically significant individual findings are (in descending order) egophony, bronchial breath sounds, and dullness on percussion [53].

Chest Radiography

Evidence Based Practice Recommendation

The American College of Radiology asserts chest x-ray is the imaging modality of choice for complicated pneumonia.

https://acsearch.acr.org/docs/69446/Narrative

Last Accessed: August 22, 2018

Strength of Recommendation: 9

When pneumonia is suspected on the basis of these clinical features, chest radiography is the standard for confirming the diagnosis, and posteroanterior and lateral radiographs are recommended [3,29]. The IDSA/ATS guideline notes that evidence of an infiltrate on chest radiograph or other imaging study is required for a diagnosis of pneumonia [47]. In addition to establishing the diagnosis, the chest radiograph can help differentiate pneumonia from other conditions with similar signs and symptoms. Some degree of infiltrate is almost always demonstrated on chest radiographs of patients who have been ill longer than 24 to 48 hours, although the appearance may be subtle or absent on initial presentation [29,47]. Pneumonia is described according to its anatomic distribution on chest radiographs as either lobar, multifocal/lobar, bronchopneumonic, or interstitial.

The characteristic symptoms and signs, combined with radiographic findings of an infiltrate, establish the clinical diagnosis of pneumonia. One validated prediction tool commonly used assigns 1 point for each of five clinical features present in conjunction with an infiltrate on chest radiography [54]:

- Temperature >37.8°C (100.04°F)

- Heart rate >100 beats per minute

- Crackles on auscultation

- Decreased breath sounds

- Absence of asthma

A score of 4 or 5 indicates a 25% to 50% probability of pneumonia; a score of 2 or 3 indicates a probability of 3% to 10%; and a score of 0 or 1 represents a probability of l% or less [29,54]. Neither clinical nor radiographic features can reliably differentiate primary viral from bacterial or combined viral-bacterial pneumonia [9,31,32]. There are some features that, if present, aid in making the distinction. The presence of a viral epidemic in the community, such as influenza or RSV, increases the likelihood of a viral etiology [32]. The patient's age can also help identify the most probable cause; as noted previously, viral infections have been found more often in young children and adults older than 60 years of age compared with younger adults [9,24]. Chest pain is significantly more frequent in adults with bacterial pneumonia than in those with viral pneumonia [9]. Radiographic findings are generally not useful in identifying a specific pathogen, although multilobar infiltrates suggest infection with S. pneumoniae, S. aureus, or L. pneumophila, and patchy, interstitial infiltrates suggest a viral or mycoplasmal etiology [47,49].

Atypical Pneumonia

The first use of the term atypical pneumonia was in 1938 to describe a series of seven patients who had developed an unusual form of tracheobronchitis [65]. There had also been descriptions of outbreaks of pneumonia that behaved atypically in Europe in the 1920s. In general, these outbreaks were milder and had higher recovery rates than expected for the typical case of pneumonia.

At the present time, atypical pneumonia is encountered, and managed, primarily in the outpatient setting. The causative pathogen most commonly identified in such cases is M. pneumoniae. According to CDC estimates, Mycoplasma infections occur at the rate of 2 million cases each year and are responsible for between 1 and 10 of every 50 cases of CAP [66].

Atypical pneumonia syndrome, best represented by mycoplasma infection, presents with a subacute prodrome of malaise, low-grade fever, headache, myalgia, and non-productive cough. Symptoms progress slowly over days to weeks; often patients are thought to have an upper respiratory infection or bronchitis and appear less ill than those with typical bacterial pneumonia [65,66]. The physical examination usually reveals fine rales but no signs of lung consolidation. In the early stage, there may be a maculopapular skin eruptions and, on examination of the ear canal, bullous myringitis of the tympanic membrane. Chest x-ray reveals patchy alveolar densities or inhomogeneous segmental infiltrates, often bilateral involving the middle lobe and lingual. The white blood cell count may be normal or only slightly elevated. Full recovery is expected with no residual effects in a previously healthy individual. However, the disease can be severe in those with sickle cell anemia, older adults, and those with immunosuppression [65].

In younger patients, C. pneumoniae (TWAR strain) infection may present as atypical pneumonia. Outbreaks tend to occur in communal settings such as military units and college dormitories [231]. The illness is similar to that seen with mycoplasma infection, except that laryngitis is a prominent feature and nonexudative pharyngitis is common [26]. Chest x-ray may show patchy consolidation, interstitial infiltrates, or funnel-shaped lesions. The white blood cell count is usually normal.

Legionellosis

The first recorded outbreak of legionellosis occurred in 1976 at an annual convention of the American Legion in Philadelphia. A total of 182 of the delegates (many of whom were elderly) became ill, and 146 were hospitalized. The mortality rate was 16%. Because the conference ended prior to the development of significant symptoms in many patients, hospitals all over the United States admitted one or more of the patients who had attended the convention. Despite an outpouring of resources, it took six months to isolate the organism, later named L. pneumophila. The pneumonia caused by the organism is commonly known as Legionnaires' disease [65].

L. pneumophila is a small gram-negative bacillus, atypical in its clinical presentation and for its lack of susceptibility to ß-lactam antibiotics. There are about 60 identified species of Legionella, although L. pneumophila is the primary pulmonary pathogen [230]. Legionella accounts for an estimated 8,000 to 18,000 cases of pneumonia requiring hospitalization in the United States each year [229,230]. Suspicion for infection with Legionella organisms should be high in older adults, in those with chronic underlying disease, and in all patients with pneumonia severe enough to require hospitalization.

Legionella bacteria are found in common sources of freshwater but not usually in sufficient numbers to cause disease. However, in commercial water systems such as those found in large buildings, storage tanks, cooling towers, decorative fountains, or hot tubs, Legionella growth exceeds the threshold required for transmission to susceptible hosts via aerosolization [229]. Because hotels, resorts, and cruise ships often use large, complex water systems and other aerosol-generating devices, travel is a risk factor for disease. This is also true for hospitals and long-term care facilities.

The onset of infection is marked by dry cough, fever of 38.3°C–38.8°C (101°F–102°F), then progressive symptoms and signs of pneumonia accompanied by multi-organ involvement—vomiting, diarrhea, headache, and altered mental status. Chest x-ray reveals rapidly progressive, asymmetric infiltrates without signs of consolidation. Prompt diagnosis relies on clinical suspicion, urine antigen assay, and specialized culture techniques.

Laboratory Diagnosis

The challenge of diagnosis is complicated by the lack of cost-effective, reliable, and rapidly available tests to discriminate between viral and bacterial pneumonia [37]. The IDSA/ATS guideline notes that routine cultures of sputum and blood are not recommended for patients treated in the ambulatory setting, as results rarely impact management decisions [47]. The primary reason for cultures and serologic testing is to identify specific pathogens suspected on the basis of clinical and epidemiologic findings or cases in which the results of testing will substantially alter the empirical treatment of the patient [47]. Testing may be useful when evaluating a critically ill patient, a patient in whom a drug-resistant or unusual organism is suspected (e.g., Legionella), or a patient whose condition is deteriorating or who is not responding within 72 hours after treatment.

Blood Culture

Blood cultures are optional and not recommended as a routine diagnostic test for CAP managed in the ambulatory setting. The principle reason is that the yield is low, and studies show that a positive culture leading to a change in antimicrobial therapy occurs in about 3% or fewer cases [55,56,222]. The IDSA/ATS guideline recommends blood cultures before treatment only for patients hospitalized with one of the following conditions [47]:

- Cavitary infiltrates

- Leukopenia

- Active alcohol abuse

- Chronic severe liver disease

- Asplenia

- Positive test result for pneumococcal urinary antigen

- Pleural effusion

- Illness severity requiring admission to the ICU

Blood cultures are indicated for patients who have severe CAP, as they are more likely to have infection with a pathogen other than S. pneumoniae [47].

The ATS and the American College of Emergency Physicians (ACEP) also note that blood cultures need not be obtained routinely in all patients admitted with CAP [57]. Similarly to IDSA/ATS, ACEP adds that blood cultures should be considered for patients at higher risk, such as persons who have compromised immune systems, significant comorbidities, severe disease, or another risk factor for infection with resistant organisms [57].

Sputum Culture and Gram Stain

Sputum stain and culture are also considered optional, but are recommended when specific conditions are present [47]:

- Cavitary infiltrates

- Active alcohol abuse

- Severe obstructive/structural lung disease

- Positive result for urinary Legionella antigen test

- Positive result for urinary pneumococcal antigen test

- Pleural effusion

Sputum culture and Gram stain should also be performed for all hospitalized patients who are moderately ill or who warrant admission to an ICU [47]. The IDSA/ATS note that examination and culture of respiratory secretions should be performed only on specimens that meet quality performance measures for collection, transport, and processing of samples.

The diagnostic utility of sputum Gram stain and culture has been demonstrated in patients hospitalized with proven (bacteremic) pneumococcal pneumonia. In a series of 58 patients, from whom good quality sputum specimens (>10 inflammatory cells per epithelial cell) were submitted before or within six hours after initiation of antibiotic therapy, pneumococci were identified by Gram stain in 63% and by culture in 89% of cases [224].

Newer Diagnostic Techniques

Assays for the detection of antigen and other components of bacterial and viral pathogens have become a useful adjunct for establishing the etiology of pneumonia. Among these is the detection of bacterial antigen in the urine of patients with CAP. In a clinical series report, an assay for S. pneumoniae cell wall polysaccharide in urine was positive in 64% of patients with pneumococcal pneumonia; the sensitivity increased to 88% in patients who were bacteremic [225].

In a meta-analysis of published studies, the assay for detection of Legionella antigen in the urine of patients with pneumonia has been shown to have excellent specificity (99%) but only modest sensitivity (74%) [226]. Thus, a urine Legionella antigen assay is very useful to "rule in" the diagnosis but does not rule it out—a negative result should be interpreted with caution. Urine samples for Legionella antigen assay should be submitted in all cases of CAP with severe illness, suspicion of Legionella infection, or with risk factors such as COPD, HIV, immunosuppressive therapy, or organ transplantation. Isolation of Legionella from sputum can be accomplished on selective media. Serologic diagnosis requires acute and convalescent serum; it is useful to confirm a case, but of little value in early diagnosis.

Testing for Viruses

Viral culture remains the criterion standard for diagnosis of viral pneumonia, but because of limitations such as the need for prompt transportation, time needed for viral detection, and the lack of sensitivity for all viruses, rapid antigen testing is often done. In adults, rapid testing has a sensitivity of 50% to 60% and a specificity of at least 90% [31]. Testing of nasal swab specimens is slightly less sensitive than testing of wash specimens, but wash specimens can be difficult to obtain in frail or cognitively impaired adults. Rapid RSV tests are usually not useful for adults, as the level of virus titers shed is low [31].

Molecular diagnostic testing of sputum holds promise for providing a rapid and accurate etiologic diagnosis. Studies show that real-time PCR is significantly more sensitive and specific for the detection of the common respiratory viruses that cause CAP, as well as M. pneumoniae and C. pneumoniae [24,33]. However, molecular assays are expensive and not currently widely available [31].

Biomarkers

Over the past several years, researchers have been evaluating biomarkers for their utility in diagnosis and for determining duration of empirical therapy for presumed bacterial pneumonia. Procalcitonin has been shown to be superior to other commonly used markers for its specificity for bacterial infection and its ability to distinguish CAP from asthma and COPD [58,59]. This marker has predictive value; however, no biomarker should be used on its own and, if used, should be considered within the context of clinical and laboratory findings [59].

MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA IN ADULTS

Guidelines for the management of pneumonia in adults were first developed independently by the ATS and the IDSA, with each publishing guidelines in the 1990s and early 2000s [36,63,64]. The recommendations in each guideline differed somewhat, but the principles were the same [36]. To eliminate the confusion associated with separate guidelines, the IDSA and ATS jointly developed the current guideline for CAP, published in 2007 (update in progress as of 2018) [47]. The IDSA/ATS guideline focuses on decision making about site of care; the empirical selection of antibiotics; and issues in the delivery of antibiotics, such as the timing of the first dose of antibiotics, the timing of switch therapy (from parenteral to oral antibiotics), and the duration of therapy [47]. The treatment of symptoms associated with CAP is not addressed in the guideline. A systematic review published in 2012 found insufficient evidence to determine if there is benefit to over-the-counter medications (e.g., mucolytics, cough suppressants) for cough associated with acute pneumonia [67].

Site of Care

One of the most important decisions in the management of CAP is determining the site of care—that is, outpatient or inpatient and, if the latter, a general care floor or an ICU [68]. Many physicians admit patients to the hospital when they could be managed effectively on an outpatient basis [47]. This decision requires a careful evaluation of the severity of illness in the context of the personal and social well-being of the patient. Objective severity-of-illness scores and prognostic models can aid in identifying patients who may require hospitalization or admission to an ICU. The most widely used scales are the CRB-65 (confusion, respiratory rate, blood pressure, age 65 years or older) (Figure 1), the CURB-65 severity score (which adds urea level to the CRB-65 criteria), and the Pneumonia Severity Index (PSI) (Table 5). These assessment tools are recommended by the IDSA/ATS as an aid to clinical judgment in determining the site of care [47,69,70]. The scales have been compared, and they do not differ significantly in overall performance [71]. However, each scale has advantages and disadvantages, and none factor in all clinical considerations (such as comorbidities or social factors) [68]. CURB-65 and CRB-65 are easier to score as they have fewer variables and are more likely to correctly classify high-risk patients (i.e., high positive-predictive value) [72]. In contrast, the PSI is more sensitive and is better at determining which patients do not require hospitalization (i.e., low false-negative rate). About 30% to 60% of patients at low risk are unnecessarily admitted to the hospital according to the PSI score [68].

Figure 1: CLINICAL SEVERITY ASSESSMENT IN THE COMMUNITY SETTING: THE CRB-65 SCORE

aDefined as a Mental Test Score of 8 or less or new disorientation in person, place, or time.

Source: Reprinted with Permission from Lim W, van der Eerden MM, Laing R, et al. Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58:377-382.

Table 5: PNEUMONIA SEVERITY INDEX: POINT SCORING SYSTEM FOR STEP 2 OF THE PREDICTION RULE FOR ASSIGNMENT TO RISK CLASSES II, III, IV, AND V

Characteristic

Points Assigneda

Nursing home resident

+10

Demographic factor (age)

Men

Age (yr)

Women

Age (yr)-10

Coexisting illnessesb

Neoplastic disease

+30

Liver disease

+20

Congestive heart failure

+10

Cerebrovascular disease

+10

Renal disease

+10

Physical-examination findings

Altered mental statusc

+20

Respiratory rate ≥30 breaths/min

+20

Systolic blood pressure <90 mm Hg

+20

Temperature <35°C or ≥40°C

+15

Pulse ≥125 beats/min

+10

Laboratory and radiographic findings

Arterial pH <7.35

+30

Blood urea nitrogen ≥30 mg/dL

+20

Sodium <130 mmol/L

+20

Glucose ≥250 mg/dL

+10

Hematocrit <30%

+10

Partial pressure of arterial oxygen <60 mm Hgd

+10

Pleural effusion

+10

aA total point score for a given patient is obtained by summing the patient's age in years (age minus 10 for women) and the points for each applicable characteristic. The points assigned to each predictor variable were based on coefficients obtained from the logistic-regression model used in step 2 of the prediction rule. A score <70 is risk class II, 71–90 is risk class III, 91–130 is risk class IV, and >130 is risk class V. Higher risk classes are associated with increased mortality.

bNeoplastic disease is defined as any cancer except basal or squamous cell cancer of the skin that was active at the time of presentation or diagnosed within one year of presentation. Liver disease is defined as a clinical or histologic diagnosis of cirrhosis or another form of chronic liver disease, such as chronic active hepatitis. Congestive heart failure is defined as systolic or diastolic ventricular dysfunction documented by history, physical examination, and chest radiograph, echocardiogram, multiple gated acquisition scan, or left ventriculogram. Cerebrovascular disease is defined as a clinical diagnosis of stroke or transient ischemic attack or stroke documented by magnetic resonance imaging or computed tomography. Renal disease is defined as a history of chronic renal disease or abnormal blood urea nitrogen and creatinine concentrations documented in the medical record.

cAltered mental status is defined as disorientation with respect to person, place, or time that is not known to be chronic, stupor, or coma.

dIn the Pneumonia PORT cohort study, an oxygen saturation of less than 90% on pulse oximetry or intubation before admission was also considered abnormal.

Source: Reprinted with permission from Fine M, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243-250.

The PSI, CURB-65, and CRB-65 were developed to predict the risk of death. Because this risk does not always equate to the need for hospitalization and/or ICU admission, other scales have been developed. For example, SMART-COP provides a score based on a composite of systolic blood pressure, multilobar involvement on chest radiograph, albumin level, respiratory rate, tachycardia, confusion, oxygenation, and arterial pH [73]. SMART-COP was found to accurately predict the need for intensive respiratory or vasopressor support. Another tool, the Severe Community-Acquired Pneumonia (SCAP) score, includes points assigned to eight variables: arterial pH, systolic pressure, confusion, blood urea nitrogen level, respiratory rate, chest radiograph findings, pulmonary arterial oxygen tension (PaO_2), and age (older than 80 years) [74]. SCAP has identified a larger proportion of patients as low risk compared with the PSI, CURB-65, and CRB-65, and is better than or as accurate as those scores at predicting adverse outcomes in hospitalized patients [74,75]. The IDSA/ATS guideline notes that the results of these objective criteria should always be accompanied by clinical judgment, including consideration of subjective factors, such as the availability of outpatient support resources and the patient's ability to safely and reliably take oral medication [47].

It is estimated that admission to an ICU is needed for 10% to 20% of patients hospitalized with CAP [76]. The IDSA/ATS guideline establishes major and minor criteria for direct admission to an ICU [47]. The major criteria are septic shock requiring vasopressors or acute respiratory failure requiring intubation and mechanical ventilation. The presence of at least three of the following minor criteria suggests the need for ICU admission [47]:

- Increased respiratory rate (≥30 breaths per minute)

- Low PaO_2/fraction of inspired oxygen ratio (≤250)

- Multilobar infiltrates

- Confusion/disorientation

- Uremia (blood urea nitrogen level ≥20 mg/dL)

- Leukopenia (white blood cell [WBC] count <4,000 cells/mm^3)

- Thrombocytopenia (platelet count <100,000 cells/mm^3)

- Hypothermia (core temperature <36°C [96.8°F])

- Hypotension requiring aggressive fluid resuscitation

These criteria were validated as being useful for predicting the severity of CAP [77,78].

Selection of Antibiotics

Evidence Based Practice Recommendation

The Infectious Diseases Society of America (IDSA) recommends empirical therapy for MRSA pending sputum and/or blood culture results for hospitalized patients with severe community-acquired pneumonia defined by any one of the following: a requirement for ICU admission, necrotizing or cavitary infiltrates, or empyema.

https://academic.oup.com/cid/article/52/3/e18/306145

Last Accessed: August 22, 2018

Level of Evidence: A-III (Good supporting evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees)

The goal of antibiotic treatment of pneumonia is to eradicate the infection or to reduce the bacterial load that the patient's own immune response is able to limit spread and speed recovery. The choice and duration of therapy is based on consideration of known or suspected etiology, age and severity of illness, comorbidities, and knowledge of resistance patterns in the community. One should strive to tailor therapy and avoid unnecessarily prolonged treatment so as to minimize the potential for the development of resistance [37].

Pending results of culture or serologic testing, the initial treatment is empirical and is selected according to patient variables and clinical setting (Table 6) [47]. Patients with mild illness and no serious coexisting disease may be managed as outpatients. The ATS/IDSA guideline recommends a macrolide for outpatient treatment of CAP, provided the patient has not received antimicrobials within the previous three months and the prevalence of macrolide resistance among pneumococci in the community is <25% [47]. S. pneumoniae resistance to macrolides is four times more likely in adult patients who have received this class of drug within the previous three months, in which case a fluoroquinolone or ß-lactam plus macrolide combination should be selected. A respiratory fluoroquinolone (levofloxacin or moxifloxacin) is recommended for adults who have comorbidities or a compromised immune system [47]. Fluoroquinolones should not be used routinely, as widespread use increases the possibility that resistance will develop. Alternatively, a ß-lactam plus a macrolide can be used.

Table 6: RECOMMENDED EMPIRICAL ANTIMICROBIAL THERAPY ACCORDING TO 2007 IDSA/ATS GUIDELINE FOR THE MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA

Site of Care and Patient Characteristics

Recommended Drug Class

Specific Drug Options

Level of Evidence

Previously healthy outpatient, no exposure to antibiotics within past three months

Macrolide

Azithromycin, clarithromycin, or erythromycin

Strong recommendation, level I evidence

Tetracycline

Doxycycline

Weak recommendation, level III evidence

Outpatients with comorbiditiesa or exposure to antibiotics within the previous three monthsb

Respiratory fluoroquinolone

Moxifloxacin, gemifloxacin, or levofloxacin

Strong recommendation, level I evidence

ß-lactam + macrolide

High-dose amoxicillin or amoxicillin-clavulanate

Strong recommendation, level I evidence

Alternatives: ceftriaxone, cefpodoxime, or cefuroxime

Level II evidence

ß-lactam + tetracycline

High-dose amoxicillin and doxycycline

Level II evidence

Inpatient (not ICU)

Respiratory fluoroquinolone

—

Strong recommendation, level I evidence

ß-lactam + macrolide

—

Strong recommendation, level I evidence

Inpatient (ICU)

ß-lactam + azithromycin

OR

ß-lactam + respiratory fluoroquinolone

Alternative for penicillin allergy: respiratory fluoroquinolone and aztreonam

Cefotaxime, ceftriaxone, or ampicillin-sulbactam

Strong recommendation, level I and II evidence

aComorbidities include chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignant disease; or asplenia or use of immunosuppressant drugs.

bIf patient has been exposed to antibiotics within previous three months, a different drug from a different class should be used.

Source: [47]

The selection of a respiratory fluoroquinolone or a ß-lactam plus macrolide combination is recommended also for patients with CAP who are hospitalized on a general floor [47]. Adults admitted to an ICU need empiric treatment for S. pneumoniae and Legionella spp., as well as consideration of coverage for S. aureus and gram-negative bacteria infection, pending sputum and blood culture results. This is achieved with a regimen that combines a broad-spectrum ß-lactam with either azithromycin or a respiratory fluoroquinolone, adding vancomycin or linezolid to cover MRSA if there is clinical suspicion of S. aureus infection. Aztreonam, a monobactam, may be substituted for gram-negative bacteria coverage in patients allergic to ß-lactams [47]. The IDSA/ATS guideline also specifies antibiotic selection in reference to specific pathogens (Table 7) [47].

Table 7: RECOMMENDED ANTIBIOTIC THERAPY FOR SPECIFIC PATHOGENS ACCORDING TO 2007 IDSA/ATS GUIDELINE FOR THE MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA

Pathogen

Preferred Antibiotic

Alternative Options

Streptococcus pneumoniae, not penicillin resistant

Penicillin G, amoxicillin

Macrolide, cephalosporins, clindamycin, doxycycline, respiratory fluoroquinolone

Streptococcus pneumoniae, penicillin resistant

Based on susceptibility (cefotaxime, ceftriaxone, fluoroquinolone)

Vancomycin, linezolid, high-dose amoxicillin

Haemophilus influenzae, non-ß-lactamase producing

Amoxicillin

Fluoroquinolone, doxycycline, azithromycin, clarithromycin

Haemophilus influenzae, ß-lactamase producing

Second- or third-generation cephalosporin, amoxicillin-clavulanate

Fluoroquinolone, doxycycline, azithromycin, clarithromycin

Mycoplasma pneumoniae/Chlamydophila pneumoniae

Macrolide, a tetracycline

Fluoroquinolone

Legionella spp.

Fluoroquinolone, azithromycin

Doxycycline

Pseudomonas aeruginosa

Antipseudomonal ß-lactam plus ciprofloxacin or levofloxacin or aminoglycoside

Aminoglycoside plus ciprofloxacin or levofloxacin

Acinetobacter spp.

Carbapenem

Cephalosporin-aminoglycoside, ampicillin-sulbactam, colistin

Staphylococcus aureus, methicillin susceptible

Antistaphylococcal penicillin

Cefazolin, clindamycin

Staphylococcus aureus, methicillin resistant

Vancomycin or linezolid

Trimethoprim/sulfamethoxazole

Source: [47]

For adults who present with presumed viral CAP, it is unclear whether antibiotic treatment is beneficial. When there is epidemiologic, clinical, or laboratory evidence of active influenza, a neuraminidase inhibitor should be administered [32].

Timing of Initial Antibiotic Therapy

The time to the first dose of antibiotics for adults with CAP has engendered debate. A 2003 guideline developed by the IDSA recommended initiation of antibiotic therapy within four hours after hospitalization. Quality measures linked to this timeframe were developed by the Joint Commission and the Centers for Medicare and Medicaid Services [2,66,79,80]. Experts have criticized the timeframe requirement, with some noting that it has the potential to result in less-than-optimal care and others adding that diagnosis of pneumonia in the emergency department is challenging, especially in older patients who have an atypical presentation [51,52,79,80]. In a survey of 121 emergency physicians, 55% of the respondents said they had prescribed antibiotics to patients they did not believe had pneumonia in an effort to comply with the Centers for Medicare and Medicaid Services quality measure; 42% of these respondents said they had prescribed as such more than three times a month [80]. Sixty percent of the respondents said they did not believe that the guideline improves patient care. The results of a systematic review and a large-scale study have shown no decrease in mortality with a first dose administered within four hours [57,81,82].

As emphasized by the IDSA/ATS guideline committee, the recommendation at present is to begin antibiotic treatment promptly, without delay, administering the initial dose at the site of care (e.g., emergency department, clinic, office) where the diagnosis is first made [47].

Duration of Therapy

With the availability of well-absorbed, effective oral antibiotics, hospitalized adults do not require intravenous antibiotics for the duration of treatment. Intravenous therapy can be changed to an oral regimen when the patient is hemodynamically stable, improving clinically, and able to take oral medications safely [47]. For patients on a general ward floor, this transition can often be made by the third hospital day; patients in the ICU usually reach this point within seven days. It is recommended that the oral antibiotic be either the same drug or within the same drug class as the intravenous antibiotic [47]. Patients can be discharged from the hospital as soon as clinical stability has been achieved, provided they have no comorbidities requiring inpatient care and have a safe home environment and reliable follow-up. The IDSA/ATS note the following criteria for determining clinical stability [47]:

- Temperature ≤37.8°C (100.04°F)

- Heart rate ≤100 beats per minute

- Respiratory rate ≤24 breaths per minute

- Systolic blood pressure ≥90 mm Hg

- Arterial oxygen saturation ≥90% or partial pressure of oxygen ≥60 mm Hg on room air

- Ability to maintain oral intake

- Normal mental status

The IDSA/ATS recommend that antibiotic therapy be given for a total of at least five days. The duration of therapy should be extended at least 48 to 72 hours beyond resolution of fever, assuming significant clinical improvement and no more than one pneumonia-associated active clinical sign [47]. A five- to seven-day course should suffice for most uncomplicated cases that show a prompt and satisfactory response to treatment.

The duration of treatment for gram-negative bacillary and staphylococcal pneumonia bears further comment. Unlike pneumococcal pulmonary infection, which usually heals without residual damage, these pathogens often cause destructive changes and small cavities in the lung, which clear slowly and heal by fibrosis. Thus, a more prolonged course of therapy (two to three weeks) should be considered, depending on severity of illness and response to therapy.

Treatment Failure

The clinical response to initial antibiotic therapy is unsatisfactory in approximately 15% of adults with CAP [47]. Failure to respond has no clear definition, and the IDSA/ATS guideline suggests using a systematic classification of cases, with attention to timing and character of response, as a guide to further evaluation and management. In general, treatment failures may be classified as persistent or non-responding, as a delay in achieving clinical stability, or as progressive pneumonia with clinical deterioration. Some clinical deterioration during therapy is not uncommon in the first 24 hours of treatment; as many as 45% of adults admitted to the hospital later require transfer to the ICU [47]. When the diagnosis of CAP is correct and guideline-recommended therapy has been used, the most common reason for treatment failure is an inadequate host response. For these patients, the appropriate management depends on individual case considerations, such as comorbidities, adequacy of pulmonary toilet, and whether the intravenous regimen has been reliably and consistently administered [47].

Benefits of Guideline-Adherent Antibiotic Therapy

Guideline-directed management of CAP has been associated with many benefits. In one study, use of guideline-recommended antibiotics was associated with a significantly shorter time to clinical stability; clinical stability was achieved by seven days in 71% of patients treated with guideline-recommended antibiotics and in 57% of those treated with nonadherent regimens [15]. Adherence to recommendations guiding the selection of antibiotics was also associated with a significantly shorter length of stay (8 vs. 10 days) and a significantly lower overall in-hospital mortality rate (8% vs. 17%) [15]. In a Canadian study of adults (mean age: 51 years) who, in the main, had mild pneumonia, guideline-adherent selection of antibiotic treatment was associated with a lower mortality rate (1%) than that found when treatment selection that was not adherent to guidelines (6%) [83]. The mortality rate associated with the use of macrolides was also significantly lower than that with the use of fluoroquinolones (0.2% vs. 3%) [83]. In a large study of 54,619 patients who were hospitalized at 113 community hospitals (not in the ICU), use of guideline-adherent treatment was associated with a lower in-hospital mortality rate, lower rate of sepsis and renal failure, and shorter length of stay and duration of parenteral therapy [17]. Decreased mortality has also carried over to populations with more severe disease, with nonadherent therapy being associated with an increase in inpatient mortality (25% vs. 11%) among older adults (median age: 71 years) who were admitted to an ICU [16]. In addition to the higher rates of adverse outcomes, the low rate of adherence has also resulted in the inappropriate use of antimicrobials in at least half of cases [21].

Despite the benefits of guideline-directed treatment and the wide dissemination of the guidelines for management of pneumonia in adults, adherence has been low, especially with regard to antibiotic selection, with rates ranging from 9% to 82% [15,16,17,18,20]. In a study of more than 34,000 patients in a managed care organization, adherence to the 2003 IDSA guidelines in ambulatory settings was 52% for patients who were previously healthy and had not had recent exposure to antibiotics [20]. The rate of adherence was better (82%) for patients who had comorbidities and no recent exposure to antibiotics [20]. One study found that most cases of guideline-discordant use of antibiotics for older adults represent undertreatment [15]. The use of recommended antibiotics in the emergency department significantly increased from 1993 through 2008, but the percentage of patients receiving these drugs is still not optimal, with 60% to 70% of patients not receiving recommended antibiotics [84].

Strategies to Enhance Adherence to Therapeutic Guidelines

As the low rate of guideline adherence demonstrates, disseminating clinical practice guidelines alone is not enough to change practice. Physician education should address barriers to guideline adherence, including lack of familiarity, concerns about the practicality of recommended antibiotics, increased cost, lack of documented improved outcomes, and potential conflict with other guidelines [23]. Physician practices and healthcare systems should implement strategies that have changed physician behavior in other health condition settings, such as face-to-face educational outreach, use of local opinion leaders, and individualized audit with peer-comparison feedback [85]. In a study of six Dutch hospitals, significant increases in adherence to guideline-recommended care were achieved with an intervention that included the establishment of a local committee, a lecture by a respected opinion leader, feedback on performance, and critical care pathway pocket cards [86]. The intervention also included a second phase that focused on aspects of treatment in most need of improvement. In another study, weekly e-mail reminders listing performance data on antibiotic administration recommendation for individual emergency physicians helped to increase guideline adherence [87]. The use of a standardized evidence-based order set was associated with a decrease in mortality and was also cost-effective [88].

Follow-Up Care

Evidence suggests that severe pneumonia is a cause of long-term morbidity and excess mortality among adults. In a population-based follow-up study of adults with CAP in Canada, conducted over a median of four years, the re-hospitalization rate for pneumonia was 16% to 72% for all causes [9].

The PSI classification and the time to clinical stability can both help predict adverse outcomes. Mortality has been reported to be higher for people originally classified as PSI class V than PSI classes I and II, with rates of 82% compared with 15% [9]. A time to clinical stability of more than 72 hours has been associated with a significantly higher rate of adverse outcomes than shorter times [90]. Overall, severe CAP has been associated with a 30-day re-hospitalization rate as high as 20%, a 30-day mortality rate as high as 23%, and all-cause mortality within one year as high as 28% [76].

These findings indicate that adults with severe pneumonia should be followed up closely to monitor for adverse events after discharge. The time to clinical stability is a useful guide for a follow-up plan; patients in whom clinical stability is not achieved until more than 72 hours after admission should be seen in follow-up soon after discharge [3,90]. Strategies to prevent influenza and pneumonia should also be emphasized for all hospitalized patients. When indicated, immunization against pneumococcal infection should be initiated before or shortly after discharge, as recommended by the Advisory Committee on Immunization Practices (ACIP) and others [47,91,94,227].

Patient and Family Education

After a diagnosis of pneumonia has been made, patient education should include directions for use of the antibiotic and information on potential untoward effects of the drug. Follow-up instructions, depending on the clinical situation, may include 24-hour telephone contact or follow-up in the office after 24 to 48 hours. This will improve adherence to the prescribed therapy, provide an opportunity to address side effects of drug therapy, and allow progress to be monitored. The need for hospitalization should be assessed throughout the course of the illness. Education should also include instructions to drink plenty of fluids and to use an antipyretic to control fever and myalgias when needed. Use of cough suppressants should be avoided, as the cough reflex and sputum expectoration enhance removal of thick secretions. However, in the event of a constant, nonproductive cough, as found especially with mycoplasmal infection, a narcotic such as codeine at night may allow for more restorative sleep.

Provisions for patients with limited English language proficiency are required under federal law, and the U.S. Department of Health and Human Services and the Office of Civil Rights view a lack of adequate interpretation as discrimination, based on the Civil Rights Act of 1964 [19]. According to U.S. Census Bureau data, more than 60 million Americans speak a language other than English at home, with more than 25 million (8.6% of the population) reporting that they speak English less than "very well" [127]. Immigrant patients with chronic illness may feel unable to return to their home countries due to a lack of available medical care. Changes in healthcare law restricting federal funding of services to only legal residents may cause significant problems for certain facilities, with conflicts arising from providing life-saving care for patients who have no means of reimbursement and no medical services waiting for them in their home countries.

ILLUSTRATIVE CASE

A semi-retired man, 68 years of age, presents one Sunday morning to the emergency department with malaise, fever, productive cough, and right pleuritic chest pain of less than 24 hours duration. He has been active, works as a custodian, has never been hospitalized, takes no medications, and does not regularly see a physician. On review of systems, the patient states that he gave up smoking years ago, has a mild chronic cough and morning sputum production, and has noted mild dyspnea on exertion for the past six months. He drinks only beer, never after work, but every Saturday afternoon he likes to take a six-pack out into the backyard, where he relaxes in his lounge chair. When asked whether there was anything different about the Saturday before the onset of the illness, his wife relates that he consumed two six-packs and failed to come in that evening. She found him later, after dark, asleep in his lounge chair, and helped him in to bed. He awoke this morning with fever and chills. On exam, the patient's temperature is 102.6°F, blood pressure 154/80 mm Hg, pulse 94 beats per minute, and respiration 20 breaths per minute. He is alert, with signs of mild emphysema and crackles audible over the right lower posterolateral chest. The chest x-ray shows patchy alveolar opacification in the right lower lobe and slight cardiomegaly.

The working diagnosis here is CAP, likely caused by S. pneumoniae or H. influenzae, as the patient has no prodromal upper respiratory symptoms to suggest viral or mycoplasma infection.

Why is this happening now? COPD/chronic bronchitis appears to have developed in recent years. Such patients have damaged, poorly functioning mucociliary epithelium and rely on compensatory cough to promote tracheobronchial clearance. Moreover, they often have colonization with pneumococcus and H. influenzae. An additional risk factor in this patient may be mild heart failure with ambient alveolar edema in the basal segments of the lower lungs. Excessive beer consumption the evening before onset of illness made him somnolent and suppressed his cough reflex, thus rendering him vulnerable to aspiration and retention of upper tract secretions (if not gastroesophageal reflux and aspiration). Encumbered by alveolar edema, and perhaps impaired by the metabolic effects of alcohol, pulmonary macrophages in the basal segment of the right lung were simply overwhelmed.

What is the best site of care and treatment for this patient? While he does not meet the criteria for ICU admission, his age, comorbidities, degree of illness, and social situation taken together suggest the need for hospital admission, parenteral antibiotic therapy, and close observation, anticipating a short hospital stay. He was treated with a ß-lactam and macrolide, improved rapidly, and was discharged day 3 on a matching oral regimen, to complete a 10-day course of therapy.

What preventive measures were taken to reduce the risk of this happening again? The 23-valent polysaccharide vaccine (PPSV23) (Pneumovax) was administered prior to discharge and arrangements were made for primary care follow-up. The patient and his wife were educated regarding the need for yearly influenza vaccination. The role of alcohol was discussed, as well as the importance of keeping the Saturday afternoon beer consumption within clearly defined limits.

PNEUMONIA IN THE PEDIATRIC PATIENT

Etiology

Viral pathogens are reported to be responsible for most cases of CAP in preschool-aged children and as many as 80% of cases in children younger than 2 years of age [30]. In children younger than 2 years of age, the most common viral pathogen, occurring in up to 40% of cases, is RSV; other viral pathogens include adenoviruses, bocavirus, human metapneumovirus, influenza A and B viruses, parainfluenza viruses, coronaviruses, and rhinovirus [9,29,30,32].

RSV infection is common in infants and young children; it is estimated that most children have had RSV by 2 years of age [31]. It is leading cause of pneumonia in infants younger than 1 year of age, with 25% to 40% of those infected developing signs of pneumonia or bronchiolitis [29]. Premature birth, very young age, compromised immune system, and impaired lung or heart function are all risk factors for RSV-related pneumonia in infants. In contrast to preschool-aged children, the percentage of viral cases is much lower among older children and adolescents (10 to 16 years of age), and pneumonia caused by RSV is rare in this population.

In older children, viral and atypical bacterial infection account for most mild CAP managed in the ambulatory setting, while pyogenic respiratory bacterial infection is responsible for the majority of CAP in seriously ill, hospitalized children [30]. S. pneumoniae is the most common bacterial pathogen in school-aged children. Studies show that atypical pathogens account for 3% to 23% of cases, most commonly mycoplasma in older children and chlamydia in infants and young children [30]. A 2009 European study examining causative agents in hospitalized pediatric patients with radiographic evidence of pneumonia found bacterial infection in 53% of patients and viral pathogens in 67% of patients, with 33% of children in the study showing evidence of both [63]. S. pneumoniae was the most common bacterial pathogen (46%), followed by M. pneumoniae and C. pneumoniae. The primary viral pathogens identified were influenza A or B, parainfluenza, rhinovirus, RSV and, human metapneumovirus [63].

As with adults, severe CAP caused by S. aureus is encountered during outbreaks of influenza [223]. Legionella spp. and fungal pathogens are uncommon in children. A combination of viral and bacterial pathogens occurs in up to half of children with CAP [30,32].

Clinical Features and Diagnosis

The clinical presentation of CAP in children is similar to that in adults, but can vary according to age and developmental stage. For example, cough productive of purulent sputum may be elicited in older children, but nonproductive cough is common in young children and infants [30,60]. Nonspecific irritability and restlessness may be the primary symptoms in infants.

During the physical examination of pediatric patients, the clinician should look for signs of hypoxia and dehydration, as well as retractions, tachypnea, and use of accessory muscles of respiration [60]. The clinician should also evaluate the upper respiratory tract for evidence of rhinorrhea, otitis media, and pharyngitis [60]. Auscultation of the chest should be carried out, and the Pediatric Infectious Diseases Society (PIDS)/IDSA guideline recommends pulse oximetry for children with suspected hypoxemia [30].

One of the most common reasons for pediatric emergency room visits is fever, and fever is present in 88% to 96% of identified pneumonia cases in developed countries [70]. However, children with fever and wheezing commonly have either upper respiratory disease or reactive airway disease. As with pneumonia in adults, the accuracy of any one sign or symptom in predicting the likelihood of pneumonia is limited [61]. Nonspecific symptoms such as vomiting and abdominal discomfort are common. Careful attention should be given to the chest exam, as diminished breath sounds and fine end-inspiratory crackles are subtle, important clues to the presence of pneumonia in the pediatric patient. In one study, non-specific crackles were present in more than 90% of children with pneumococcal or mycoplasma pneumonia [70]. Infants with pneumonia commonly present with poor feeding and irritability as well as tachypnea, retractions, grunting, and hypoxemia; cough is rare [64].

Several clinical rules have been developed for predicting the likelihood of pneumonia in children on the basis of discernable clinical signs. The presence of at least two of the following signs—fever, tachypnea, and reduced oxygen saturation—is associated with a high probability of the disease; the absence of all three indicates a low probability [61]. Other signs of respiratory distress, such as cough, nasal flaring (in infants), rales, and decreased breath sounds, have also been found to be independent predictors of pneumonia in infants and children [60,62]. Bronchial breath sounds, rales, and dullness to percussion are more likely to occur in older children and adolescents [60].

Unlike diagnosis in adults, a chest radiograph is not the diagnostic standard to be applied for all CAP in children. The PIDS/IDSA guideline notes that routine chest radiographs are not necessary for children who can be treated as outpatients [30]. However, postero-anterior and lateral chest radiographs should be obtained when there is fever and respiratory distress suspected or documented hypoxemia, or illness severe enough to warrant hospitalization [30]. In a study of 99 children hospitalized with what was later determined to be pneumonia, the most common abnormal finding was "diminished" breath sounds; only 21% were described as having "normal" breath sounds. Radiographic evidence of pulmonary consolidation was present in 79% of patients, and correlation between diminished breath sounds and a positive chest x-ray was 60.2% [63].

Laboratory Tests

Unlike the situation in adults, titers of shed virus in children are high [31]. Thus, rapid antigen testing of nasal or throat swabs for influenza and other respiratory viruses should be done for infants and young children [30]. However, it should be noted that negative results of influenza virus on rapid antigen tests do not conclusively rule out infection with influenza virus. Testing for C. pneumoniae is not recommended.

Blood cultures are not routinely needed but should be obtained in children hospitalized for moderate-to-severe pneumonia that is presumed to be bacterial [30]. Urinary antigen detection tests often have false-positive results in children and are therefore not recommended for the diagnosis of pneumococcal pneumonia.

Management of Community-Acquired Pneumonia in Children

The PIDS/IDSA guidelines, published in 2011, addresses the management of CAP in children 3 months of age and older who are otherwise healthy; the guideline does not provide guidance for neonates and infants younger than 3 months of age or children with comorbidities [30]. The guidelines were developed in an effort to decrease morbidity and mortality, as had been shown with the guideline for adults. Similar to the IDSA/ATS guideline, the management issues addressed in the PIDS/IDSA guidelines are site of care and selection and duration of antibiotic therapy, as well as adjunctive surgical and nonantibiotic treatment for complications. As with the guideline for adults, treatment of pneumonia-related symptoms is not included in the pediatric guideline. The discussion here is limited to site of care and antibiotic therapy.

Site of Care

To aid in making site-of-care decisions, the PIDS/IDSA guidelines recommend that a child or infant with CAP be hospitalized if any of the following factors are present [30]:

- Moderate-to-severe illness, as defined by several features, including respiratory distress and hypoxia

- Suspected or documented infection caused by a pathogen with increased virulence, such as community-associated MRSA

- Uncertainty about care at home or availability for follow-up

Most children with pneumonia do not require care in an ICU. The guideline states that a child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child [30]:

- Requires invasive ventilation via a nonpermanent artificial airway (endotracheal tube)

- Has impending respiratory failure or sustained tachycardia, inadequate blood pressure, or need for pharmacologic support of blood pressure or perfusion

- Has altered mental status as a result of pneumonia

- Has a pulse oximetry measurement <92% on inspired oxygen of ≥0.50

- Requires acute use of noninvasive positive pressure ventilation

Selection of Antibiotics or Antivirals

Evidence Based Practice Recommendation

According to the Pediatric Infectious Diseases Society and the IDSA, influenza antiviral therapy should be administered as soon as possible to children with moderate-to-severe community-acquired pneumonia consistent with influenza virus infection during widespread local circulation of influenza viruses, particularly for those with clinically worsening disease documented at the time of an outpatient visit. Because early antiviral treatment has been shown to provide maximal benefit, treatment should not be delayed until confirmation of positive influenza test results.

https://academic.oup.com/cid/article/53/7/e25/424286

Last Accessed: August 22, 2018

Strength of Recommendation/Level of Evidence: Strong recommendation; moderate-quality evidence

The PIDS/IDSA guideline recommends empiric antibiotic therapy according to patient age, immunization status, and site of care. Among infants and children 3 months to 5 years of age, antibiotic therapy is not routinely recommended because viral infection is the predominate cause of CAP in this age group [30]. When the cause is thought to be an influenza virus, influenza antiviral therapy should be started as soon as possible, as maximal benefit has been found when treatment begins within 48 hours after symptomatic infection. (Treatment should not be delayed while waiting for the results of viral testing.) The PIDS/IDSA guideline recommends three U.S. Food and Drug Administration (FDA)-approved influenza antiviral therapies: oseltamivir (Tamiflu), zanamivir (Relenza), and amantadine (Symmetrel) [30]. A fourth antiviral therapy, rimantadine (Flumadine), is included in the guideline, with a note that the agent is FDA-approved for prophylaxis—not treatment—in children 1 year of age and older [30]. The guideline adds that data on the safety and efficacy of the agent for children 1 year of age and older have been published.

As in adults, S. pneumoniae is the most common bacterial cause of CAP in children; thus, if a bacterial pathogen is thought to be the cause, amoxicillin or amoxicillin/clavulanate is recommended as first-line therapy for mild-to-moderate illness in previously healthy children 3 months to 5 years of age who are up-to-date with immunization [30]. Several alternatives can be used for children who are allergic to amoxicillin (Table 8). Amoxicillin is also the preferred antibiotic for mild-to-moderate CAP in adolescents and children 5 years of age and older [30]. For children of all ages, especially children older than 5 years of age and adolescents, a macrolide is recommended if an atypical bacterial pathogen is thought (or documented) to be the cause.

Table 8: EMPIRIC ANTIBIOTIC THERAPY FOR COMMUNITY-ACQUIRED PNEUMONIA IN CHILDREN ACCORDING TO PIDS/IDSA GUIDELINE

Site of Care, Patient Characteristics

Presumed Bacterial Pneumonia

Presumed Atypical Pneumonia

Outpatient

<5 years

Amoxicillin

Alternative: amoxicillin clavulanate

Azithromycin

Alternatives: clarithromycin or erythromycin

≥5 years

Amoxicillina

Alternative: amoxicillin clavulanate

Azithromycin

Alternatives: clarithromycin, erythromycin, doxycycline (children >7 years)

Inpatient (all ages)

Fully immunizedb and minimal local penicillin resistance in invasive strains of pneumococcus

Ampicillin or penicillin G

Alternatives: ceftriaxone or cefotaxime (with vancomycin or clindamycin if MRSA suspected)

Azithromycin (with ß-lactam if atypical pneumonia is doubtful)

Alternatives: clarithromycin, erythromycin, doxycycline (children >7 years), or levofloxacin (children who have reached growth maturity or who cannot tolerate macrolides)

Not fully immunized and/or significant local penicillin resistance in invasive strains of pneumococcus

Ceftriaxone or cefotaxime (with vancomycin or clindamycin if MRSA suspected)

Alternative: levofloxacin (with vancomycin or clindamycin if MRSA suspected)

Azithromycin (with ß-lactam if atypical pneumonia is doubtful)

Alternatives: clarithromycin, erythromycin, doxycycline (children >7 years), or levofloxacin (children who have reached growth maturity or who cannot tolerate macrolides)

aA macrolide plus ß-lactam can be used for children 5 years of age and older with presumed bacterial pneumonia who have clinical, radiographic, or laboratory evidence to distinguish bacterial from atypical pneumonia.

bHas received conjugate vaccines for Haemophilus influenzae b and Streptococcus pneumoniae.

Source: [30]

For fully immunized infants and school-aged children who are hospitalized, treatment with ampicillin or penicillin G is recommended when local epidemiologic data show a low level of penicillin resistance to S. pneumoniae [30]. For children who are not fully immunized or are hospitalized in an area with a high level of penicillin-resistant S. pneumoniae, treatment with a third-generation cephalosporin (ceftriaxone or cefotaxime) should be given intravenously. If M. pneumoniae or C. pneumoniae is strongly suspected, treatment should include a macrolide (orally or intravenously) with a ß-lactam and diagnostic testing should be done as soon as possible [30]. The PIDS/IDSA guideline also recommends antimicrobial treatment for specific pathogens; however, a discussion of all possible pathogens is beyond the scope of this course.

According to a systematic review, zinc supplementation in addition to standard antibiotic therapy was not shown to have significant benefit on clinical recovery of severe or nonsevere pneumonia in children 2 to 59 months of age [89].

Duration of Therapy

Most studies have evaluated 10-day therapy, and this duration is associated with good outcomes. However, a shorter duration may be equally as effective, especially for mild disease treated on an outpatient basis [30].

Benefits of Guideline Adherence

Because the PIDS/IDSA guideline for management of CAP in children is relatively recent, data are lacking on the benefits of guideline-adherent treatment in the pediatric population. One study did show that more children received appropriate antibiotics after the development of a clinical practice guideline based on the PIDS/IDSA guideline and an antimicrobial stewardship program [14]. It is assumed that more data will become available over time.

Late Complications

Data on the long-term effects of pneumonia during childhood are lacking. A systematic review demonstrated that severe pneumonia in children younger than 5 years of age is associated with long-term sequelae, with restrictive lung disease being the most common sequela [95]. Overall, major respiratory sequelae (e.g., restrictive lung disease, obstructive lung disease, bronchiectasis) occurred in 5.5% of children treated on an outpatient basis and in 13.6% of children hospitalized for treatment [95]. Sequelae occurred in approximately 54% of children who had pneumonia caused by adenovirus.

7. PREVENTION OF PNEUMONIA

IMMUNIZATION

The primary preventive strategy for pneumonia is immunization with pneumococcal and influenza vaccines, especially for older individuals (older than 65 years of age), young children, and groups at high risk (Table 9) [91]. Other strategies include improved hand hygiene compliance and adherence to healthy lifestyle behaviors.

Table 9: HIGH-PRIORITY AND HIGH-RISK GROUPS FOR VACCINATION

Vaccination

Priority Groups

Annual influenza vaccination

Adults 65 years of age and older

Children 6 to 59 months of age

Residents of long-term care facilities

Adults and children with chronic medical conditions

Women who are pregnant during the influenza season

Pneumococcal vaccination

Adults 65 years of age and older with no history of pneumococcal vaccination

Adults younger than 65 years of age with at least one of the following:

- Chronic disease (e.g., lung, cardiovascular, or liver disease or diabetes)

- Compromised immune system

- Alcoholism

- Cochlear implants

- Cerebrospinal fluid leaks

- Functional or anatomic asplenia

- Resident of nursing home or long-term care facility

- Current or recent past history of smoking

Source: [28,91]

Pneumococcal Vaccination

Pneumococcal vaccines have been improved over time by broadening the coverage of serotypes in the vaccine to include those that are causing the most common invasive infections. In the past, a single agent, PPSV23, has been recommended for use in selected adults with conditions of impaired immunity, and for all adults older than 65 years of age [96]. This vaccine provides some protection against 85% to 90% of the pneumococcal serotypes that cause invasive disease in these populations [97]. Pneumococcal conjugate vaccines are used for younger children, as polysaccharide vaccines are not effective in children younger than 2 or 3 years of age. In 2010, a 13-valent pneumococcal conjugate vaccine (PCV13) replaced the 7-valent vaccine (PCV7) previously in use since 2000 [97].

The use of pneumococcal conjugate vaccines in the pediatric age group has been followed by a reduction in the incidence of pneumococcal disease among children, and, indirectly, among adults as well. By 2013, the incidence of invasive pneumococcal disease caused by serotypes represented in the PCV13 vaccine had declined in the adult population older than 65 years of age by approximately 50% compared with 2010 [227]. In 2012, upon approval by the FDA, the ACIP recommended the use of PCV13 for adults with immune deficits and other conditions that impose a heightened risk for invasive pneumococcal infection. After reviewing additional data in 2014, the ACIP extended its recommendation for PCV13 use to all adults older than 65 years age [227].

The ACIP now recommends that both PCV13 and PPSV23 be administered routinely in series to all adults older than 65 years of age (Table 10) [227]. Only a single dose of PCV13 is recommended for adults. No additional dose of PPSV23 is indicated for adults who have previously received this vaccine at or after age 65 years. Pneumococcal vaccine-naïve older adults or those for whom the vaccine history is unknown should receive a dose of PCV13 first, followed by a dose of PPSV23 in 6 to 12 months. Current information, schedules, and guidance for adult immunizations is maintained at the CDC/ACIP website at https://www.cdc.gov/vaccines/schedules.

Table 10: IMMUNIZATION SCHEDULE RECOMMENDED BY THE ACIP

Vaccination

Recommended Recipients

Influenza vaccination (annually)a

Adults and children 6 months of age and older

Pneumococcal vaccination (PCV13 and PPSV23, in series 6 to 12 months apart)b

Adults 65 years of age and older

High-risk children and adults (2 to 64 years of age)

Haemophilus influenzae b (series of 4)

Infants at 2, 4, 6, and 12 to 15 months of age

Pneumococcal conjugate vaccine (series of 4)

Infants at 2, 4, 6, and 12 to 15 months of age

aIn its 2012 immunization schedule for adults, the ACIP notes that the trivalent inactivated vaccine (TIV) may be used for all adults, including pregnant women. Adults older than 65 years of age may receive either standard-dose or high-dose TIV. The live, attenuated influenza vaccine (LAIV) may be used in healthy, nonpregnant adults who are younger than 50 years of age and have no high-risk medical conditions. Healthcare staff who care for severely immunocompromised patients should receive TIV rather than LAIV.

bBoth the 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23) should be administered routinely in series to all adults older than 65 years of age. The dose of PPSV23 should be given 6 to 12 months after a dose of PCV13.

Source: [91,92,227]

Influenza Vaccination

The influenza vaccine is developed each year to contain the three virus strains that are expected in the upcoming influenza season. The vaccine has traditionally been a trivalent inactivated vaccine (TIV), but in 2003, a trivalent live, attenuated influenza vaccine (LAIV) was introduced in the United States [97]. In 2010, a new high-dose formulation of TIV became available. The LAIV, which contains four times the amount of influenza antigens as other TIVs, is designed to induce a higher immune response in older people [97]. The LAIV is administered as a nasal spray.

The ACIP once recommended a risk-stratified approach to influenza vaccination, but it updated its recommendations to universal vaccination beginning in the 2010–2011 influenza season (Table 10) [91]. The ACIP's immunization schedule also notes which types of vaccines should be used according to age and other factors. In their guideline for the management of CAP, the IDSA/ATS make the following strong recommendations for prevention based on the ACIP recommendations [47]:

- All persons 50 years of age and older, others at risk for influenza complications, household contacts of high-risk persons, and healthcare workers should receive inactivated influenza vaccine as recommended by the ACIP (level I evidence).

- The intranasally administered LAIV is an alternative vaccine formulation for some persons 5 to 49 years of age without chronic underlying diseases, including immunodeficiency, asthma, or chronic medical conditions (level I evidence).

- Pneumococcal vaccines are recommended for persons 65 years of age and older and for those with selected high-risk concurrent diseases, according to the current ACIP guideline (level II evidence).

The IDSA/ATS guideline for management of CAP also states that vaccination status should be assessed at the time of hospital admission for all patients, especially those with medical illnesses [47]. If vaccination is needed, it may be done either at hospital discharge or during outpatient treatment. The Joint Commission developed measures for influenza and pneumococcal vaccination, as appropriate, for inpatients, which became effective for discharges on and after January 1, 2012 [94].

The PIDS and the IDSA also echo the ACIP recommendations in their guideline [30]:

- Children should be immunized with vaccines for bacterial pathogens, including S. pneumoniae, H. influenzae type b, and pertussis (strong recommendation, high-quality evidence).

- All infants 6 months of age or older and all children and adolescents should be immunized annually with vaccines for influenza virus (strong recommendation, high-quality evidence).

- Parents and caretakers of infants younger than 6 months of age, including pregnant adolescents, should be immunized with vaccines for influenza virus and pertussis to protect the infants from exposure (strong recommendation, weak-quality evidence).

- High-risk infants should be provided immune prophylaxis with RSV-specific monoclonal antibody to decrease the risk of severe pneumonia and hospitalization caused by RSV (strong recommendation, high-quality evidence).

Vaccine Efficacy

Declining rates of pneumonia and pneumonia-related deaths are thought to represent the effectiveness of influenza and pneumococcal vaccination [40,98,99]. In a study of a community-dwelling older population, influenza vaccination decreased the risk of hospitalization for pneumonia or influenza, as well as the risk of death, across 10 influenza seasons [7]. Systematic reviews and meta-analyses have shown that pneumococcal vaccination reduces the incidence of invasive pneumococcal disease in both older adults and children, although the findings are unclear for adults with chronic illness [100,101]. Other studies of adults have shown that pneumococcal vaccination is associated with benefit in terms of a lower risk of adverse outcomes associated with the disease. For example, in a study of nearly 3,500 older people (median age: 75 years) who were hospitalized for CAP, the rate of mortality or ICU admission was 40% lower among those who had received prior PPSV23 vaccination [8].

Among children, the introduction of the PCV7, and later PCV13, has led to a substantial decrease in the rate of invasive pneumococcal disease, but the decrease in the rate of CAP has been less dramatic. Early studies showed substantial improvements in the hospitalization rate for CAP only among young children. In one study, the hospitalization rate decreased 39% for children younger than 2 years of age [98]. In another study, the decrease was substantial only for children younger than 1 year of age (22%) and was minimal for children 1 to 5 years of age; the rate increased for adolescents and children older than 5 years of age [4]. The rate of outpatient CAP visits has not changed significantly for this population [5,10].

Vaccination Rates

Despite the wide distribution of the ACIP immunization schedule and public campaigns about the importance of vaccination, rates of both pneumococcal and influenza vaccination remain relatively low. According to National Center for Health Statistics data collated for 2016, the estimated rate of influenza vaccination is 49.9% for children, 31.8% for adults 18 to 49 years of age, 45.2% for adults 50 to 64 years of age, and 67.2% for adults 65 years of age and older [103].

According to the CDC, influenza vaccination coverage for the 2014–2015 season among adults 19 years of age or older was 44.8%, an increase of 1.6% from the 2013–2014 season [102]. Coverage among white adults was higher (48.5%) than that for blacks (37.7%) and Hispanics (33.0%). Influenza coverage was 32.5% among adults 19 to 49 years of age and 48.7% among adults 50 to 64 years of age. Coverage among adults 65 years of age or older (73.5%) was higher compared with younger age groups. Among healthcare personnel , influenza vaccination coverage overall was 68.6%. Among healthcare personnel with and without direct patient care responsibilities, influenza vaccination coverage was 68.9% and 67.9%, respectively.

The national rate of influenza vaccination among all adults has improved over the past decade, yet racial disparities persist. Comparing rates at five-year intervals from 2005 to 2015, the rate of vaccination has more than doubled for adults younger than 65 years of age and for each ethnic category (Table 11) [113]. The rate disparity between white adults (44.2%) and that observed for black (36.7%) and Hispanics (31.2%) remains evident. Previous studies have also shown higher rates of vaccination for white older adults compared with black and Hispanic older adults [104,105,106,107]. Racial disparities have also been found when rates of pneumococcal and influenza vaccination for residents of long-term care facilities were compared, with substantially lower rates for black residents [108,109,110].

Table 11: RATE OF INFLUENZA VACCINATION AMONG ADULTS ACCORDING TO AGE AND RACE/ETHNICITY, FIVE-YEAR INTERVALS, 2005–2015

Age/Ethnicity

Rate

2005

2010

2015

18 to 44 years of age

10.1%

24.6%

30.9%

45 to 64 years of age

20.2%

37.8%

45.1%

65 years of age and older

59.7%

63.9%

69.1%

White

22.5%

36.9%

44.2%

Black

15.5%

28.1%

36.7%

Hispanic

12.0%

26.5%

31.2%

Source: [113]

Data on influenza vaccination readiness among children and adults comes from national survey for the 2017–2018 influenza season. Only approximately two of every five persons in the United States had received an influenza vaccination by early November 2017. The rate was 38.6% for all persons 6 months of age and older. Among children, influenza vaccination coverage was somewhat higher for Hispanic children (41.3%) than for non-Hispanic white (38.0%) and non-Hispanic black (34.6%) children.

According to national surveys, the overall rate of pneumococcal vaccination is approximately 64% for adults 65 years and older, and the rate is substantially lower (approximately 23%) for younger adults in high-risk groups. The CDC report on pneumococcal vaccination coverage (PPSV23 and PCV13) for 2015 is summarized in Table 12 [102].

Table 12: RATE OF PNEUMOCOCCAL VACCINATION AMONG ADULTS 19 YEARS OF AGE AND OLDER, 2015

Race/Ethnicity

High-Risk Adults 19 to 64 Years

Adults 65 Years and Older

All races

23.0%

63.6%

White (non-Hispanic)

24.0%

68.1%

Black (non-Hispanic)

24.0%

50.2%

Hispanic or Latino

19.4%

41.7%

Asian

24.0%

49.0%

Based on data from the National Health Interview Survey, United States, 2015.

Source: [102]

In addition, adherence to the recommendation for pneumococcal and influenza vaccinations for older adults admitted to the hospital has been low. In a study of nearly 105,000 patients 65 years of age and older who had not received either vaccination before admission to the hospital, 99.4% did not receive the pneumococcal vaccine and 97.3% did not receive the influenza vaccine before hospital discharge [111].

Rates of both pneumococcal and influenza vaccination are higher among children than adults. Overall, approximately 83% of children 19 to 35 months of age have received at least four PCV13 doses [112]. The rate varies according to race/ethnicity, with the lowest rates among Asian and black children (Table 13) [112].

Table 13: RATE OF VACCINATION WITH AT LEAST FOUR PCV DOSES AMONG CHILDREN 19 TO 35 MONTHS OF AGE

Race/Ethnicity

Rate

White (non-Hispanic)

84.1%

Black (non-Hispanic)

74.5%

Hispanic

81.4%

American Indian/Alaska Native

80.1%

Asian

81.0%

Multiracial

83.6%

Total

83.3%

PCV = pneumococcal conjugate vaccine.

Source: [112]

Barriers to Vaccine Use

In its Healthy People 2020 initiative, the U.S. Department of Health and Human Services has set objectives for improving pneumococcal and influenza vaccination rates among adults and children, with targets of 80% to 90% (Table 14) [114]. To reach these targets, healthcare providers must address documented barriers to recommended vaccinations and gain a better understanding of other challenges to vaccination. Unequal access to health care appears to account for a low percent of racial disparities [105]. Rather, lack of awareness of the need for vaccination and misconceptions about vaccines have been reported as the primary barriers in several studies [104,105,106,115,116,117].

Table 14: HEALTHY PEOPLE 2020 TARGETS FOR PNEUMOCOCCAL AND INFLUENZA VACCINATION RATES

Target Population

Target Rate

Baseline Rate for Improvement (Year)

Pneumococcal vaccination

Four doses of PCV by 19 to 35 months of age

90%

80% (2008)

Adults 65 years of age and older

90%

60% (2008)

High-risk adults 16 to 64 years of age

60%

17% (2008)

Institutionalized adults 18 years of age and oldera

90%

66% (2006)

Annual influenza vaccination

Three doses of Hib vaccine by 19 to 35 months of age

90%

57% (2009)

Children 2 to 4 years of age

80%

40% (2008)

Children 5 to 12 years of age

80%

26% (2008)

Children 13 to 17 years of age

80%

10% (2008)

Adults 18 to 64 years of age

80%

25% (2008)

Adults 65 years of age and older

90%

67% (2008)

High-risk adults 18 to 64 years of age

90%

39% (2008)

Institutionalized adults 18 years of age and older

90%

62% (2006)

aAdults residing in long-term care facilities and nursing homes.

PCV = pneumococcal conjugate vaccine; Hib = Haemophilus influenzae type b.

Source: [114]

Among adults, misconceptions about vaccines range from the belief that healthy people do not need vaccinations to a fear of side effects [104,106,116]. Beliefs about vaccines vary by race/ethnicity, age, education, and gender. For example, in a survey of more than 6,700 older adults, lack of awareness that influenza vaccination was needed was more common among Hispanic (33%) and black individuals (25%) than among white individuals (21%) [105]. In contrast, concern about side effects was more common among white individuals (15%) than among black and Hispanic individuals (10% and 6%, respectively) [105]. The belief that vaccination would not prevent illness was consistent across the racial/ethnic groups. In other studies, lower rates of influenza vaccination among older black adults have been significantly associated with lower rates of positive attitudes about vaccination [105,118]. It is unclear whether the negative attitude represents mistrust of the vaccine itself or of healthcare/healthcare providers in general [105]. The findings of one study showed that, compared with white adults, more black and Hispanic adults believed that they had become sick from a previous influenza vaccination [106]. Language proficiency and level of acculturation have been associated with lower vaccination rates among older Hispanic adults [107,119].

Parental attitudes about vaccines are an important factor in vaccination rates among children. The primary attitude is concern about the safety and efficacy of the vaccine, including fear of adverse events, the discomfort associated with vaccination, distrust of advocates of vaccination, and belief that the vaccine should not be given when a child has a minor illness [117,120,121,122]. Difficulty remembering or confusion about the vaccination schedule for children is also a major challenge [120,122]. Changes in access to health care have been noted as a factor in the low rate of influenza vaccination among teenagers [117].

Healthcare provider-related factors should also be addressed. Slightly more than half of older adults have said that their healthcare provider did not recommend influenza vaccination, and this percentage has been consistent across races/ethnicities [105,106]. The lack of provider recommendation may be a misperception or may be a reality. It has been noted that nearly half of providers do not follow the ACIP recommendations for vaccination [116]. Provider recommendation is essential, as it has been found to be the strongest predictor of whether a person will receive vaccination, even among those who have negative attitudes toward vaccines [104,106,115,116,123]. Providers have said that the lack of an effective reminder system is a factor in low vaccination rates [116,123].

Strategies to improve rates of vaccination and other preventive measures rely on effective patient-clinician communication. Among the most important factors for effective communication across all healthcare settings are knowledge of the language preference of the patient and family; an awareness of the patient's and family's health literacy levels; and an understanding of and respect for the patient's and family's cultural values, beliefs, and practices [124,125,126]. These issues are significant, given the growing percentages of racial/ethnic populations. According to U.S. Census Bureau data from 2013, more than 60.3 million Americans speak a language other than English in the home, with more than 25.1 million of them (8.6% of the population) reporting that they speak English less than "very well" [127]. Clinicians should ask their patients what language is spoken at home and what language they prefer for their medical care information, as some patients prefer their native language even though they have said they can understand and discuss medical information in English [128]. When the healthcare professional and the patient speak different languages, a professional interpreter should be used. Studies have demonstrated that the use of professional interpreters rather than "ad hoc" interpreters (e.g., untrained staff members, family members, friends) facilitates a broader understanding, leads to better outcomes, and is better aligned with patient preferences [129,130,131].

Studies have indicated that as many as 26% of patients have inadequate health literacy, which means they lack the ability to understand health information and make informed health decisions; an additional 20% have marginal health literacy [132,133,134]. Health literacy varies widely according to race/ethnicity, level of education, and gender. Clinicians are often unaware of the literacy level of their patients and family, but several instruments are available to test the health literacy level [126,135]. These instruments vary in the amount of time needed to administer and the reliability in identifying low literacy. Among the most recent tools is the Newest Vital Sign (NVS), an instrument named to promote the assessment of health literacy as part of the overall routine patient evaluation [136]. The NVS takes fewer than three minutes to administer, has correlated well with more extensive literacy tests, and has performed moderately well at identifying limited literacy [126,135]. Two questions have also been found to perform moderately well in identifying patients with inadequate or marginal literacy: "How confident are you in filling out medical forms by yourself?" and "How often do you have someone help you read health information?" [126]. Clinicians should adapt their discussions and educational resources to the patient's and family's identified health literacy level and degree of language proficiency and should also provide culturally appropriate and translated educational materials when possible.

Cultural competency is essential for addressing healthcare disparities among minority groups [124]. Clinicians should ask the patient about his or her cultural beliefs, especially those related to health, and should be sensitive to those beliefs.

Targeted evidence-based strategies can help clinicians improve vaccination rates (Table 15). Education about the importance of vaccination is the cornerstone of most strategies. Messages should be clear and emphasize the benefits of vaccination and the risks of not receiving vaccination. Acknowledging the risks of vaccines can help enhance patient trust [117]. Clinicians should give their patients a list of online resources that provide balanced information on vaccines (Table 16). Differences in beliefs about vaccines across racial/ethnic groups indicate that targeted messages developed for specific demographic subgroups may be useful [219]. In addition, language-specific educational resources may also help increase vaccination rates by enabling patients to better understand the need for vaccination and its safety.

Table 15: BARRIERS TO OPTIMAL VACCINATION AND POSSIBLE SOLUTIONS

Barriers

Solutions

Decreased knowledge about pneumonia and its seriousness

Provide education resources (language-specific, as appropriate) that highlight the potential severity of disease and the consequences of not receiving protection through vaccination.

Belief that vaccines are unsafe or will cause illness

Refer patient (or parent) to objective information about vaccines.

Lack of awareness for the need of vaccination

Take advantage of all visits (well and acute) to remind patients (or parents) about the need for vaccination, to administer vaccination, or to schedule appointment for vaccination.

Lack of provider recommendations

Identify high-risk patients and encourage them to receive vaccination.

Lack of effective practice systems

Implement effective reminder systems and standing orders.

Source: Compiled by Author

Table 16: RESOURCES ABOUT VACCINATIONS FOR PATIENTS AND PARENTS

American Academy of Pediatrics

https://www.aap.org

American Academy of Family Physicians

https://www.aafp.org

U.S. Department of Health and Human Services Vaccines

https://www.vaccines.gov

The History of Vaccines

https://www.historyofvaccines.org

Immunization Action Coalition

http://www.vaccineinformation.org

Centers for Disease Control and Prevention Vaccines for Children (VFC) Program

https://www.cdc.gov/vaccines/programs/vfc

Source: Compiled by Author

Education and provider recommendation are particularly important for high-risk people, as the lowest vaccination rates are reported for this population [102,103]. One survey showed that provider recommendations for pneumococcal and influenza vaccination were low for this population; the rate of recommendation was lowest for people with a weakened immune system and those receiving radiation therapy or chemotherapy (Table 17) [116]. Clinicians should identify high-risk patients in their practice and take special steps to ensure that these patients receive appropriate vaccinations.

Table 17: HEALTHCARE PROVIDER RECOMMENDATIONS FOR INFLUENZA AND PNEUMOCOCCAL VACCINATIONS BY PATIENT TYPE

Patient Type

Influenza Vaccine

Pneumococcal Vaccine

Physicians

PA/NP/RNs

Physicians

PA/NP/RNs

All adults

39%

59%a

—

—

Aged ≥50 years

28%a

15%

4%

18%a

Aged ≥65 years

37%

28%

65%

55%

Chronic lung disease

45%

40%

68%

55%

Diabetes mellitus

31%

25%

44%a

26%

Heart disease

20%

11%

29%a

12%

Chronic liver disease

22%

16%

27%

20%

Chronic kidney disease

22%

12%

25%

17%

Weak immune system

17%

20%

24%

29%

Radiation/chemotherapy

14%

9%

17%

10%

Asplenia

—

—

27%a

8%

Complications or risk from other illness

25%

17%

28%

23%

Smoker

—

—

13%

11%

Close contact with someone at high risk

24%

22%

11%

10%

aSignificantly greater (P <0.05) than other provider group.

NP = nurse practitioner; PA = physician assistant; RN = registered nurse.

Source: Reprinted with permission from Johnson D, Nichol KL, Lipczynski K. Barriers to adult immunization. Am J Med. 2008;121:S28-S35.

Missed opportunities represent another practice-related area in which clinicians can improve vaccination rates. Although many clinicians check immunization status during well visits, most do not check the status during acute visits, nor do they take advantage of the visit to administer the vaccination [105,115]. Healthcare providers can close the gap on missed opportunities for vaccination by taking advantage of every office visit to administer vaccinations, reminding their patients about the need for vaccination, or scheduling a future appointment for vaccination [105,115,117]. Educational fliers and pamphlets in the waiting room and examination rooms can engage patients and parents and help prompt discussions about vaccination [116].

Patient reminder and recall systems in primary care settings have been effective in improving vaccination rates. A meta-analysis found that rates among both children and adults increased up to 20% with several types of reminders, including postcards, letters, and phone calls [137]. The most effective reminder system was phone calls, but it was also the most expensive. Given that about 25% of primary care physicians currently use reminder systems, increasing the number of physicians who use such systems can in turn increase vaccination rates [123]. Standing orders for vaccinations have been shown to substantially increase vaccination rates, yet are used by only 20% to 33% of physicians [123,138]. Again, adopting this system results in improved vaccination rates.

Many people have turned to facilities outside of their primary healthcare provider to receive vaccinations. Health fairs, pharmacies, grocery stores, senior centers, and workplaces have become more common settings for vaccination because of their convenience and lower cost [123,138]. Clinicians can also help increase vaccination rates by participating in community events that provide vaccinations and by promoting these settings as alternative options.

Programs to provide vaccinations to high-risk patients in the emergency room have been successful at increasing vaccination rates [139,140]. In a three-week intervention program at one inner city emergency department, participants were provided appropriate immunizations when they were at high risk for specific diseases [139]. During the study period, rates of influenza and pneumococcal vaccinations increased from 16% to 83% and from 18% to 84%, respectively. Such programs can help healthcare systems adhere to guideline recommendations for vaccinating hospitalized patients.

8. PNEUMONIA ASSOCIATED WITH HEALTHCARE FACILITIES

Pneumonia associated with healthcare facilities encompasses the broad category of cases that arise in persons who reside in, or have had significant recent exposure to, facilities such as hospitals, nursing homes, dialysis clinics, and transfusion centers. Despite advances in clinical care and prevention, this category of pneumonia remains a serious cause of morbidity and mortality and a challenging, costly public health issue. The IDSA and the ATS subdivide and defines this category of pneumonia as follows:

- HAP is hospital-acquired pneumonia that occurs 48 hours or more after admission and did not appear to be incubating at the time of admission.

- VAP is a separate type of HAP that develops more than 48 hours after endotracheal intubation.

- HCAP is defined as pneumonia that occurs in a nonhospitalized patient with extensive healthcare contact, as defined by one or more of the following:

- Intravenous therapy/chemotherapy or wound care within the prior 30 days

- Residence in a nursing home or other long-term care facility

- Discharge from an acute care hospital or chronic care facility within the prior 90 days

- Attendance at a hospital or hemodialysis clinic within the prior 30 days

HAP and VAP have been studied most often, and the bulk of data on causative pathogens comes from studies of VAP. All three categories of pneumonia carry an increased risk for drug-resistant infection, though the risk of multidrug-resistant infection has been more consistently applicable to HAP and VAP [28]. Within the category of HCAP, nursing home-acquired pneumonia is the type with the most published data and will be discussed in this course. The ATS and the IDSA have collaborated to provide evidence-based recommendations, updated in 2016, for the diagnosis and treatment of HAP and VAP [28].

EPIDEMIOLOGY

Approximately 3 to 10 cases of HAP occur per 1,000 hospital admissions [26]. Pneumonia as a complication of hospitalization increases length of stay (by more than one week), increases mortality risk, and adds an additional cost of care that can reach $40,000 per case [26].

The rate of VAP is higher than that for HAP, with a reported rate of 1 to 4 cases per 1,000 ventilator-days, and rates as high as 10 cases per 1,000 in some neonatal and surgical populations [12,28,141]. An estimated 10% of patients requiring mechanical ventilation will develop VAP, and the mortality rate directly attributable to VAP is estimated at 13% [28]. Excess cost of care resulting from prolongation of hospital stay is estimated to be range from $30,000 to $40,000 per patient [28]. Pediatric VAP has not been as well studied as in adults. It occurs most commonly in children 2 to 12 months of age [142].

Pneumonia develops in approximately 2.3% of nursing home residents [1]. The mortality rate attributed to nursing home-acquired pneumonia is 10% to 30% [143].

RISK FACTORS

Illness and injury requiring admission to a healthcare facility often confers an increased risk for infection. Multiple factors account for this, including weakness and debility, use of indwelling catheters, compromised immune function, and poor nutrition [26,144]. To these may be added sedating medication intended to promote sleep or permit invasive procedures; this in turn increases the risk for aspiration of nasopharyngeal secretions colonized with nosocomial bacterial pathogens.

The nasopharynx tends to become colonized by enteric gram-negative bacilli within a few days after admission to a hospital. Risk factors for colonization by multidrug-resistant pathogens include exposure to critical care units, prolonged hospital stay, prior antibiotic therapy, history of cigarette smoking, major surgery, multiple organ-system failure, and foreign bodies such as nasogastric and endotracheal tubes [26,144].

Hospital-Acquired Pneumonia

In a systematic review, the American College of Physicians found several patient-related and surgery-related factors that increased the risk of postoperative pulmonary complications. The most common patient-related factors were the presence of COPD and an age older than 60 years [145]. Other significant factors were an American Society of Anesthesiologists (ASA) class of 2 (defined as a patient with mild systemic disease) or higher, functional dependence, and congestive heart failure. Cigarette use was associated with a modest increase in risk, and obesity and mild or moderate asthma were not found to increase risk [145]. Use of a PPI or histamine2 receptor antagonist is also thought to be a risk factor [45]. Surgery-related factors included prolonged duration of surgery (i.e., more than three to four hours), emergency surgery, and surgical site, with abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, and aortic aneurysm repair being associated with the greatest risks [145].

Ventilator-Associated Pneumonia

The risk for VAP appears to be greatest during the first week after intubation. In one study, the risk was estimated to be 3% per day during the five-day period following intubation, decreasing to 2% per day for days 5 through 10, and to 1% per day for longer durations [147]. In a population of children who had cardiothoracic surgery, pneumonia risk correlated with mechanical ventilation for longer than three days [144]. Nearly half of all cases of VAP develop within the first four days of mechanical ventilation [148].

Other identified risk factors among adults include prolonged placement of the patient's head in the supine position; use of a nasogastric tube, paralytic agents, or PPI or histamine2 receptor antagonist; advanced age; chronic lung disease; and head trauma [45,149]. Among children, VAP has been significantly associated with subglottic/tracheal stenosis, trauma, and tracheostomy [150]. In one study, VAP was most frequently associated with ICU admission diagnoses of postoperative care, neurologic conditions, sepsis, and cardiac complications [151].

Nursing Home-Acquired Pneumonia

The risk factors reported to be associated with nursing home-acquired pneumonia include profound disability, immobility, urinary incontinence, deteriorating health status, difficulty swallowing, and inability to take oral medications [42]. Older age, male gender, and antipsychotic and anticholinergic medications have also been reported to increase risk [23,42].

ETIOLOGY

Gram-negative enteric bacilli and Pseudomonas spp. rarely colonize the upper respiratory tract of healthy individuals, but often do so in persons with an underlying disease, such as alcohol use disorder, and in those who are hospitalized or reside in nursing homes. Therefore, a history of recent hospitalization or nursing home residency should heighten suspicion for a gram-negative pathogen when such a patient presents with clinical signs of infection.

Most cases of pneumonia that develop in a healthcare facility are caused by aspiration of oropharyngeal or gastric secretions colonized with hospital bacterial flora [26,28]. Consequently, the prevalent causation as well as the antibiotic sensitivity pattern of resident pathogens will vary from region to region in relation to the type of facility and burden of antimicrobial usage. The selection of initial antibiotic therapy in these cases is based on the patient's risk factors for infection with a multidrug-resistant organism, such as MRSA, P. aeruginosa, K. pneumoniae, or Acinetobacter. The ATS/IDSA lists the following risk factors for multidrug-resistant pathogens in patients presenting with HAP or VAP [233,28]:

- Prior intravenous antibiotic use within 90 days

- Septic shock at time of VAP

- ARDS prior to onset of VAP

- High frequency of antibiotic resistance in the community of residence or the hospital unit of residence

- Five or more days of hospitalization prior to onset of pneumonia

- Home infusion therapy

- Chronic dialysis within 30 days

- Family member with multidrug-resistant infection

- Immunosuppression

Viral and fungal pathogens are rare causes of HAP, VAP, and nursing home-acquired pneumonia in immunocompetent adults. Outbreaks of viral pneumonia may occur during influenza season, and influenza, parainfluenza, adenovirus, and RSV are involved in about 70% of those cases [28]. Candida spp. and Aspergillus fumigatus may cause pneumonia in patients who have had organ transplantation or who have a compromised immune system and neutropenia.

Hospital-Acquired Pneumonia

Among adults with no previous antibiotic exposure, the most common bacterial causes of HAP are S. pneumoniae, H. influenzae, Escherichia coli, K. pneumoniae, and S. aureus [26,28,35,148]. Gram-negative bacilli resistant to first-generation cephalosporins also frequently develop in late-onset HAP. For up to 40% of adults with previous antibiotic exposure, late-onset HAP is caused by potentially multidrug-resistant pathogens, including Pseudomonas aeruginosa, Acinetobacter baumannii, and MRSA [26]. In a study of more than 3,600 patients admitted to an ICU, Pseudomonas spp. was the cause of pneumonia in 25% of patients; MRSA in 18%; and Acinetobacter spp. in 6% [35]. Other studies have shown that S. aureus is common among patients who are in a coma or have diabetes or renal failure. P. aeruginosa is common among patients who have had a prolonged stay in the ICU, have received prior antibiotics or corticosteroids, or who have structural lung disease. Legionella is usually found in patients who have compromised immune systems [35].

The causes of HAP in children have not been well studied. However, outbreaks of pneumonia caused by RSV have been common in pediatric wards [28].

Ventilator-Associated Pneumonia

The most common pathogens associated with VAP in adults are S. aureus and P. aeruginosa, followed by Enterobacter spp., A. baumannii, and K. pneumoniae[26,148,152,153]. These bacteria are among those that have become resistant to antibiotics, and the frequency of infection with MRSA is increasing. Almost half of all cases are caused by infection with more than one pathogen [148]. Although bacteria are the primary causative agents, viruses and saprophytic fungi have also been implicated as well [154].

As with HAP, few data are available on the etiology of VAP in children. In one report, P. aeruginosa was the most common cause, accounting for 22% of cases [142].

Nursing Home-Acquired Pneumonia

The bacterial pathogens that cause pneumonia in residents of nursing homes (and other long-term care facilities) differ according to the severity of disease. S. pneumoniae and H. influenzae are the most common causes of mild-to-moderate pneumonia in long-term care facilities [155]. In cases requiring hospitalization, C. pneumoniae, S. aureus, and influenza virus are frequently observed as well. Patients with severe illness commonly are infected with methicillin-sensitive S. aureus or MRSA, gram-negative enteric pathogens, or P. aeruginosa[23,155].

DIAGNOSIS

The difficulty in recognizing HAP, VAP, or nursing home-acquired pneumonia has been well documented [28,147,156]. The clinical signs often resemble other, noninfectious conditions, and the specificity of clinical criteria is low [148]. According to the CDC definition, the diagnosis in adults is made on the basis of clinical signs and results of laboratory testing or imaging and must meet one of two criteria [157].

Criterion 1 is rales or dullness to percussion on physical examination of the chest and at least one of the following:

- New onset of purulent sputum or change in character of sputum

- Organisms cultured from blood

- Isolation of an etiologic agent from a specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy

Criterion 2 is chest radiograph that shows new or progressive infiltrate, consolidation, cavitation, or pleural effusion and at least one of the following:

- New onset of purulent sputum or change in character of sputum

- Organisms cultured from blood

- Isolation of an etiologic agent from a specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy

- Isolation of virus from or detection of viral antigen in respiratory secretions

- Diagnostic single antibody titer immune globulin M or fourfold increase in paired sera immune globulin G for pathogen

- Histopathologic evidence of pneumonia

A set of clinical diagnostic criteria for HCAP includes the presence of a new and persistent (more than 48 hours) infiltrate in addition to one of the following [148]:

- Radiographic evidence of cavitation or necrosis

- Histopathologic evidence of pneumonia

- Positive pleural or blood culture for the same micro-organism as that found in respiratory secretions

Plus two of the following signs:

- Core temperature >38.3°C (100.94°F)

- WBC count >10,000 cells/mm^3

- Purulent tracheal secretions

There are no compelling data to recommend a specific approach to diagnosing HAP and VAP. For patients who are not receiving mechanical ventilation, collection of a sputum specimen should be attempted before antibiotic therapy is begun [35,158]. Specimens for culture can be obtained by bronchoscopy with a protected specimen brush to limit contamination or by bronchoalveolar lavage. The latter method has been found to lead to higher rates of treatment than diagnosis based on the CDC definition, and one study showed that preferential sampling of the right lung (rather than the left) improved the diagnostic accuracy of bronchoalveolar lavage [35,159,160]. However, the invasive procedure has disadvantages, including high cost, need for technical expertise, and the potential for false-negative results [35,159].

The ATS/IDSA guideline recommends collecting specimens from the lower respiratory tract for culture, preferably by noninvasive techniques, and reliance on semiquantitative culture technique [28]. Noninvasive methods to obtain respiratory samples in patients with HAP (non-VAP) include spontaneous expectoration, sputum induction, nasotracheal suctioning (in a patient unable to produce a sample), and endotracheal aspiration in a patient with HAP who subsequently requires mechanical ventilation [28]. A 2012 meta-analysis found no evidence that the use of quantitative cultures of respiratory secretions resulted in decreased mortality, reduced time in ICU and on mechanical ventilation, or higher rates of antibiotic change compared with qualitative cultures in patients with VAP [161]. In addition, there was no difference in mortality whether invasive or noninvasive methods were used to obtain specimens.

TREATMENT

The treatment of HAP and VAP is complicated by two divergent needs: the need for empiric therapy with a broad-spectrum antibiotic, to aid in reducing mortality rates, and the need to avoid the indiscriminate use of antibiotics, to avoid the development of resistance. To address this complex issue, the strategy of de-escalation therapy was developed. With this treatment approach, a broad-spectrum antibiotic targeted to likely pathogens is administered, and the antibiotic regimen is modified after the results of cultures are known [154,162]. This strategy has reduced the mortality rate while achieving an overall objective of a more judicious use of antibiotics [154,163]. In one study, de-escalation led to a significantly lower mortality rate compared with either escalation therapy or therapy that was neither escalated nor de-escalated (17% vs. 43% and 24%, respectively) [151].

The empiric treatment of nosocomial pneumonia in general, requires knowledge of the infection history (hospital flora) of the healthcare facility and of individual patient units [35,148,164]. The selection of an empiric antibiotic regimen for HAP and VAP should be guided by local antibiotic-resistance data. The ATS/IDSA recommend that all hospitals regularly generate and disseminate a local antibiogram, ideally one that is specific to their intensive care population(s), if possible [28].

In managing a case of HAP and VAP, the clinician should review in detail the guidance provided by the ATS/IDSA, and consider consultation with appropriate subspecialty colleagues [28]. Recommendations governing selected issues of initial management emphasize the following principles [28]:

- Obtain sputum samples from the lower respiratory tract for culture before beginning antibiotic therapy. Do not delay initiation of therapy for critically ill patients in order to obtain specimens.

- Begin treatment promptly, selecting an empiric antibiotic regimen that coversS. aureus, P. aeruginosa, and other gram-negative bacilli.

- In selecting coverage for S. aureus, choose an agent active against MRSA (vancomycin or linezolid) for patients with risk factor(s) for antimicrobial resistance, treatment in hospital or units where >10% of isolates are methicillin-resistant, and patients in settings where the prevalence of MRSA is unknown.

- In selecting coverage for P. aeruginosa, one antibiotic active against this pathogen is satisfactory if the patient has no risk factors for antimicrobial resistance and <10% of gram-negative isolates from the patient's unit are resistant to the agent chosen; otherwise, prescribe two antipseudomonal antibiotics from different classes.

- Consider de-escalation of antibiotics after the results of cultures and sensitivities are known and the clinical response is satisfactory.

- After an optimal antibiotic regimen is confirmed, a seven-day course of therapy is recommended, provided the rate of improvement of clinical, radiographic, and laboratory parameter is satisfactory.

- For patients with HAP/VAP, it is suggested to use serum procalcitonin levels plus clinical criteria to guide discontinuation of antibiotic therapy, rather than clinical criteria alone.

Selection of specific antimicrobial therapy is influenced by the timing of onset of clinical signs, as well as the presence or absence of risk factors for infection with multidrug-resistant organisms. For early-onset pneumonia and/or patients with no such risk factors, limited-spectrum antibiotic therapy is recommended (Table 18) [28]. For late-onset pneumonia and/or patients at increased risk for multidrug-resistant organisms, a broad-spectrum antibiotic regimen is recommended.

Table 18: RECOMMENDED ANTIBIOTIC THERAPY FOR HEALTH FACILITY-ASSOCIATED PNEUMONIA ACCORDING TO SITE OF CARE

Site of Care

Recommended Regimen

Nursing home

Antipneumococcal fluoroquinolone or either a high-dose ß-lactam/ß-lactamase inhibitor or a second- or third-generation cephalosporin in combination with azithromycin

Hospital

Antipseudomonal cephalosporin, antipseudomonal carbapenem, or extended-spectrum ß-lactam/ß-lactamase inhibitor and antipseudomonal fluoroquinolone or aminoglycoside and anti-MRSA agent (vancomycin or linezolid)

Intensive care unit

Empiric MRSA and double coverage of Pseudomonas pneumonia

Source: [28]

Ventilator-Associated Pneumonia and Multi-Drug Resistant Pathogens

Evidence Based Practice Recommendation

For healthcare-associated or community-acquired MRSA pneumonia, the IDSA recommends IV vancomycin or linezolid 600 mg PO/IV twice daily, if the strain is susceptible, for 7 to 21 days, depending on the extent of infection.

https://academic.oup.com/cid/article/52/3/e18/306145

Last Accessed: August 22, 2018

Level of Evidence: A-II (Good evidence from one or more 1 well-designed clinical trial, without randomization to support a recommendation for use)

VAP is often caused by MRSA and gram-negative bacilli such as Acinetobacter spp. and Pseudomonas. Vancomycin has been considered the first choice for treatment of MRSA infections [154]. However, the ATS/IDSA guidelines note that linezolid may have advantages over vancomycin for pneumonia caused by MRSA [28]. Linezolid has been compared with vancomycin for the treatment of pneumonia caused by MRSA in many studies, and linezolid has been found to improve survival and to be more cost-effective [147,165,166,167,168]. In a 2008 study, the rate of early microbiologic cure was not significantly higher for linezolid than for vancomycin, although there were trends favoring linezolid in several secondary clinical outcomes, such as clinical cure; duration of ventilation, hospitalization, and stay in ICU; survival time not on a ventilator; and overall survival [169]. The findings led the authors to suggest that the benefit of linezolid may be related to factors other than bacterial clearance.

Role of Inhaled Antibiotic Therapy

For cases of VAP caused by gram-negative bacilli that are susceptible only to aminoglycosides or polymyxins, the ATS/IDSA suggests both inhaled and systemic antibiotics, rather than systemic antibiotics alone [28]. It is also reasonable to consider adjunctive inhaled antibiotic treatment as a last resort for patients who are not responding to intravenous antibiotics alone, whether or not the infecting organism is multi-drug resistant.

According to a meta-analysis, a short fixed-course (7 or 8 days) of antibiotic therapy may be more appropriate than a prolonged course (10 to 15 days) for patients with VAP not caused by nonfermenting gram-negative bacilli [170]. The short course reduced recurrence of pneumonia caused by multiresistant organisms without adversely affecting other outcomes. Among patients with nonfermenting gram-negative bacilli, recurrence was greater after the short course.

Nursing Home-Acquired Pneumonia

The ATS/IDSA guideline provides some direction for choice of antibiotic therapy but do not specify a distinct management protocol for nursing home-acquired pneumonia. This is expected to be addressed in the forthcoming updated guidelines for management of CAP.

Adherence to Guideline-Directed Treatment

The lack of adherence to guideline-directed treatment of pneumonia cases associated with healthcare facilities is evidenced by wide variations in practice. For example, one study showed that more than 100 different antibiotic regimens had been prescribed as initial treatment and that de-escalation therapy was used for only 22% of patients [151]. Adherence rates for pneumonia associated with healthcare facilities have been reported to be lower than rates of adherence to guidelines for treatment of CAP. In one survey, guideline-recommended antibiotics were used 78% of the time for CAP, compared with 9% for HCAP [18]. This lack of adherence was not due to unfamiliarity or disagreement with the guidelines; 71% of the survey respondents said they were aware of the guidelines, and 79% said they agreed with and practiced according to them. In contrast, another survey showed that fewer than half of physicians were familiar with the ATS/IDSA guideline for treatment of nursing home-associated pneumonia [23]. It is reasonable to expect that strategies used to enhance adherence to guidelines in the setting of CAP would also be beneficial in the setting of pneumonia associated with healthcare facilities. Thus, feedback on performance, reminder systems, standardized order sets, and education emphasizing outcomes and cost-effectiveness would be valuable.

PREVENTION

The CDC has published a guideline for the prevention of HAP and VAP, with a focus on strategies to decrease or eliminate modifiable risk factors for pneumonia associated with healthcare facilities [93]. These strategies are related to preoperative and postoperative care and measures to reduce the risk of transmission of etiologic pathogens. In addition, steps to prevent the spread of influenza virus are essential, especially during influenza season.

Hospital-Acquired Pneumonia

The prevention of postoperative pneumonia has long been a part of initiatives to decrease complications among patients undergoing surgery. The Respiratory Risk Index was developed to classify patients as being at low, medium, or high risk for postoperative respiratory failure [26]. The factors in the index include the complexity of the surgery, the ASA status, and comorbidities.

Smoking triples the risk for pulmonary complications after surgery, and smoking cessation for at least eight weeks before surgery, when possible, is recommended for current smokers [26]. The risk for complications in patients with respiratory disease or congestive heart failure can be ameliorated by optimum treatment before surgery (e.g., treatment with steroids for patients with COPD or asthma) [26].

Effective pain management after surgery also helps to decrease the risk of pulmonary complications. For postoperative patients who are not mechanically intubated, the ability to cough and clear secretions is important for preventing pulmonary complications [26]. The use of incentive spirometry and deep breathing exercises are recommended, especially for people at high risk for pulmonary complications, as are frequent coughing and early movement (in bed and/or walking) [26,93,145]. Fair evidence supports the selective (rather than routine) use of a nasogastric tube after abdominal surgery [145].

Ventilator-Associated Pneumonia

Two guidelines were developed to focus specifically on the prevention of VAP; one was jointly developed by the Society for Healthcare Epidemiology of America (SHEA) and IDSA, and the other was jointly developed by the Canadian Critical Care Trials Group and the Canadian Critical Care Society [149,171]. In addition, the CDC guideline addresses the prevention of HAP and VAP [93]. All of these agencies suggest a multicomponent strategy for prevention of pneumonia. Compliance with guidelines, however, has been slow; nursing surveys demonstrate rates of adherence to specific preventive measures ranging from 15% to 50% [12,172]. Education is beneficial, and training sessions are a proven means to enhance knowledge and practice among healthcare professionals caring for intubated patients [173].

The Institute for Healthcare Improvement (IHI) found that implementation of its ventilator bundle, a collection of five prevention strategies drawn from these guidelines, led to a 45% reduction in the incidence of VAP [174]. The bundle includes the following interventions [174]:

- Assessment of readiness to extubate and daily interruptions of sedation

- Elevation of the head of the bed

- Daily oral care with chlorhexidine

- Prophylaxis of peptic ulcer disease

- Prophylaxis of deep venous thrombosis

The IHI how-to guide on preventing VAP provides several practical recommendations, and posting compliance with the ventilator bundle in a prominent place in the ICU can encourage and motivate staff (Table 19) [174].

Table 19: PRACTICAL STEPS IN FOLLOWING GUIDELINES TO PREVENT VENTILATOR-ASSOCIATED PNEUMONIA

Assessment of Readiness to Extubate and Sedative Interruptions

Implement a protocol to lighten sedation daily at an appropriate time to assess for neurologic readiness to extubate. Include precautions to prevent self-extubation, such as monitoring and vigilance, during the trial.

Include a sedative interruption strategy in the overall plan to wean the patient from the ventilator; add the strategy to the weaning protocol, if available.

Assess compliance each day on multidisciplinary rounds.

Consider implementation of a sedation scale, such as the Riker scale, to avoid oversedation.

Elevation of the Head of the Bed

Include the intervention on nursing flow sheets and discuss at multidisciplinary rounds.

Encourage respiratory therapy staff to notify nursing staff if the head of the bed is not elevated or empower respiratory therapy staff to place the bed in this position with the help of nursing staff.

Include the intervention on order sets for initiation and weaning of mechanical ventilation, delivery of tube feedings, and provision of oral care.

Oral Care with Chlorhexidine

Include the intervention as part of the intensive care unit admission order set and ventilator order set. Make application of prophylaxis the default value on the form.

Include intervention as an item for discussion on daily multidisciplinary rounds.

Post compliance with the intervention in a prominent place to encourage change and motivate staff.

Develop a comprehensive oral care process that includes the use of 0.12% chlorhexidine oral rinse.

Schedule chlorhexidine as a medication, which then provides a reminder for nursing staff and triggers the oral care process delivery.

Prophylaxis of Peptic Ulcer Disease

Include intervention as part of the intensive care unit admission order set and ventilation order set. Make application of prophylaxis the default value on the form.

Include intervention as an item for discussion on daily multidisciplinary rounds.

Empower pharmacy staff to review orders for patients in the intensive care unit to ensure that some form of prophylaxis is in place at all times for patients.

Prophylaxis of Deep Venous Thrombosis

Include intervention as part of the intensive care unit admission order set and ventilation order set. Make application of prophylaxis the default value on the form.

Include intervention as an item for discussion on daily multidisciplinary rounds.

Empower pharmacy staff to review orders for patients in the intensive care unit to ensure that some form of prophylaxis is in place at all times for patients.

Source: [174]

Assessment of Readiness to Extubate

Because of the increasing risk of infection as the duration of ventilation increases, the primary goal is to extubate patients as early as possible. Thus, assessment of the readiness for extubation and weaning protocols are key aspects in the preventive approach [28,35]. Daily interruption of sedation until the patient is awake has been shown to significantly decrease the number of days on mechanical ventilation, from 7.3 days to 4.9 days in one study [175]. There are risks to this approach, including the potential for increased pain, anxiety, and desaturation [174]. However, sedation interruption has been further demonstrated to reduce the complications of prolonged mechanical ventilation [176]. The SHEA/IDSA guideline recommends daily assessment of the readiness to wean and the use of weaning protocols [171]. For children, daily assessment of readiness to extubate should be carried out, but sedation interruption is not recommended because of the high risk of unplanned extubation [177].

Elevation of the Head of the Bed

Evidence Based Practice Recommendation

The Institute for Clinical Systems Improvement recommends that, in the absence of medical contraindications, the head of the bed should be elevated at an angle of 30–45 degrees for patients at high risk for aspiration.

https://www.icsi.org/_asset/y24ruh/VAP-Interactive1111.pdf

Last Accessed: August 22, 2018

Strength of Recommendation/Level of Evidence: A (Randomized, controlled trial) and R (Consensus statement)

Reducing the risk of aspiration and contamination with gastric secretions also helps to prevent the development of pneumonia. Positioning the head of the bed at an angle of 30 to 45 degrees reduces the risk of aspiration significantly [149,178,179]. In one randomized, controlled trial, there were 18% fewer cases of VAP among intubated patients in the group assigned to the recumbent position (45 degrees) compared with the group assigned to the supine position [179]. In another study, elevation of the head of the bed to 30 degrees was the most effective measure among a group of preventive interventions, resulting in a 52% variance in the rate of VAP [180]. Both the ATS/IDSA and SHEA/IDSA guidelines recommend maintaining the head of the bed at a 30- to 45-degree angle [28,171]. An angle of 30 to 45 degrees is also recommended for infants and children, but a lower angle (15 to 30 degrees) should be used for neonates [177].

Daily Oral Care with Chlorhexidine

Oral care interventions have been suggested by some, in part because of an association between a high level of dental plaque and a high rate of colonization with aerobic pathogens, including S. aureus, gram-negative bacilli, and P. aeruginosa [181]. Research has shown that oral decontamination with chlorhexidine leads to a significant reduction in the colonization of pathogens in the oropharynx. In most studies, the intervention has not had a significant effect on the rate of VAP or associated mortality, but more recent studies have shown a significant decrease in the rate of pneumonia [180,182,183,184,185,186]. Brushing the teeth with chlorhexidine does not seem to add benefit [183]. Regular oral care with an antiseptic solution or chlorhexidine is recommended in the ATS/IDSA and SHEA/IDSA guidelines [28,171].

Prophylaxis of Peptic Ulcer Disease

Prophylaxis of peptic ulcer disease has evolved with some conflicting views. Antacids, histamine2 receptor antagonists, and sucralfate have been traditionally given to patients receiving mechanical ventilation to prevent the formation of stress ulcers. However, reducing the amount of gastric acid can increase the risk of colonization of gram-negative bacilli in the stomach. As a result, the WHO recommends avoiding the use of these agents [187]. The CDC notes that there was insufficient evidence on the use of peptic ulcer prophylaxis and includes no recommendations in this regard in its guideline [93]. The ATS/IDSA guideline states that the risks and benefits of prophylaxis should be weighed carefully [28]. The most recent guideline, developed by SHEA/IDSA, notes that histamine2 receptor antagonists and PPIs should be avoided in patients who are not at high risk for developing a stress ulcer or stress gastritis [171]. However, peptic ulcer prophylaxis is recommended for children, as appropriate for age and health status [177].

Prophylaxis of Deep Venous Thrombosis

There is no clear relation between prophylaxis of deep vein thrombosis and VAP pneumonia, but the ACCP reported a decrease in the rate of VAP when such prophylaxis was implemented as part of a package of interventions and included this measure in its clinical practice guideline [188]. This recommendation also applies to children, as appropriate for age and health status [177].

Other Measures

In addition to the interventions in the ventilator bundle, other measures have been recommended to help prevent VAP. One such measure is selective decontamination of the digestive tract, which involves the use of either topical antiseptic, oral antibiotics, or a brief course of systemic antibiotics [26]. A meta-analysis of 28 studies showed that selective decontamination of the digestive or respiratory tract with use of topical antiseptic or antimicrobial agents helped reduce the frequency of VAP in the ICU [146]. The estimate of efficacy in prevention was 27% for antiseptics and 36% for antibiotics. Neither had an effect on mortality. This intervention is recommended in the SHEA/IDSA guideline [171].

Other preventive measures are targeted primarily to the care and use of ventilator equipment and practices in direct patient care. Meticulous attention to aseptic care of the equipment is necessary, and all reusable components, such as nebulizers, should be disinfected or sterilized. Tubing circuits should be replaced after 48 hours or earlier if there are signs of malfunction or contamination [93]. Changes in the design of the endotracheal tube have also been evaluated; for example, a tube with a suction port above the cuff allows for continuous aspiration of subglottic secretions. Use of this specially designed endotracheal tube has led to significantly lower rates of VAP as well as shorter durations of ventilation and shorter stays in the ICU [189,190]. Among patients who had major cardiac surgery, the greatest benefit was found for patients who received ventilation for more than 48 hours [190]. Although the cost of the tube is higher than traditional tubes, the overall cost savings in preventing VAP more than compensates [189]. In one meta-analysis, subglottic secretion drainage was significantly associated with a decreased incidence of VAP, shorter time on mechanical ventilation, and longer time to the development of pneumonia [191]. The CDC, the ATS/IDSA, and the SHEA/IDSA guidelines recommend subglottic secretion drainage with this tube when possible [28,93,171].

The use of noninvasive ventilation is another measure that has reduced the incidence of VAP [93,192,193,194]. In one study, the incidence decreased from 20% to 8% when noninvasive techniques were used routinely for critically ill patients with acute exacerbation of COPD or severe cardiogenic pulmonary edema [192]. Again, the CDC, the ATS/IDSA, and the SHEA/IDSA guidelines recommend the use of noninvasive ventilation when possible [28,93,171].

Quality Improvement Initiatives and Enhanced Infection Control Strategies

Quality improvement and infection control initiatives and strategies have led to a substantial decrease in the rates of VAP since the early 2000s [195]. The use of physician-led multidisciplinary rounds with team decision-making, checklists, and a focus on the ventilator bundle has led to significant reductions in the risk for pneumonia [196,197,198]. Strong downward trends were also found for the average length of stay in the ICU and the financial costs per patient [196].

Nursing Home-Acquired Pneumonia

As with HAP, strategies to decrease or eliminate modifiable risk factors for nursing home-acquired pneumonia should be implemented. In a guideline developed by a multidisciplinary panel, three recommendations were made for preventing pneumonia among nursing home residents [199]:

- Pneumococcal vaccination of patients at admission, if indicated

- Annual influenza vaccination for residents

- Annual influenza vaccination for nursing facility staff

Influenza Outbreaks

The vaccination status of healthcare workers has been found to have a direct effect on transmission of influenza virus to patients. Outbreaks of influenza in healthcare settings have been associated with low rates of vaccination among healthcare workers, and lower rates of nosocomial influenza have been related to higher vaccination rates among healthcare workers [200,201]. Because of these findings, the ACIP recommends annual influenza vaccination for all healthcare workers, and the IDSA/ATS guideline endorses this recommendation [47]. The ACIP notes that the TIV is preferred over LAIV for workers who are in close contact with severely immunosuppressed people requiring protective isolation [112]. In addition, the Joint Commission began including vaccination programs in its accreditation standards in 2007 [123].

Despite these recommendations, only 29% to 69% of healthcare workers receive the influenza vaccination each year [202,203,204]. Healthcare workers have given many reasons for not being vaccinated, and the reasons vary among professions. Across all categories, shortage of the vaccine is the primary reason for not being vaccinated; other reasons include concern about side effects, inconvenience, and forgetfulness [204].

Efforts to increase the vaccination rate among healthcare workers are ongoing. A CDC guideline includes four level I recommendations to help increase rates of vaccination [205]:

- Offer influenza vaccine annually to all eligible healthcare workers

- Provide influenza vaccination to healthcare workers at the work site and at no cost as one component of employee health programs. Use strategies that have been demonstrated to increase influenza vaccine acceptance, including vaccination clinics, mobile carts, vaccination access during all work shifts, and modeling and support by institutional leaders.

- Monitor influenza vaccination coverage and declination of healthcare workers at regular intervals during influenza season and provide feedback of ward-, unit-, and specialty-specific rates to staff and administration.

- Educate healthcare workers about the benefits of influenza vaccination and the potential health consequences of influenza illness for themselves and their patients, the epidemiology and modes of transmission, diagnosis, treatment, and non-vaccine infection control strategies, in accordance with their level of responsibility in preventing healthcare-associated influenza.

Hand Hygiene

Hand hygiene is the most important preventive measure in hospitals, and the Joint Commission mandates that hospitals and other healthcare facilities comply with the Level I recommendations in the CDC guideline for hand hygiene [206]. The CDC guideline states the specific indications for washing hands, the recommended hand hygiene techniques, and recommendations about fingernails and the use of gloves [207]. The guideline also provides recommendations for surgical hand antisepsis, selection of hand-hygiene agents, skin care, educational and motivational programs for healthcare workers, and administrative measures.

Despite the simplicity of the intervention, its substantial impact, and wide dissemination of the guideline, compliance with recommended hand hygiene has ranged from 16% to 81%, with an average of 30% to 50% [207,208,209,210,211,212]. Among the reasons given for the lack of compliance are inconvenience, understaffing, and damage to skin [207,210,213]. The development of effective alcohol-based handrub solutions addresses these concerns, and studies have demonstrated that these solutions have increased compliance [211,214,215]. The CDC guideline recommends the use of such solutions on the basis of several advantages, including [207]:

- Better efficacy against both gram-negative and gram-positive bacteria, mycobacteria, fungi, and viruses than either soap and water or antimicrobial soaps (such as chlorhexidine)

- More rapid disinfection than other hand-hygiene techniques

- Less damaging to skin

- Time savings (18 minutes compared with 56 minutes per eight-hour shift)

The guideline suggests that healthcare facilities promote compliance by making the handrub solution available in dispensers in convenient locations (such as the entrance to patients' room or at the bedside) and provide individual pocket-sized containers [207]. The handrub solution may be used in all clinical situations except for when hands are visibly dirty or are contaminated with blood or body fluids. In such instances, soap (either antimicrobial or nonantimicrobial) and water must be used.

However, there are many other reasons for lack of adherence to appropriate hand hygiene, including denial about risks, forgetfulness, and belief that gloves provide sufficient protection [207,210,213]. These reasons demand education for healthcare professionals to emphasize the importance of hand hygiene. Also necessary is research to determine which interventions are most likely to improve hand-hygiene practices, as no studies have demonstrated the superiority of any intervention [216]. Single interventions are unlikely to be effective.

ILLUSTRATIVE CASE

A man, 73 years of age, with a history of coronary disease, COPD, benign prostatic hyperplasia, and type 2 diabetes is hospitalized on transfer from an assisted-living facility because of weakness, loss of appetite, and low-grade fever. He had been admitted elsewhere for similar symptoms six months earlier and was diagnosed with urinary tract infection and treated with an unknown antibiotic. On evaluation, the patient's temperature is 37.6°C (99.8°F) and his other vital signs are stable; his exam is unremarkable. The WBC is normal, and the urinalysis shows pyuria. The admission chest x-ray shows hyperlucent lung fields and flattened diaphragms indicative of emphysema, but no infiltrate. Empiric treatment with a first-generation cephalosporin is begun for presumed urinary tract infection. The patient has no further fever, and his appetite and strength improve over the next 48 hours. He does have periods of mild agitation and insomnia, which are treated with a benzodiazepine at bedtime.

On the fourth day, as plans for discharge were in place, the patient appears worse, with a cough and a temperature of 38°C (100.4°F). A repeat chest x-ray shows a small focal opacity in the left upper lobe, thought to represent "aspiration." No change in antibiotics is made, and he is observed. Over the next 36 hours, the patient's condition worsens; he now has a cough productive of purulent sputum, fever (102°F to 103°F), shortness of breath, and tachypnea. A follow-up chest x-ray now shows an extensive opacification/infiltrate in the left upper lobe, with signs suggestive of either central cavitation or consolidation high-lighting emphysematous blebs.

In this elderly, somewhat debilitated man with chronic lung disease, who may be at risk of aspiration, a rapidly progressive, necrotizing (hospital-acquired) pneumonia developed while he was being treated with an oral cephalosporin for urinary tract infection, and receiving a nightly sedative medication for sleep.

What are the etiologic considerations and how should the patient be managed? Within days of admission to a hospital, and especially if treated with antibiotics, many patients develop nasopharyngeal colonization by hospital flora (e.g. gram-negative bacilli and occasionally S. aureus). When pneumonia supervenes, it reflects this colonization; moreover, prior antibiotic therapy tends to select out resistant pathogens. Therefore, the selection of empiric antibiotic treatment for this patient is based on the presumption of hospital-acquired bacterial infection in the lung caused by one or more pathogens resistant to first-generation cephalosporins. Cultures of blood and sputum should be obtained; gram stain of the sputum is often helpful in cases such as this, as it may demonstrate a predominate pathogen and whether it is gram-positive or gram-negative. Empiric antibiotic therapy, following ATS/IDSA recommendations for HAP, should be started promptly. A good choice here would be either an extended-spectrum ß-lactam/ß-lactamase inhibitor or a carbapenem with activity against Pseudomonas, combined with a fluoroquinolone and vancomycin, pending culture results.

Gram stain of the patient's sputum shows many polys and gram-negative bacilli; the culture is positive for K. pneumoniae and P. aeruginosa. His management, including empiric antibiotic therapy followed by de-escalation (of vancomycin) after culture data are available, conforms to ATS/IDSA recommendations. The patient is treated for 10 days and recovers following a brief period in the ICU.

This case illustrates that the pathogenesis of adult bacterial HAP is essentially the same as for CAP; namely, nasopharyngeal and upper respiratory colonization by virulent bacteria combined with aspiration of infected secretions during a period of impaired host pulmonary defenses. The difference lies in the burden of vulnerability imposed by hospitalization, including the propensity for colonization by gram-negative bacilli and the likelihood of antimicrobial resistance — so uncommon in healthy individuals outside of healthcare facilities, but so prevalent among patients hospitalized longer than 48 hours.

9. SUMMARY

Pneumonia-related mortality and morbidity have decreased since the late 1990s, but the disease still represents a substantial healthcare concern, especially for high-risk adults and children. Pneumonia is primarily classified according to the setting in which it develops, and the epidemiology, etiology, and risk factors vary according to setting. Diagnosis can be challenging because of differences in presentation and the lack of reliable, cost-effective, and rapidly available diagnostic testing methods. Specialty society guidelines for prevention, diagnosis, and treatment are available for CAP, HAP, and VAP. Guideline-directed treatment has been shown to improve the care of patients while promoting good antibiotic stewardship, minimizing exposure to inappropriate antibiotic treatment and reducing the emergence of antibiotic-resistant pathogens.

For CAP and nursing home-acquired pneumonia, determining the site of care is an important initial decision point. Guidelines from the IDSA/ATS, the PIDS/IDSA, and the ATS outline useful criteria for determining need for hospitalization and ICU care. These objective criteria are important factors in decision-making, but clinical judgment is also necessary for selecting the most appropriate site of care. Initial antibiotic treatment of all types of pneumonia is empirical. The selection is best made in relation to the most likely pathogens in a given clinical setting and to patient variables, such as comorbidities, recent exposure to antibiotics, and immunization status (for children). The timeliness of antibiotic treatment is also important; treatment should begin as soon as possible after diagnosis is made, administering the first dose promptly at the originating site of care.

Guideline-directed therapy of pneumonia has been shown to decrease morbidity and mortality, but adherence varies across settings and specialties and has been suboptimal. Physician practices and healthcare systems can improve adherence by implementing evidence-based strategies, such as standardized order sets, reminders, performance feedback, and easy-to-carry resources.

The incidence of pneumonia and its associated morbidity and mortality can be reduced further by adherence to effective preventive measures. Several guidelines are available for preventing specific types of pneumonia. The primary preventive strategy for CAP is immunization with influenza and pneumococcal vaccines, especially for individuals at high risk. These vaccinations have been shown to decrease the incidence and severity of pneumococcal pneumonia, as well as the risk of long-term morbidity and mortality. However, rates of vaccination vary across age, race/ethnicity, and risk. Two target populations with the lowest immunization rates are high-risk adults in need of pneumococcal vaccination and teenagers in need of influenza vaccination. Rates of vaccination among healthcare professionals are also low. Clinicians and healthcare systems should encourage vaccination and offer convenient access, especially during influenza season.

Lack of awareness about the need for vaccination, misconceptions about vaccines, and low level of knowledge about pneumonia have been reported to be the primary barriers to vaccination, especially among minority populations. Clinicians should promote practice strategies and public health efforts designed to target these barriers and address the populations in greatest need. Several strategies have been shown to increase vaccination rates, and education is the cornerstone. Clinicians should emphasize to patients the need and benefit of immunization, address concerns about the safety of vaccines, and incorporate routine immunization protocols into their practices. Provider recommendation is essential, as it is the strongest predictor of vaccination. System-related strategies such as automatic reminders and standing orders have also been effective.

Guidelines for prevention of HAP focus on measures to reduce pulmonary complications after surgery. Prevention of VAP relies on strategies to reduce the risk of transmission of etiologic agents. Use of a ventilator "bundle" (a set of interventions) has been shown to markedly reduce VAP. Although adherence to guidelines is suboptimal, healthcare facilities are increasingly implementing initiatives to help enhance adherence.

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189. Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med. 2005;118(1):11-18.

190. Bouza E, Pérez MJ, Muñoz P, Rincón C, Barrio JM, Hortal J. Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. Chest. 2008;134(5):938-946.

191. Wang F, Bo L, Tang L, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: an updated meta-analysis of randomized controlled trials. J Trauma Acute Care Surg. 2012;72(5):1276-1285.

192. Girou E, Brun-Buisson C, Taille S, Lemaire F, Brochard L. Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema. JAMA. 2003;290(22):2985-2991.

193. Isakow W, Kollef MH. Preventing ventilator-associated pneumonia: an evidence-based approach of modifiable risk factors. Semin Respir Crit Care Med. 2006;27(1):5-17.

194. Osmon S, Kollef MH. Prevention of pneumonia in the hospital setting. Clin Chest Med. 2005;26(1):135-142.

195. Craven DE, Hjalmarson K. Prophylaxis of ventilator-associated pneumonia: changing culture and strategies to trump disease. Chest. 2008;134(5):898-900.

196. Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care. 2006;15(4):235-239.

197. Stone MJ, Snetman D, O'Neill A, et al. Daily multidisciplinary rounds to implement the ventilator bundle decreases ventilator-associated pneumonia in trauma patients: but does it affect outcome? Surg Infect (Larchmt). 2011;12(5):373-378.

198. Cachecho R, Dobkin E. The application of human engineering interventions reduces ventilator-associated pneumonia in trauma patients. J Trauma Acute Care Surg. 2012;73(4):939-943.

199. Hutt E, Kramer AM. Evidence-based guidelines for management of nursing home-acquired pneumonia. J Fam Pract. 2002;51(8):709-716.

200. Salgado CD, Giannetta ET, Hayden FG, Farr BM. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol. 2004;25(11):923-928

201. Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination on health-care workers on mortality of elderly people in long-term care: a randomized controlled trial. Lancet. 2000;355(9198):93-97.

202. Dash GP, Fauerbach L, Pfeiffer J, et al. APIC position paper: Improving health care worker influenza immunization rates. Am J Infect Control. 2004;32(3):123-125.

203. Centers for Disease Control and Prevention. Estimated influenza vaccination coverage among adults and children—United States, September 1, 2004–January 1, 2005. MMWR. 2005;54(12):304-307.

204. Christini AB, Shutt KA, Byers KE. Influenza vaccination rates and motivators among healthcare worker groups. Infect Control Hosp Epidemiol. 2007;28(2):171-177.

205. Pearson ML, Bridges CB, Harper SA. Influenza vaccination of health-care personnel. MMWR. 2006;55(RR02):1-16.

206. U.S. Food and Drug Administration. Reprocessing of Reusable Ultrasound Transducer Assemblies Used for Biopsy Procedures. Available at https://wayback.archive-it.org/7993/20170112170658/http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm151526.htm. Last accessed August 14, 2018.

207. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. MMWR. 2002;51(RR16):1-44.

208. Burke JP. Infection control-a problem for patient safety. N Engl J Med. 2003;348(7):651-656.

209. Leapfrog Group. Press Release: Eighty-Seven Percent of U.S. Hospitals Do Not Take Recommended Steps to Prevent Avoidable Infections. Available at http://www.leapfroggroup.org/media/file/Leapfrog_hospital_acquired_infections_release.pdf. Last accessed August 20, 2015.

210. Clark AP, Houston S. Nosocomial infections: an issue of patient safety: part 2. Clin Nurse Spec. 2004;18(2):62-64.

211. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet. 2000;356(9238):1307-1312.

212. Larson EL, Quiros D, Lin SX. Dissemination of the CDC's hand hygiene guideline and impact on infection rates. Am J Infect Control. 2007;35(10):666-675.

213. Weinstein R. Hospital-acquired infections. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, Isselbacher KJ (eds.) Harrison's Principles of Internal Medicine. 16th ed. New York, NY: McGraw Hill; 2004.

214. Johnson PDR, Rhea M, Burrell LJ, et al. Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Aust. 2005;183(10):509-514.

215. Gordin FM, Schultz ME, Huber RA, Gill JA. Reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based handrub. Infect Control Hosp Epidemiol. 2005;26(7):650-653.

216. Gould DJ, Chudleigh JH. Moralejo D, Drey N. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2007;(2):CD005186.

217. Mason CM, Nelson S. Pulmonary host defenses and factors predisposing to lung infection. Clin Chest Med. 2005;26(1):11-17.

218. Johnstone J, Eurich DT, Jamumdar SR, Jin Y, Marrie TJ. Long-term morbidity and mortality after hospitalization with community-acquired pneumonia: a population-based cohort study. Medicine (Baltimore). 2008;87(6):329-334.

219. Santibanez T, Mootrey GT, Euler GL, Janssen AP. Behavior and beliefs about influenza vaccine among adults ages 50–64 years.Am J Health Behav. 2010;34(1):77-89.

220. Griffin M, Zhu Y, Moore M, Whitney C, Grijalva C. U.S. hospitalizations for pneumonia after a decade of pneumococcal vaccination. N Engl J Med. 2013;369:155-163.

221. Nuorti J, Butler J, Farley M, et al. Cigarette smoking and invasive pneumococcal disease. N Engl J Med. 2000;342:681-689.

222. Marrie T, Poulin-Costello M, Beecroft M, Herman-Gnjidic Z. Etiology of community-acquired pneumonia in the ambulatory setting. Respir Med. 205;99:60-65.

223. Kallen AJ, Reed C, Patton M, et al. Staphylococcus aureus community-onset pneumonia in patients admitted to children's hospitals during autumn and winter of 2006–2007. Epidemiol Infect. 2010;138:666-672.

224. Musher D, Montoya R, Wanahita A. Diagnostic value of microscopic examination of Gram-stained sputum and sputum cultures in patients with bacteremic pneumococcal pneumonia. Clin Infect Dis. 2004;39:165-169.

225. Gutiérrez F, Masiá M, Rodríguez JC, et al. Evaluation of the immunochromatographic Binax NOW Assay for detection of Streptococcus pneumoniae urinary antigen in a prospective study of community-acquired pneumonia in Spain. Clin Infect Dis. 2003;36(3):286-292.

226. Toshihiko S, MD, Yoshinori N, Jackson J, et al. Systematic review and meta-analysis: urinary antigen tests for legionellosis. Chest. 2009;136:1576-1585.

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Evidence-Based Practice Recommendations Citations

1. Kirsch J, Mohammed TH, Kanne JP, et al. ACR Appropriateness Criteria: Acute Respiratory Illness in Immunocompetent Patients. Reston, VA: American College of Radiology; 2013. Available at https://acsearch.acr.org/docs/69446/Narrative. Last accessed August 22, 2018.

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31432 • Burnout: Impact on Nursing and Quality of Care

Lori L. Alexander, MTPW, ELS, MWC

www.netce.com

Copyright © 2018 NetCE, All rights reserved.

This course provides an overview of burnout, including the evolution of its definition, its causes, related symptoms, identification, and measurement. The effects of burnout are broad, with consequences not only for the individual personally and professionally but also for patient care and healthcare systems; these implications will be explored. Among the most significant implications is the nursing shortage and a subsequent decrease in the quality of patient care. A review of the literature provides insights into the primary sources of job dissatisfaction, stress, and burnout among healthcare professionals and nurses in particular. Knowledge of the most common risk factors for burnout can help individuals modify their personal and professional lifestyles more effectively. Suggestions are given for ways organizations and nursing leadership can create a healthy work environment in which priority is given to nurses' psychosocial well-being and to fostering supportive relationships. While these strategies are aimed at creating a better work environment for nurses, they also ultimately promote better care and safety of patients.

Table of Contents

31432 • Burnout: Impact on Nursing and Quality of Care

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. HISTORY AND DEFINITION OF BURNOUT

3. DEVELOPMENT OF BURNOUT

CAUSES OF STRESS AND BURNOUT

4. IDENTIFICATION AND MEASUREMENT OF BURNOUT

DISTINGUISHING BURNOUT FROM OTHER ENTITIES

SIGNS AND SYMPTOMS OF STRESS

MEASURING BURNOUT

5. BURNOUT AMONG NURSES

DEMOGRAPHIC FACTORS

WORK ENVIRONMENT FACTORS

6. CONSEQUENCES OF STRESS AND BURNOUT

PERSONAL CONSEQUENCES

PROFESSIONAL CONSEQUENCES

7. STRATEGIES TO PREVENT AND COPE WITH STRESS AND BURNOUT

STRATEGIES FOR INDIVIDUALS: PERSONAL LIFESTYLE

STRATEGIES FOR INDIVIDUALS: PROFESSIONAL LIFESTYLE

STRATEGIES FOR INSTITUTIONS/ORGANIZATIONS

8. CASE STUDY: A TALE OF TWO NURSES

9. CONCLUSION

Works Cited

31432 • Burnout: Impact on Nursing and Quality of Care

Education Category. Management

Release Date. 04/01/2018

Expiration Date. 03/31/2021

Course Overview

This course provides an overview of burnout, including the evolution of its definition, its causes, related symptoms, identification, and measurement. The effects of burnout are broad, with consequences not only for the individual personally and professionally but also for patient care and healthcare systems; these implications will be explored. Among the most significant implications is the nursing shortage and a subsequent decrease in the quality of patient care. A review of the literature provides insights into the primary sources of job dissatisfaction, stress, and burnout among healthcare professionals and nurses in particular. Knowledge of the most common risk factors for burnout can help individuals modify their personal and professional lifestyles more effectively. Suggestions are given for ways organizations and nursing leadership can create a healthy work environment in which priority is given to nurses' psychosocial well-being and to fostering supportive relationships. While these strategies are aimed at creating a better work environment for nurses, they also ultimately promote better care and safety of patients.

Audience

This course is designed for nurses and nurse practitioners at all levels and in all settings, especially oncology, palliative care, mental health, and critical care.

Course Objective

Given the integral relationship between work-related stress, job dissatisfaction, burnout, and patient care, properly addressing nursing burnout is essential. The purpose of this course is to provide nurses with information to identify burnout and with effective strategies to manage work-related stress and prevent burnout.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define burnout and its relationship to job dissatisfaction and stress.

2. Identify the work environment and personal risk factors for burnout.

3. Recognize the most common physical, psychologic, and interpersonal/social signs and symptoms of stress and burnout.

4. Describe tools to measure burnout.

5. Discuss the prevalence of burnout among nurses.

6. Explain the primary sources of work- related stress, job dissatisfaction, and burnout among nurses.

7. Describe the personal and professional consequences of nursing burnout and the nursing shortage.

8. Implement personal strategies to manage stress and prevent burnout.

9. Identify strategies that institutions/ organizations should implement to help prevent job dissatisfaction and burnout.

Faculty

Lori L. Alexander, MTPW, ELS, MWC, is President of Editorial Rx, Inc., which provides medical writing and editing services on a wide variety of clinical topics and in a range of media. A medical writer and editor for more than 30 years, Ms. Alexander has written for both professional and lay audiences, with a focus on continuing education materials, medical meeting coverage, and educational resources for patients. She is the Editor Emeritus of the American Medical Writers Association (AMWA) Journal, the peer-review journal representing the largest association of medical communicators in the United States. Ms. Alexander earned a Master’s degree in technical and professional writing, with a concentration in medical writing, at Northeastern University, Boston. She has also earned certification as a life sciences editor and as a medical writer.

Faculty Disclosure

Contributing faculty, Lori L. Alexander, MTPW, ELS, MWC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Jane C. Norman, RN, MSN, CNE, PhD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

1. INTRODUCTION

Work is a significant source of stress in all occupations; according to a 2014 nationwide survey by the American Psychological Association (APA) and the American Institute of Stress (AIS), job pressure was the leading cause of stress, and other surveys have shown that approximately one-third of working Americans experience chronic work stress, with 37% saying they were excellent or very good at managing job work stress [1,2]. High costs are associated with work-related stress in terms of absenteeism, decreased productivity, and employee turnover, as are a wide variety of physical conditions, from headaches and insomnia to cardiovascular and immune diseases [1,2]. Work-related stress that is left unaddressed has the potential to develop into burnout over a long period of time. The costs of burnout are even higher than stress and affect not only the well-being of the individual but that of the individual's family, friends, and colleagues. Burnout has been more prevalent in the so-called helping professions, and high levels of burnout have been documented in the healthcare professions, especially among registered nurses.

This course provides an overview of burnout, addressing its development, characteristics, and measurement. The characteristics of burnout unique to nursing are outlined. Nurses are especially vulnerable to the syndrome, and this is of particular concern for several reasons. First, nurses represent the largest faction of healthcare professionals, with more than 2.95 million nurses in the United States, and they are the frontline for direct patient care in hospitals [3]. Second, job dissatisfaction and subsequent burnout have been strongly linked to nursing turnover, which is a driver of the nursing shortage that began in the late 1990s [4,5]. This shortage remains ongoing, and a 2012 analysis indicated that the shortage of registered nurses (RNs) will reach a total national deficit of nearly 920,000 by the year 2030 [6]. The same researchers published a follow-up analysis in 2017 and indicated an improvement of almost 50%, noting that the recalculated deficit of RNs will be approximately 510,000 in the year 2030 [178]. This improvement is likely due to the concerted effort of nursing recruitment, as shown by the much faster than average job outlook (15% growth) by 2026; however, the deficit still remains and further efforts are required to strengthen the nursing workforce [3,178]. Third, and most important, inadequate nursing staff levels caused by excessive turnover have been significantly associated with nursing errors and poorer patient outcomes, and higher levels of burnout have been associated with lower ratings of the quality of care [7,8,9,10,11,12,13,14]. Thus, enhancing job satisfaction and avoiding burnout is crucial to maintaining an adequate population of nurses, and an adequate population of nurses is vital to maintaining high-quality patient care. After a discussion of the primary sources of work-related stress, job dissatisfaction, and burnout among nurses, several strategies for preventing burnout at the individual and organizational level are presented. Most registered nurses work in hospitals and nursing homes, so these nursing populations are the focus of the course. In addition, while nursing burnout is a global issue, this course is built primarily on research in U.S. institutions.

2. HISTORY AND DEFINITION OF BURNOUT

The term "burnout" originated in the 1940s as a word to describe the point at which a jet or rocket engine stops operating [15]. The word was first applied to humans in the 1970s by the psychiatrist Herbert Freudenberger, who used the term to describe the status of overworked volunteers in free mental health clinics [16]. He compared the loss of idealism in these volunteers to a building—once a vital structure—that had burned out, and he defined burnout as the "progressive loss of idealism, energy, and purpose experienced by people in the helping professions as a result of the condition of their work" [17].

Use of the term burnout is now widespread (perhaps overused), and definitions have varied since the time the word was first applied to humans. The term has been used to describe a mild degree of unhappiness caused by stress, as well as any degree of distress, from fatigue to major depression [18]. In the early 1980s, social psychologist Christina Maslach and her colleagues began to explore the loss of emotional feeling and concern for clients among human services professionals. Since then, she has researched burnout extensively, becoming the leading authority on the topic and the author of the criterion standard tool to assess burnout, the Maslach Burnout Inventory (MBI) [19,20,21].

Maslach emphasizes that burnout is not a problem related to an individual [21]. Instead, her research indicates that burnout is a problem of the social environment in which people work and is a function of how people within that environment interact with one another and perform their jobs [21]. She notes that burnout is more likely when there is a "major mismatch between the nature of the job and the nature of the person who does the job" [21]. These mismatches are at the core of the development of burnout. The term burnout is now usually limited to mean burnout as described by Maslach: a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment [18].

Burnout can occur in any setting, and it has been studied most extensively in a wide range of occupations within the human services field, from healthcare professionals to teachers, police, and prison workers [18,22]. High levels of burnout among healthcare professionals have been well-documented.

3. DEVELOPMENT OF BURNOUT

In general, when an individual first enters a chosen career, he or she is motivated. If the work environment is not supportive of the individual's efforts and concerns, the reality of the job and the individual's expectations begin to diverge and frustration and disappointment arise [18]. These feelings can lead to job dissatisfaction, resulting in decreased productivity, loss of confidence and enthusiasm, and behavior changes. If the situation is not addressed, stress accumulates and causes typical stress-related symptoms. These physical symptoms, when coupled with emotional distance, signify the first stage of burnout: mental and physical exhaustion [18]. If these symptoms are not addressed, they will evolve over four more stages: frustration and indifference, feelings of powerlessness and failure as a professional, isolation and apathy, and true burnout. For nurses, these stages affect not only them and their family and friends, but also their peers and patients (Figure 1) [23,24].

Figure 1: FIVE STAGES OF BURNOUT IN NURSING

Source : Author

CAUSES OF STRESS AND BURNOUT

The specific factors within the work environment that lead to stress and subsequent burnout vary across occupations and among individuals within a single occupation. The root of burnout is in the work environment, but because not all individuals working in a single environment will experience burnout, personal risk factors must have a role in making an individual vulnerable. These personal risk factors include demographic variables and personality traits (Table 1) [18,25,26,27].

Table 1: Potential Risk Factors for Burnout

Dimension

Risk Factor

Work environment

Work overload

Lack of control over one's work

Insufficient reward for one's contributions

Absence of community

Lack of fairness

Conflict in values

Demographic variables

Younger age

Early in career

Lack of life partner or children

Higher level of education

Personality traits

Low self-esteem or confidence

No recognition of personal limits

Need for approval

Overachieving

Need for autonomy

Impatience

Intolerance

Empathy

Extreme conscientiousness

Perfectionism

Self-giving

Type D personality

Source: [18,25,26,27]

Work Environment Factors

Burnout is more likely when an individual's experience (actual or perceived) does not match one or more situational factors in a work environment [21]. Among the mismatches that most commonly lead to burnout in any work environment are [21]:

- Work overload: limitations in terms of staff, time, and other resources

- Lack of control: inability to perform job functions the way an individual believes is the "right" way

- Insufficient reward: absence of acknowledgment of an individual's contributions in the work environment and lack of opportunities to advance

- Absence of community: poor working relationships, absence of adequate supervisory or peer support, poor leadership style

- Lack of fairness: inequality in workload, salary, or other signs of professional respect

- Conflict in values: disagreement between job requirements and an individual's personal principles

Personal Risk Factors

Demographic variables have been studied in relation to burnout, and several have been found to influence the risk of burnout, alone or in combination, including [18]:

- Age

- Race/ethnicity

- Family status

- Educational status

- Gender

- Personality traits

Burnout is less prevalent among older individuals because they tend to be more stable and have a more balanced perspective on life [18]. In addition, the increased rate of burnout among younger individuals is a function of a "survival of the fittest" concept. Burnout usually occurs early in one's career (in the first one to five years), and many young, burned out individuals leave the profession; as a result, the remaining individuals in an occupation are the "survivors" [18].

Comparing burnout across racial/ethnic groups is difficult, as most studies have been small or have not involved sufficient numbers of minority workers [18]. For example, one study involved 180 childcare professionals (131 white and 49 black women), in which the scores for components of burnout were higher among black professionals than among white professionals [28]. Family status also seems to play an important role in burnout; rates of burnout are higher among single workers and workers with no children than among married workers and those with children [18]. The emotional resources provided by a family are thought to be the reason for this difference.

Educational status seems to have an effect, with higher levels of burnout among workers with higher levels of education [18]. This difference could be the result of the expectations associated with advanced education and job choices [18].

Across most work settings, levels of burnout have been somewhat consistent among men and women. One meta-analysis demonstrated similar overall rates of burnout among men and women, but there were gender differences in burnout components, with slightly higher levels of emotional exhaustion among women and somewhat higher levels of depersonalization among men [29]. Gender differences have also been found with respect to other demographic variables [18]. For example, a survey of 3,424 employees in a Finnish study indicated that a low educational level and low social status increased the risk of burnout for women, whereas marital status (single, divorced, or widowed) increased the risk for men [30].

Studies have also been done to explore relationships between personality traits and the risk of burnout. Maslach noted that characteristics such as low self-esteem or lack of confidence, failure to recognize personal limits, need for approval, drive to overachieve, need for autonomy, impatience, intolerance, and empathy increased susceptibility to burnout [18]. Others have postulated that extreme conscientiousness, perfectionism, and self-giving (selflessness) also increase susceptibility, as does a type D personality (a joint tendency for negative emotions and social inhibition) [25,26,27].

Many of the personal risk factors described here are common among nurses and other healthcare professionals; in fact, several are essential for success in the healthcare field. This may explain, in part, the high levels of burnout among nurses.

4. IDENTIFICATION AND MEASUREMENT OF BURNOUT

Identifying the signs of stress and burnout is important to preserve the overall health and well-being of individuals. Burnout is associated with many signs and symptoms. For accurate identification, care should be taken to distinguish burnout from other conditions, such as stress, prolonged fatigue, compassion fatigue, and depression (Table 2) [18,23,25,31,32,33,34,38,179].

Table 2: DISTINCTION BETWEEN BURNOUT AND CLINICAL ENTITIES WITH SIMILAR PRESENTATION

Other Clinical Entity

Burnout

Stress

Precipitated by isolated or situational instances

Result of prolonged stress

Prolonged fatigue

Associated with health-related factors

Associated with job-related factors

Compassion fatigue

Usually a reaction to an immediate or specific situation

Often still cares and is involved

Develops over a longer period of time

Becomes uncaring and distant

Depression

Related to factors within every domain

Related to specific factors in the work setting

Source: [18,23,25,31,32,33,34,38,179]

DISTINGUISHING BURNOUT FROM OTHER ENTITIES

Stress can cause many of the same physical, psychologic, and interpersonal/social symptoms as burnout. However, stress is distinct from burnout in that it is usually precipitated by isolated or situational instances, whereas burnout is the result of prolonged stress [18]. Prolonged fatigue often overlaps with burnout, but the precipitating factor differs for each; fatigue is usually associated with health-related causes, whereas burnout is caused by job-related factors [34,35,179]. In general, overall health and psychologic distress are worse for individuals who have concurrent prolonged fatigue and burnout [36].

Compassion fatigue was originally described as a unique form of burnout that affected people who were caregivers [37]. Compassion fatigue is usually a reaction to an immediate or specific situation, whereas burnout develops over a longer period of time [38]. Also, an individual with compassion fatigue can still care and be involved; an individual with burnout becomes indifferent, disengaged, and distant [39,40].

Depression and burnout may have a similar clinical presentation, and signs of depression can be associated with burnout. However, depression is related to factors within every domain of an individual's life and is not limited to specific factors in the work setting [31,41]. Depression is more likely among individuals who have had a recent loss or a personal or family history of depression, but burnout is more likely if symptoms are worse in the work environment and if the individual works long hours and has no time for outside interests.

The most important distinction between burnout and all of these entities is that only burnout is characterized by the collective features of emotional exhaustion, depersonalization, and lack of accomplishment, as measured on the MBI.

SIGNS AND SYMPTOMS OF STRESS

Stress is a precursor to burnout, making it important to identify the signs and symptoms associated with stress. These signs and symptoms are multidimensional, with physical, psychologic/psychiatric, and interpersonal/social manifestations [1,2,20]. As such, a multidisciplinary approach should be taken not only to confirm the presence of stress and/or burnout but also to rule out other illnesses or conditions. In addition to the traditional medical history and physical examination, a social and occupational history should be obtained in an effort to identify potential stress factors and possible social consequences [20]. An evaluation of the type, course, and frequency of symptoms can help distinguish them as signs of stress or burnout, and a drug history can help to identify potential substance abuse problems. The signs and symptoms of stress discussed here are similar across work settings. Burnout among healthcare workers is associated with these characteristics as well as some unique features, which will be described later.

Physical Effects

Stress has been linked to many somatic conditions of varying degrees of severity. The 2014 survey led by the APA and the AIS showed that 77% of the American population reported stress-related physical symptoms [2]. Fatigue was the leading physical symptom, reported by more than half of the respondents, and headache, upset stomach, and muscle tension were other top stress-related physical symptoms (Table 3) [2].

Table 3: MOST COMMON PHYSICAL AND PSYCHOLOGIC SYMPTOMS RELATED TO STRESS

Symptoms

Frequency

Physical

Fatigue

51%

Headache

44%

Upset stomach

34%

Muscle tension

30%

Change in appetite

23%

Teeth grinding

17%

Change in sex drive

15%

Dizziness

13%

Psychologic

Irritability or anger

50%

Nervousness

45%

Lack of energy

45%

Feeling of wanting to cry

35%

Source: [2]

Stress has been found to be an important factor leading to hypertension and adverse cardiac events [42,43]. The data are inconclusive on whether stress is a direct cause of cardiovascular disease or adverse cardiac events [42]. In a large-scale study (10,000 subjects) in London, work-related stress was an important contributor to coronary heart disease through direct effects on the neuroendocrine stress pathways and indirect effects on health behaviors [44]. In fact, the researchers found that nearly one-third of the effect of work-related stress was attributable to health behaviors, especially a low level of physical activity, poor diet, and metabolic syndrome [44]. Psychologic stress has also been associated with gastrointestinal disorders upper respiratory infections, and disrupted immune responses [45,46,47,48].

Psychologic Effects

Stress is also associated with a range of psychologic symptoms. In the 2014 survey by the AAP and the AIS, irritability and anger was the leading psychologic symptom, reported by half of the respondents [2]. Other common signs and symptoms included nervousness, lack of energy, and a feeling of wanting to cry [2].

Interpersonal/Social Effects

Interpersonal and social relationships may also be compromised by burnout. Individuals experiencing burnout may have a difficult time communicating with others in the work environment as well as with friends and family and may create emotional distance [18]. The cynicism that is characteristic of the syndrome may lead individuals to treat co-workers with suspicion and to have critical attitudes toward them [18]. Other effects include marital conflict and divorce, neglect of family and social obligations, and questioning of previously held spiritual beliefs [18].

MEASURING BURNOUT

As noted, the criterion standard for measuring burnout is the MBI, a self-assessment tool first published in 1981 by Maslach and Jackson [19]. The MBI was originally developed for the human services industry, and since then, two additional versions have been developed—a general survey and an educator-specific survey [20]. The tool has been shown to be reliable, valid, and easy to administer and has been translated into several languages for use around the world. The MBI is often used in conjunction with other assessments to evaluate the relationship between burnout and organizational policies, productivity, and social support [19].

The MBI addresses the three defining aspects of burnout syndrome with 22 statements in three subscales [18]:

- Emotional exhaustion: Nine statements to measure feelings of being emotionally overextended and exhausted by one's work

- Depersonalization: Five statements to measure an unfeeling and impersonal response to the recipients of one's services, care treatment, or instruction

- Personal accomplishment: Eight statements to measure feelings of competence and successful achievement in one's work

Each statement in the MBI expresses a particular feeling or attitude; for example, one statement in the depersonalization subscale is "I've become more callous toward people since I took this job" [18]. For each statement, the respondent indicates how frequently he or she experiences that feeling by using a fully anchored scale ranging from 0 (never) to 6 (every day). Higher scores on the emotional exhaustion and depersonalization subscales indicate higher degrees of burnout. A lower score on the personal accomplishment subscale corresponds to a lower degree of burnout. A separate score is determined for each subscale, and a scoring key provides threshold scores to indicate a low, average, or high degree of burnout on each subscale.

Because the length of the MBI may limit its usefulness, researchers have explored the use of single-item measures from the instrument. Studies of healthcare professionals have shown that responses to one statement in the emotional exhaustion subscale ("I feel burned out from my work") and one statement in the depersonalization subscale ("I have become more callous toward people since I took this job") correlate well with the results of the full MBI [49,50,51]. More recently, a nonproprietary single-item measure has been shown to be a reliable substitute for the single-item measure on the emotional exhaustion subscale of the MBI [52].

The use of psychologic assessment tools in conjunction with the MBI can help professionals gain a better understanding of the sources of stress for individuals. The General Health Questionnaire, developed by Goldberg, is designed to measure common mental health problems (domains of depression, anxiety, somatic symptoms, and social withdrawal) and was developed as a measure to identify individuals who are likely to have or be at risk for the development of psychiatric disorders [53]. The General Health Questionnaire is frequently used in conjunction with the MBI to evaluate psychologic morbidity and burnout, as the pathways to both are related [54].

The General Health Questionnaire has been translated into several languages and is available in a variety of versions, with a range of 12 to 60 items; the version with 28 items (GHQ-28) has been used most often in workplace settings [54]. A score of 0 to 3 is assigned to four possible responses ("not at all," "no more than usual," "rather more than usual," and "much more than usual") to such questions as:

- Have you found everything getting on top of you?

- Have you been getting scared or panicky for no good reason?

- Have you been getting edgy and bad tempered?

Another exercise, the Burnout Risk Survey, was developed by Pfifferling, the director of the Center for Professional Well-Being, who has extensively studied stress in healthcare professionals (Table 4) [55]. This tool is designed to demonstrate the probability of mismatches between an individual and his or her work environment. A "yes" response to three or more of these items indicates a risk of burnout and a "yes" response to four or more items indicates a high risk.

Table 4: BURNOUT RISK SURVEY

Are your achievements your self-esteem?

Do you tend to withdraw from offers of support?

Will you ask for/accept help?

Do you often make excuses, like, "It's faster to do it myself than to show or tell someone?"

Do you always prefer to work alone?

Do you have a close confidant with whom you feel safe discussing problems?

Do you "externalize" blame? (Obsessively seek to place blame away from yourself)

Are your work relationships asymmetrical? Are you always giving?

Is your personal identity bound up with your work role or professional identity?

Do you value commitments to yourself to exercise/relax as much as you value those you make to others?

Do you often overload yourself—have a difficult time saying "no?"

Do you have few opportunities for positive and timely feedback outside of your work role?

Do you abide by the "laws:" "Don't talk, don't trust, don't feel?"

Do you easily feel frustrated, sad, or angry from your regular work tasks?

Is it hard for you to easily establish warmth with your peers and/or service (patients/clients) recipients?

Do you feel guilty when you "play" or rest?

Do you get almost all of your needs met by helping others?

Do you put other's needs before or above your own needs?

Do you often put aside your own needs when someone else needs help?

Source: [55]

5. BURNOUT AMONG NURSES

Healthcare professionals certainly fall into the category of human services professionals and so are especially vulnerable to burnout [18]. In addition to the emotional strain of dealing with people who are sick or dying and who have extreme physical and/or emotional needs, the evolving state of health care has created additional stress for healthcare professionals. The economic constraints related to health care reform often hamper the ability of healthcare professionals to deliver high-quality care according to their standards [18,56].

Burnout has been studied in populations of all types of healthcare professionals around the world, including allied healthcare professionals, medical students and residents, and dentists [57,58,59,60,61,62,63,64]. The rates of burnout vary among these subgroups, but in general, the rates are higher among healthcare professionals than among individuals in nonhelping occupations. In addition, the most recent research suggests that rates of severe burnout among healthcare professionals are even higher [56]. Burnout has been studied most extensively in physicians and nurses. Studies indicate the rate of burnout among physicians has increased slightly, from 46% in 2015 to 51% in 2017 [65,66,180]. A 2012 study demonstrated that burnout was more common among physicians than among other workers in the United States [65].

As with physicians, the rate of burnout among nurses is higher than the average rate among other workers. According to the most recent data for nurses, the overall burnout rate is 34% to 43%, with rates varying according to several factors [67,68,69,181].

Among nurses, burnout is directly linked to work-related stress and job dissatisfaction. A systematic review demonstrated that work-related stress is significantly related to job satisfaction, with higher stress levels associated with less job satisfaction [70]. In addition, low job satisfaction is associated with burnout [70]. Given these facts, an understanding of the prevalence and causes of job dissatisfaction among nurses can help to define the sources of stress and burnout. Studies have indicated that among nurses, factors within the work environment are greater predictors of job dissatisfaction than factors related directly to the care of patients [71,72]. It is important to distinguish between job dissatisfaction and career dissatisfaction. An increase in job dissatisfaction among nurses has been noted when comparing a 2013 survey with a 2017 follow-up survey of 3,400 nurses [73,182]. In these surveys, similar rates were seen in the percentage of nurses satisfied with their career choice (10% vs. 9%), but there was a significant disparity in the percentage of nurses satisfied with their current job (27% vs. 40%). The percentages of nurses that indicated they often felt like resigning from their job were similar (35% vs. 38%) [73,182]. Although work environment factors are more predictive of job dissatisfaction, stress, and burnout than demographic factors, a brief discussion of demographic differences is warranted [7,71,74].

DEMOGRAPHIC FACTORS

In the 2017 survey of nurses, rates of job satisfaction were similar across the three age groups: millennials (19 to 36 years of age); generation X (37 to 53 years of age); and "baby boomers" (54 years of age and older) [182]. All three age groups were similarly likely to report feeling like resigning (36% for all groups) [182]. These statistics differ from an earlier survey that showed a similar pattern of job dissatisfaction increasing with age. A 2008 survey of more than 33,000 nurses in the United States demonstrated that moderate job dissatisfaction was high among nurses younger than 25 years of age, but the rate of moderate or extreme job dissatisfaction was the highest for nurses 40 to 44 years of age (12%) and 45 to 49 years of age (13%). The highest rate of extreme dissatisfaction (only) was found for nurses 55 to 59 years of age and 45 to 49 years of age (approximately 3% each) [72,182].

In terms of burnout, studies have shown that burnout levels are high among nurses (high scores on the MBI), and age was a factor [71,75]. In one study, researchers found that levels of burnout were higher among nurses younger than 30 years of age than among nurses older than 30 years of age [75].

Differences in job satisfaction, stress, and burnout according to gender are not well known because of the great predominance of women in nursing (93% vs. 7%) [73,76]. Limited data have indicated that the rates of job satisfaction do not differ between male and female nurses [77]. No studies were found in which rates of burnout were compared for male and female nurses working in the United States. However, one meta-analysis demonstrated that the rates of emotional exhaustion were higher for women than men in female-typed occupations [29].

Similarly, data are limited on racial/ethnic differences in job satisfaction, stress, and burnout among nurses. An analysis of the 2008 survey of registered nurses showed that the risk for job dissatisfaction was greater for black, American Indian/Alaska Native, and multiracial nurses than for white nurses [78]. No clear difference in job satisfaction could be found among Hispanic, Native Hawaiian/Pacific Islander, and white nurses [78]. In a 2017 survey of physicians, similar rates of burnout were seen among all racial/ethnic groups in the United States, with Chinese physicians experiencing a slightly greater prevalence than the national average (56% vs. 52%), and Hispanic/Latino and black physicians experiencing slightly less burnout (51% and 48% vs. 52%, respectively). Asian Indian physicians were least likely to experience burnout (46%) [180].

WORK ENVIRONMENT FACTORS

Nurses' job dissatisfaction varies according to position and setting. In the 2008 survey, rates of moderate or extreme job satisfaction were lowest for staff nurses (79%), patient coordinators (82%), and nursing managers/administrators (83%); the highest rates were found for certified nurse anesthetists (94%), midwives (93%), and clinical nurse specialists and educators (90%) [72].

With regard to setting, the highest rates of job dissatisfaction have been reported among nurses in nursing homes and hospitals, even for nurses who do not provide direct patient care [68,72]. In a survey of more than 95,000 nurses, the most common sources of dissatisfaction for hospital and nursing home nurses were opportunities to advance, professional status, work schedule, and independence at work [68]. Salary/wages and benefits (health, retirement, tuition reimbursement) have also been common sources of dissatisfaction, but have had little influence on burnout [68,69].

Rates of burnout are also highest among nurses who provide direct patient care in hospitals and nursing homes [68,72]. Approximately one-third of nurses providing direct patient care in a hospital said they were burned out, and nearly 40% of nurses providing direct patient care in a nursing home reported being burned out [68].

As has been reported for physicians, many studies have indicated that the prevalence of burnout among nurses is higher in some specialties, such as oncology, mental health, emergency medicine, and critical care [79,80,81,82]. Factors contributing to stress and burnout may differ according to specialty. For example, substandard staffing was associated with burnout among oncology nurses whereas low manager support was a significant predictor of burnout among emergency room nurses [79,83].

Several studies, including a systematic review, have identified a variety of work-related stressors associated with one or more dimensions of burnout among nurses across settings [10,33,68,70,80,82,83,84,85,86,87,88,89]. The most common source of burnout is work overload, and others include:

- Inadequate nurse staffing

- Overtime work

- Fear of not completing tasks

- Job demands

- Job complexity

- Lack of professional recognition, respect, or reward

- Role conflict, insufficiency, and/or ambiguity

- Poor peer relationships

- Ineffective managers, supervisors, and/or leaders

- Inadequate communication with physicians

These sources of dissatisfaction can be correlated with four of the mismatches identified by Maslach, namely, work overload, lack of control, insufficient reward, and absence of community (Table 5) [18,70]. An additional factor that should be considered is the emotional demands of nursing.

Table 5: CORRELATION OF SOURCES OF DISSATISFACTION AND AREAS OF MISMATCH

Area of Mismatch

Dissatisfaction

Specific Factors

Work overload

Low nurse staffing

Overtime work

Job complexity

Fear of not completing tasks

Work hours/schedule

Imbalance in patient acuity

Lack of control

Role conflict, insufficiency, and/or ambiguity

Job functions defined by non-nurses

Lack of "voice" on policies affecting direct patient care

Insufficient reward

Lack of professional recognition or reward

Inadequate salary

Lack of opportunities for advancement

Absence of community

Poor relationships with other healthcare professionals

Nonsupportive relationships with peers

Inadequate communication with physicians

Low support from managers

Source: [18,70]

Many of these sources of dissatisfaction are directly related to nursing turnover, as they have been given as the reason for nurses leaving their job or position. In the 2008 survey, a stressful work environment was given as the reason by 22% of nurses who left their job [72]. Respondents were allowed to choose more than one reason, and approximately 27% specifically noted too many hours, and 21% noted inadequate staffing. A low salary was also one of the more common reasons for leaving (Table 6) [72].

Table 6: REASONS GIVEN FOR LEAVING A NURSING JOB OR POSITION IN THE 2008 NATIONAL SAMPLE SURVEY OF REGISTERED NURSES

Specific Work-Related Reason

Percentage

Too many hours

27%

Low salary

22%

Inadequate staffing

21%

Lack of good management/leadership

13%

Lack of collaboration/communication

10%

Lack of advancement opportunities

8%

Source: [72]

A 2017 survey of 600 RNs conducted by RNnetwork found similar results, with approximately 50% of the nurses having considered leaving nursing due to feeling overworked (27%), not enjoying their job anymore (16%) and spending too much time on paperwork (15%) [183]. The survey also found that more than 50% of the RNs surveyed did not feel respected by administration, citing that as a reason for considering leaving nursing. In addition, 43% of respondents indicated that their workplace did not support a healthy work/life balance [183].

Work Overload

The most common source of burnout, work overload, is created primarily by inadequate staffing, a prevalent problem in today's hospitals and nursing homes [69,71,79,84,90,183]. A 2011 study of 665 hospitals demonstrated that 20% had a patient-to-nurse ratio of seven or more, whereas 25% had a ratio of four or less [14]. Other studies have shown that the mean patient-to-nurse ratio in U.S. hospitals is approximately 5:1 [69,91]. Nurses have consistently reported that these ratios are inadequate for providing high-quality care. In a study of 534 hospitals (26,005 nurses), staffing was considered to be poor in 25% [69]. In a survey of nearly 11,000 registered nurses, only 46% said there was enough staff to accomplish the necessary work, and 48% said there were enough registered nurses on staff to provide high-quality care [67]. Other surveys have shown that less than half of nurses had the time needed to spend with patients [73]. Increased patient-to-nurse ratios are associated with lower rates of job satisfaction and higher rates of burnout [7,70]; inadequate staffing was the reason that 21% of nurses gave for changing their position or employer in 2007–2008, and adequate staffing is the second-leading consideration of nurses seeking a new position [72,92]. In a study of more than 10,000 nurses, the rate of burnout increased 23% for every additional patient per nurse [7].

Increased workload is related to other factors besides patient-to-nurse ratios, including a high number of work hours per week, extended shifts, overtime (often mandatory), many consecutive days of work, rotating shifts, weekend work, and on-call requirements. Among 3,413 nurses in a 2013 survey, more than 30% worked more than 40 hours per week, with 13% working 46 to 50 hours per week and 8% working more than 50 hours per week [73]. In another study, more than one-third of nurses said they had worked six or more days in a row at least once in the preceding six months [93]. In addition to long work weeks, nurses typically work long work days. Twelve-hour shifts offer many benefits to nurses and patient care and, as a result, the percentage of nurses who routinely work this shift has increased to approximately 65% [94]. However, moderate to high levels of acute fatigue and moderate levels of chronic fatigue have been found among nurses working 12-hour day shifts [95]. As well, several studies have indicated a strong relationship between long work hours or 12-hour shifts and adverse nurse outcomes, such as increased fatigue, job dissatisfaction, burnout, and intention to leave the job [94,96].

The increase in working hours for nurses has substantial professional consequences. The odds of job dissatisfaction and burnout were as much as 2.5 times higher for nurses who worked longer shifts compared with nurses who worked eight- to nine-hour shifts [94]. Most important, fatigue and long hours have been significantly associated with nursing errors [97]. Twelve-hour shifts have been linked to a greater risk of nursing errors, with some studies indicating nearly three times a higher risk of error [97,98,99,100]. Long shifts (10 hours or more) have also been associated with a greater odds of nurses reporting that the quality of care is fair or poor on their unit compared with shifts of eight to nine hours [101].

Shift length has also been associated with patients' perceptions of the quality of care. In a study of 577 hospitals in four states, patients' ratings for seven of the 10 outcomes on the Hospital Consumer Assessment of Healthcare Providers and Systems survey were significantly adversely affected by the proportion of nurses who worked shifts of 13 hours or more [94]. These lower ratings included the global assessments of overall rating for the hospital and whether the patient would recommend the hospital [94].

Also contributing to fatigue—and its consequences—are rotating shifts and mandatory overtime, which has often been used to solve staffing issues [97].

Increased levels of patient acuity also contribute to workload, and advances in treatment have led to nursing care that is often demanding and challenging. This high level of care, coupled with shorter stays as a result of changes in the healthcare system and the nursing shortage, result in nursing workloads that are not balanced across various levels of care within the patient population.

Lack of Control

A sense of control, or autonomy, is important to nurses, and job satisfaction is greater and job stress is lower when nurses feel as if they have some control over how they perform their job. Meta-analyses have demonstrated a strong correlation between job satisfaction and autonomy, empowerment, and control [70,102,103]. Other studies have found that autonomy, empowerment, and decision making opportunities are strongly related to job satisfaction and retention among nurses [104,105]. However, this sense of control appears to be lacking for many nurses. In surveys, 40% to 75% of nurses said they feel they lack the authority they want and that is necessary for safe, high-quality patient care [75,175]. Additionally, in a study of more than 1,200 nurses in nursing home settings, one of the most stressful factors noted by nurses was nonhealth professionals determining how nurses' work should be done [84].

The risk of burnout is increased among nurses who perceive a lack of control in their work environment [82,84]. A sense of control varies across nursing specialties, which in part explains the range of burnout rates among specialties. For example, in a study of nurse managers, emergency department nurses, and nurse practitioners, the least amount of control was reported by emergency department nurses, who also had the highest rate of burnout; in contrast, nurse practitioners reported having the most control and the lowest rate of burnout [82].

Insufficient Reward

Insufficient reward relates to several aspects, including lack of recognition of contributions, inadequate compensation (salary), and few opportunities for advancement. Being fairly rewarded and recognized for contributions is important to nurses; in one survey, autonomy, professional status, and pay were the most important determinants of career satisfaction for registered nurses [106]. Nurses who perceive respect and recognition are more likely to be satisfied with their job and to have a lower likelihood of burnout [107,108]. In a 2007 survey of nurses, a culture that supports the nursing profession was the factor most strongly associated with job satisfaction [92]. Lack of professional recognition and professional uncertainty have both been significantly associated with all three subscales on the MBI [70,85]. However, nurses' sense of feeling rewarded for their contributions has been reported to be low; in a study by Aiken et al., 39% of nurses said that their contributions were publicly acknowledged [71]. A later survey showed that 34% of nurses said they were not respected or appreciated for their efforts or expertise; 84% said they do not feel respected and appreciated in some capacity within their workplace [175].

Although wage has been associated with job dissatisfaction and intent to leave, it has had little effect on burnout, and nurses have fairly consistently ranked other work environment factors as being of more concern than money [69,102].

Absence of Community

The nurse's community consists of peers, nursing leaders, and physicians. Positive, supportive relationships with all these constituencies have been related to job satisfaction and a decreased likelihood of stress and burnout [33,109]. In contrast, lack of peer cohesion, inadequate administrative and supervisor support, and difficulties with nurse-physician interactions, have all been factors in high rates of burnout, especially on the emotional exhaustion and depersonalization subscales [32,110,111].

Nurse-Peer Relationships

In a 2005 survey of 76,000 registered nurses, the highest level of satisfaction was given to relationships with other nurses [112]. Still, the survey showed that one-third of nurses were dissatisfied with interactions with their peers [112]. A 2017 survey of 600 nurses found that 45% had been verbally harassed by other nurses [183]. Interpersonal conflict with other nurses is a stress factor in and of itself, but a lack of close working relationships deprives nurses of their colleagues as a source of support. This lack of support is important, as nurses have ranked their peers as providing the most support within the hospital community, and higher levels of support from co-workers have been related to lower levels of emotional exhaustion on the MBI [80,86]. Similarly, lack of peer cohesion has correlated with high levels of emotional exhaustion and depersonalization [87].

Although resolving conflicts can mitigate stress, the style of conflict resolution has also been a significant predictor of burnout. A study of three conflict resolution styles—avoidance, confrontational, and cooperative—showed that the avoidance and confrontational styles were associated with a higher rate of burnout, while the cooperative style was associated with a lower rate [113].

Nurse-Nurse Leader Relationships

Support from nursing leaders and administration is essential for nurses' job satisfaction. Studies have indicated, however, that most nurses do not have or perceive supportive leadership. Approximately 45% to 70% of nurses are dissatisfied with nursing management and administration because they do not listen to or address nurses' concerns or deal with nurses truthfully about decisions affecting their jobs [67,71,108,112]. One study found that 41% of nurses reported having been verbally harassed by managers or administrators [182,183]. One survey showed that 62% of nurses thought they had a nurse manager who is a good manager and leader or had a head nurse who backed nursing staff in decision-making [67]. Another survey found that 82% of respondents believed that more nurse leaders are needed in health care; however, 61% of also indicated that they were not interested in moving into a leadership position [182] Leadership style and lack of administrator and supervisor support has been related to both job satisfaction and burnout [88,110,111]. Among emergency department nurses, a low level of manager support was a significant predictor of burnout [83].

Nurse-Physician Relationships

Nurse-physician relationships and their effect on nurses have an extensive history. Daily interactions between nurses and physicians strongly influence nurses' morale, and difficulties in nurse-physician relationships are perceived by most nurses, physicians, and hospital executives as having negative or worsening effects on stress, frustration, concentration, communication, collaboration, and information transfer between nurses and physicians [114,115]. Nurses value collaborative relationships with physicians, and place more importance on the collaboration than do physicians [116]. The findings of surveys have varied with regard to nurses' perceptions of nurse-physician relationships at their facility. According to a 2007 survey, 42% of nurses had collegial relationships with physicians [92]. In a later statewide survey, 72% of nurses said collaboration existed between nurses and physicians and 80% said nurses and physicians had good working relationships [67]. A meta-analysis of 31 studies (14,567 nurses) demonstrated that job satisfaction correlated strongly with good nurse-physician collaboration [102]. Studies have indicated that positive nurse-physician relationships significantly correlate with lower emotional exhaustion and depersonalization and higher personal accomplishment [89]. Similarly, a low score on organizational climate (of which nurse-physician collaboration is a factor) has correlated with high rates of burnout [111].

Emotional Demands

The emotional demands of the nursing profession are well recognized, and human suffering has been noted to be a stressor for nurses [90]. In a 2002 American Nurses Association (ANA) survey, 44% of nurses said they left their job each day feeling discouraged and saddened by what they could not provide for their patients [75]. Despite this prevailing emotion, little is known about how emotional demands relate to burnout. A 2007 study represented a step forward in that area; the findings of that study indicated that how nurses handle their emotions influences the risk of burnout [75]. Levels of emotional exhaustion on the MBI were higher among nurses who masked their emotions or who pretended to feel "expected" emotions [75].

Emotional demands are greater in settings such as oncology, palliative care, and critical care, where grief and loss have been identified as a source for stress among nurses and other healthcare professionals [33]. The sense of loss extends beyond the loss of the relationship with the patient to identifying with the pain of the family, past unresolved loss and anticipated future loss, and loss of one's goals and expectations [117]. Nurses in these settings may experience stress when they cannot provide adequate care at the end of life or help a patient die a "good death" [33,118].

6. CONSEQUENCES OF STRESS AND BURNOUT

Nurses are susceptible to the same physical, psychologic, and interpersonal/social effects of stress and burnout as the general workforce. However, the stakes are higher for nurses, as the consequences of nurse burnout have serious implications not only for nurses but also for patients.

PERSONAL CONSEQUENCES

In a 2011 survey, 74% of 4,614 nurses said their top health concern was the acute or chronic effects of stress and overwork [119]. In 2013, about half of 3,413 nurse respondents to a survey said they worry that their job is affecting their health [73]. Evidence supports nurses' concern about their health. Studies have indicated that nurses' physical and mental health are negatively affected by many work-related stressors, including lack of social support from peers, work overload, high job demands, low job control, and nurse-physician conflict [70].

Data are limited on the health effects of burnout among nurses specifically, but some studies have evaluated the effect of its predecessor, job dissatisfaction. One meta-analysis showed higher rates of musculoskeletal disorders and musculoskeletal injuries reported by nurses who also reported dissatisfaction with staffing, scheduling, interpersonal relations, or decision making [87]. In addition, more needlestick injuries occurred among nurses dissatisfied with these same work-related factors [87]. A weak but significant association between burnout and depression among nurses has also been noted [70].

PROFESSIONAL CONSEQUENCES

A variety of professional consequences are related to prolonged stress and burnout, and poor work performance is the ultimate result. Emotional exhaustion leads to absenteeism and decreased productivity, both of which affect work overload for other nurses [176]. As a result, burned out individuals create distance between themselves and patients as well as colleagues (referred to as depersonalization). Maslach described the detrimental change in a burned-out individual's work performance [18]:

Motivation is down, frustration is up, and an unsympathetic, don't-give-a damn attitude predominates. They don't take care in making their judgments, and they don't care as much about the outcome. They 'go by the book' and are stale rather than innovative and fresh. They give the bare minimum rather than giving their all, and sometimes they give nothing at all.

Nursing Shortage

Perhaps the greatest professional consequence of nurse burnout is the nursing shortage. High turnover among nurses as a result of job dissatisfaction and burnout is a driving contributor to the nursing shortage [4,5,182,183]. Other factors are an aging nursing workforce and increased health demands in the general population [6,120]. The supply of nurses has been declining since the late 1990s, while the demand for nurses has been increasing. The downturn in the U.S. economy in the early 2000s eased the nursing shortage in the short term, but the shortage is still projected to grow to more than 260,000 by 2025 (Figure 2) [120]. A later forecast projects a total national deficit of 510,000 nurses by 2030 [178]. The problems of burnout and the nursing shortage escalate in a cyclical manner: job dissatisfaction leads to burnout, nursing turnover, and inadequate staffing, which further increases job dissatisfaction (Figure 3) [70].

Figure 2: OBSERVED AND PROJECTED AVERAGE AGE OF, SUPPLY OF, AND DEMAND FOR FULL-TIME EQUIVALENT (FTE) REGISTERED NURSES (RNs), 1973-2025

Source : [120]

Figure 3: THE NURSING SHORTAGE/BURNOUT CYCLE

The relationship between burnout and the nursing shortage is cyclical: job dissatisfaction leads to burnout, which in turn leads to nursing turnover and subsequent nursing shortage, and the inadequate staffing further increases job dissatisfaction.

Source: Compiled by Author

The nursing shortage has far-reaching effects on the quality of care and patient safety. A multitude of studies have demonstrated that factors caused by the shortage—primarily, inadequate staffing and hours worked—significantly affect nurses' perceived quality of care, patient satisfaction, the potential for nursing errors, adverse events for patients, and patient mortality.

Perceived Quality of Care and Patient Satisfaction

As already mentioned, high proportions of nurses have noted that there are not enough registered nurses on staff to provide high-quality patient care [67,73,75,178,183]. Nurses report the feeling that, in general, the quality of patient care is declining, and this feeling increases with age; 37% of nurses 19 to 39 years of age agreed that the quality of care is declining, compared with 56% of nurses 40 to 54 years of age and 66% for nurses 55 years and older [73].

Some studies have addressed nurses' perceptions about the quality of care in relation to burnout. In a study of nurses at 198 hospitals, all three subscales of the MBI were significant predictors of nurses' fair/poor quality ratings of care [13]. The findings of other studies have similarly shown a relationship between rates of burnout and nurses' ratings of fair or poor quality of care [90,110,121].

Higher levels of burnout and job dissatisfaction are also associated with lower patient satisfaction. In one study, rates of patient satisfaction were lower in hospitals with higher rates of nurses who were dissatisfied or burned out [68].

Nursing Errors

Several surveys have indicated that nursing errors are, in many cases, perceived by nurses to be a result of the nursing shortage [8,68,184]. For example, in one study, 78% of surveyed nurses said they had not given a prescribed medication or had given it at the wrong time, and 69% of these nurses believed the error was somewhat or strongly related to the nursing shortage. In addition to the harm to patients, medication and treatment errors caused moral distress for 73% and 61% of the nurses involved, respectively [8]. In the other study, 36% of hospital nurses and 47% of nursing home nurses said that their workload caused them to miss important changes in their patients' condition [68]. In another study, 46.8% of nurses had committed a medication error within the past year, with incorrect infusion rates (33.3%) and administering two doses of medicine instead of one (23.8%) being the most common errors. Almost two-thirds of these errors were not reported by the nurse. The foremost reason cited for these errors was a shortage of nurses (47.6%) [184]. As noted earlier, long work hours and nurse fatigue have also contributed substantially to nursing errors [97,98,99,100,184].

Adverse Events

The findings of studies have consistently demonstrated a relationship between inadequate staffing and higher rates of patient adverse events. A review of 28 studies on the relationship between nurse-to-patient ratios and outcomes demonstrated that an increase of one registered nurse per patient per day was associated with decreased odds of hospital-acquired pneumonia, unplanned extubation, respiratory failure, and cardiac arrest in intensive care units; of failure to rescue among postoperative patients; and of shorter stays in the intensive care unit and hospital [11]. A later literature review on adverse outcomes in adult intensive care units showed that decreased staffing was associated with adverse outcomes (infection, postoperative complications, unplanned extubation) [122].

The relationship between inadequate staffing and nosocomial infection has received widespread attention, primarily because of the high rate of infection despite its preventability. In a study in neonatal intensive care units, inadequate staffing was associated with an increased risk of nosocomial infection in very-low-birth-weight infants [123]. In a study of adults, the rates of urinary tract and surgical site infections increased when a nurse's workload was increased by one patient [12]. Furthermore, the authors found a specific and significant association between nurse burnout and the rates of these infections [12]. The authors theorized that the cognitive detachment associated with burnout led to lapses in proper infection control procedures and estimated that if burnout was reduced by 30%, the annual cost savings would be nearly $28 million to more than $69 million from preventing these infections.

Mortality

Mortality is also influenced by nurses' patient volume and thus is linked to burnout. Several studies have shown that lower nurse workloads are associated with lower hospital mortality [124,125,126]. In one study, the addition of one patient per nurse was associated with a 7% increase in the likelihood of the patient dying within 30 days after admission [7]. Analysis of pooled data has indicated that, if a causal relationship exists between patient-nurse ratios and patient outcomes, decreasing the ratio from more than six patients per nurse to one or two patients per nurse would save an estimated 25 lives per 1,000 hospitalized patients and 15 lives per 1,000 surgical patients [11].

In addition, mortality rates can be improved in intensive care units, as shown by a 2017 retrospective analysis of nearly 900 patients in two separate units. In this study, the researchers focused on workload rather than number of patients. Workload was calculated using the Therapeutic Intervention Scoring System (TISS-76), which assigns points based on therapeutic, diagnostic, and nursing activities. Workloads scored as less than 40 per nurse produced a 95% probability that survival to hospital discharge was more likely to occur. Conversely, scores of more than 52 per nurse produced a more than 95% chance that death was more likely to occur [185].

In summary, increasing the availability of nurses by reducing the frequency of burnout can have a substantial effect on patient safety and the quality of care.

7. STRATEGIES TO PREVENT AND COPE WITH STRESS AND BURNOUT

There are two primary approaches to preventing and/or coping with work-related stress and burnout. Given that the most significant factors in stress and burnout are related to the work environment, modifying the environment to eliminate the factors has the potential for the most success. However, it is often difficult to change organizational structure, which means individuals must make changes themselves.

The primary goal in any setting is to stop the burnout cycle early by preventing the accumulation of stress. When implemented appropriately, preventing burnout is easier and more cost-effective than resolving it once it has occurred; burnout that is addressed in later stages may take months or years to resolve fully [18,21]. Thus, stress management techniques and other interventions to ensure psychosocial well-being should be a priority for both individuals and institutions/organizations, with a goal of preventing stress and managing it during its early stages. Many of the strategies described in this course have been designed or suggested for the general population or for other subgroups within the healthcare setting.

Attention to personal and professional lifestyle habits is essential for individuals to prevent and manage stress effectively. Self-care, time management, and strong interpersonal relationships are key elements for maintaining physical and psychosocial well-being (Table 7). In addition, care must be taken to protect an individual's professional lifestyle. Institutions and organizations have an obligation to maintain a healthy work environment for nurses and other healthcare professionals, not only to minimize the risk of burnout but also to ensure patient safety and high-quality patient care.

Table 7: STRATEGIES FOR MANAGING STRESS AND AVOIDING BURNOUT

Strategy Classification

Specific Strategies

Personal lifestyle

Obtain adequate sleep

Ensure proper nutrition

Participate in regular physical activity

Identify and maintain priorities

Schedule adequate vacation time

Participate in outside interests

Meditate and/or practice yoga

Maintain sense of humor

Recognize limitations

Engage in self-reflection

Seek emotional support and practical assistance from family

Maintain network of friends

Engage in spirituality

Professional lifestyle

Set realistic goals

Vary work routine

Objectify negative interactions and situations

Take time away (short breaks)

Become an advocate

Seek support from colleagues

Grieve well

Enhance communication skills

Organizational level

Survey staff about organizational culture

Create a healthy work environment

Encourage and maintain strong leadership style

Engage in participatory decision making, especially with respect to direct patient care

Foster good interpersonal relationships among all healthcare professionals

Encourage and provide access to training targeted to psychosocial well-being

Source: Compiled by Author

STRATEGIES FOR INDIVIDUALS: PERSONAL LIFESTYLE

Take Care of Yourself First

The concept of self-care is one that is emphasized in every book or article on preventing job stress and burnout across occupations. Self-care warrants particular emphasis for nurses, as they have been trained to put the care of others ahead of themselves. It is important for nurses to recognize that self-care is not equivalent to selfishness; rather, self-care is essential for energizing, restoring, and maintaining the physical and emotional stamina to reduce fatigue and manage stress [18,24,127,128]. Research has shown that self-care strategies are associated with lower levels of burnout among nurses [39,129,177].

Self-care involves several universal lifestyle habits, such as proper diet, exercise, sleep, and regular health care [24,130,131]. Maintaining a healthy lifestyle through these habits is vital to avoiding the physical effects of stress [2]. The need for appropriate sleep hygiene is the most essential element for nurses, as in one survey, 64% of nurses said they rarely get seven to eight hours of sleep per night [175]. There is widespread documentation that this lack of sleep is associated with a high risk of fatigue, which is linked to job satisfaction and burnout [94,97,128,132]. In its white paper on nurse fatigue, the Emergency Nurses Association offers several recommendations for nutrition, exercise, and proper sleep [128]:

- Avoid unhealthy foods—decrease the amount of sugars and foods with empty calories

- Participate in regular exercise—find activities that fit into your daily routine

- Do not eat a heavy meal before going to bed

- Avoid caffeine for at least five hours before going to bed (consider all sources of caffeine, such chocolate, gum, sodas)

- Do not rely on medications to enhance alertness

- Eat nutritious foods during your work shift to avoid large fluctuations in blood glucose levels

Nurses should also seek outside activities that will help them disengage from their professional routine and provide enjoyment, such as yoga, music, art, reading, journaling, sports, hobbies, and volunteerism [24,133,134,135]. Spirituality may help some individuals derive a sense of purpose or meaning in life and enhance coping skills, especially for nurses who care for dying patients [33,134].

Cognitive behavior training, physical relaxation (e.g., massage), and mental relaxation (e.g., mediation) may have limited benefit, according to a meta-analysis of interventions to reduce work-related stress in healthcare workers. The study demonstrated low-quality evidence that cognitive behavior training, with or without relaxation, reduced stress compared with no intervention, but only after more than one month of follow-up [136]. Similarly, physical relaxation was most effective one to six months after the intervention [136]. Little evidence supported mental relaxation as a way to reduce work-related stress after up to six months [136].

Managing stress requires a high level of self-awareness, which can also help prevent burnout [1,39]. An individual should recognize the specific factors that cause stress and how he or she deals with it. Many informal self-assessment exercises are available to help individuals determine their own level of work-related stress. For example, a simple exercise in the book Controlling Stress and Tension asks individuals to describe how frequently (almost always, often, seldom, or almost never) they experience the following signs or symptoms associated with burnout [137]:

- Find yourself with insufficient time to do things you really enjoy?

- Wish you had more support/assistance?

- Lack sufficient time to complete your work most effectively?

- Have difficulty falling asleep because you have too much on your mind?

- Feel people simply expect too much of you?

- Feel overwhelmed?

- Find yourself becoming forgetful or indecisive because you have too much on your mind?

- Consider yourself in a high pressure situation?

- Feel you have too much responsibility for one person?

- Feel exhausted at the end of the day?

A score for the exercise is calculated by assigning 1 to 4 points for each answer (with 4 representing the "almost always" response); a total of 25 to 40 points indicates a high level of stress that could be psychologically or physically debilitating [137].

Staying in tune with the signs and symptoms of stress overload and burnout is a continuous process, and individuals should remain alert to their use of unhealthy and ineffective coping mechanisms, such as excessive use of caffeine, alcohol, or prescription medication; overeating or undereating; smoking; inactivity; or social withdrawal [24]. Such habits can be difficult to change, and individuals should focus on changing one behavior at a time and seek help from professional counseling if necessary [1].

Improve Your Work/Life Satisfaction

Work/life satisfaction is a challenge for workers in all occupations and may be particularly difficult for nurses because of their work schedules. In a survey of more than 3,000 nurses, 82% of respondents said that it was difficult to achieve an acceptable work/life balance [175]. One way to help create better work/life satisfaction is to quantify the amount of time currently spent in each primary aspect of life—work, home, leisure, and vacation—and then determine priorities and assign preferred amounts of time for each aspect [138]. Creating such a time budget can help to prevent work life from overshadowing all other aspects of life, which can be harmful to self-esteem, self-identity, and overall well-being [22].

In a year-long study of the work/personal priorities of executive men and women from 10 multinational companies, 62% of the subjects were found to be work-centric (more apt to put work above personal life) and 32% were found to be dual-centric (more apt to set work and personal life as equal priorities) [135]. Dual-centric subjects reported stress less often than work-centric subjects (26% vs. 42%) [135]. In addition, dual-centric individuals felt more successful at work and had achieved higher professional levels. The dual-centric subjects used several strategies to maintain their priorities [135]:

- Set strict boundaries between work and nonwork (did not bring work home)

- Remained emotionally present in each aspect of life

- Took time to "recover" after a particularly difficult time at work

- Engaged in personal activities that require focus (such as sports, hobbies, or community volunteering)

- Remained clear about priorities

Other ways to enhance work/life satisfaction is to maintain a balance of friends and colleagues, set boundaries with family and friends to avoid excess expectations, and remember that you cannot please everyone—know how much you can handle [130].

Enhance Interpersonal/Social Relationships

Remaining "connected" to people is important in managing stress and preventing burnout [24]. Nurses should strengthen relationships with family and friends and seek support from them as needed. Expanding the social network to involve community and volunteer activities can help increase self-esteem and provide focus and fulfillment outside of the profession [135].

Seek Professional Counseling

Persistent symptoms of unresolved stress or burnout, such as sadness, anger, worthlessness, hopelessness, anxiety, sleep disturbances, or exhaustion, should prompt an individual to seek counseling, especially if these feelings interfere with interpersonal relationships or affect job performance [1]. Substance misuse or addictive behaviors also indicate the need for professional counseling. Nurses should be alert to the signs of burnout in not only themselves but also in their colleagues and should talk openly with those who exhibit severe symptoms [139].

STRATEGIES FOR INDIVIDUALS: PROFESSIONAL LIFESTYLE

Seek Social Support

Social support has been found to have a beneficial effect on workers' psychologic well-being and professional productivity [109]. Colleagues are in a unique position to understand each other's professional needs and stressors, and a supportive work environment protects against burnout [138,140]. Social support from colleagues is especially important during times of change and uncertainty in the work environment and can provide comfort, insight, rewards, humor, help, and escape [18,32,140]. In particularly stressful settings, informal social support gatherings can help nurses and other healthcare professionals deal with emotionally demanding events (such as the loss of a patient) [129,141].

Work Smarter

Maslach defined working smarter as setting realistic goals, doing things differently (when possible), not taking things personally, and taking time away [18]. Setting realistic goals involves moving from abstract, idealistic goals to well-defined specific goals, which can help individuals gain a better sense of accomplishment. Varying work routines can help avoid feelings of being in a rut and provide a sense of better control. Taking things less personally involves objectifying negative interactions and situations to help decrease emotional involvement, thereby reducing stress.

Working smarter also means taking time away and organizing time more effectively. A typical response to work overload is to work longer or harder to help make the situation "get better" [18]. However, this approach will only exacerbate stress and burnout, not relieve it. The need to take some time away from work must be especially emphasized to nurses, most of whom do not routinely take breaks; in one survey, 37% of nurses said they "usually" took time for a meal and 24% said they "usually" took a break during their shift [92]. Other studies have shown that appropriate breaks are least likely among nurses working the longest hours, and that nurses are usually not completely free of patient care responsibilities during breaks for rest or meals [97]. Rest breaks are particularly important for nurses working the night shift, to relieve symptoms of fatigue, which can be detrimental to both nurses' well-being and patient safety [97]. Taking some time away from work—even if only a few minutes at a time—to stretch, take a walk, make a personal phone call, read, meditate, or just sit and relax can help nurses "recharge" and will improve performance and increase productivity more effectively than working continuously [1,24]. Facilities must help ensure that nurses take breaks and meals appropriately, as will be discussed later. Other time management techniques include scheduling a block of uninterrupted time (no phones, pagers, or e-mails) to complete paperwork more efficiently, creating "to do" lists to maintain control over tasks, and increasing organizational skills [1].

Continuing Education

Engaging in lifelong learning is another way to help combat burnout. Continuing education can help infuse energy into nurses and help them renew their passion for the profession [131]. The findings of a small study indicated that educational preparation was correlated with greater job satisfaction among nurses [142]. Becoming better educated can also help nurses advance in their career and become involved in decision making that affects nurses' job satisfaction. In addition, nurses' continuing education fulfills another purpose; in 2010, the Institute of Medicine recommended that nurses engage in lifelong learning as way to achieve the competencies needed to provide care for diverse populations of patients [143].

Become an Advocate

Advocating for changes in the work environment or in the healthcare profession overall can help nurses increase a sense of control [18]. Assessing the potential for burnout and taking steps toward prevention is a process that can begin with one person who assumes a leadership role in a group effort [18]. The individual leader engages a group of colleagues to work with organizational leaders to heighten awareness of common stress factors within the organization and to address issues that compromise patient safety and quality of care.

Becoming an advocate means becoming familiar with policies, laws, and regulations related to nursing practice. Yet, most nurses are not aware of their facility's policies regarding breaks or limits for work hours or overtime [92]. Nurses should gain a better understanding of these policies, as well as federal and state regulations and professional statements. For example, the ANA has developed a position statement on nurse fatigue and resources on staffing plans and mandatory overtime [127,144,145]. Nurse specialty organizations have also developed recommendations to address fatigue [128,146,147]. The Emergency Nurses Association lists several evidence-based recommendations concerning fatigue for staff nurses; among these recommendations are the following [128]:

- Speak up when fatigue is a concern, before patient safety is compromised

- Evaluate the decision to work if you have had enough rest

- Tell your nurse managers when you have worked extended shifts

- Limit the number of hours you agree to work overtime

- Identify and work the shift that fits your circadian rhythm the best

- Establish support networks

- Exchange solutions with colleagues on ways to cope with the problems of shift work

- Help co-workers by watching for signs of drowsiness

- Integrate innovative strategies that support adequate rest and time away from the workplace between worked shifts

In addition to helping manage fatigue, these recommendations can help nurses serve as a role model for others, as well as feel empowered and in control of their practice, two other factors that help to prevent burnout.

Grieve Well

Nurses learn to control their emotions to maintain a professional demeanor, but they are not immune to grief. A healthy response to the stresses associated with loss is important for avoiding burnout. As noted, burnout levels were higher among nurses who masked their emotions [75]. Instead of masking emotions, nurses must learn how to grieve well [141]. Grieving well involves accepting the reality of the loss, experiencing the pain of grief, adjusting to the absence, and moving on with life [141]. Nurses can draw strength from colleagues and others by communicating sadness, frustration, and grief and can find solace in discussing what they were able to achieve with their dying patients, such as the ability to help manage pain and other symptoms [129,148].

Enhance Communication Skills

Maintaining positive relationships with colleagues, physicians, and patients is often challenging and requires strong communication skills. Skilled communication is an essential standard in nursing and is an integral aspect of a healthy work environment [149]. Nurses can decrease their vulnerability to stress by taking advantage of programs that strengthen their communication skills and help them to become more adept at handling difficult situations.

Nurses should also learn how to better communicate with their patients across language and culture. They should ask their patients what language they prefer for their medical care information and should seek the use of professional interpreters as much as possible [150]. The use of professional interpreters has been associated with improvements in communication (errors and comprehension), clinical outcomes, and patient satisfaction with care [151,152]. In addition, a systematic review of the literature has shown that the use of professional interpreters provides better clinical care than the use of ad hoc interpreters (untrained staff members, family members, friends, strangers in the hospital), with the former improving the quality of care for patients with limited English language skills to a level equal to that for patients with no language barriers [152].

STRATEGIES FOR INSTITUTIONS/ORGANIZATIONS

Among the best ways for an institution to prevent burnout is to promote engagement by implementing strategies that enhance energy, involvement, and efficacy [21]. Promoting engagement involves increasing positive aspects as well as reducing negative ones. As a first step, Maslach suggests transforming the six mismatches to fit a sense of engagement [21]:

- Sustainable workload

- Feelings of choice and control

- Recognition and reward

- A sense of community

- Fairness, respect, and justice

- Meaningful and valued work

Another integral step in preventing burnout is to survey staff about important aspects of the organizational culture [21]. Maslach has developed a staff survey that incorporates the MBI with questions related to the six mismatches that lead to burnout (work overload, lack of control, insufficient reward, absence of community, lack of fairness, and conflict in values) and questions about management structures and processes (such as direct supervision and distant management), communication networks, health and safety concerns, and performance appraisal. Questions customized for a specific setting may also be helpful. After the survey data have been collected, the responses are analyzed to identify the issues that should be addressed [21].

Create a Healthy Work Environment

Organizations and institutions can help protect nurses from burnout by creating an organizational culture of trust, support, and open communication and fostering a healthy work environment [18,32]. Creating a healthy work environment has become a priority for enhancing nurse job satisfaction and retention and improving patient safety and satisfaction [110]. The American Association of Critical-Care Nurses (AACN) developed standards for a healthy work environment, noting that such an environment is necessary for clinical excellence and good patient outcomes. Six components were noted to be essential for establishing and sustaining a healthy work environment [153]:

- Appropriate staffing

- Meaningful recognition

- True collaboration

- Skilled communication

- Effective decision making

- Authentic leadership

The AACN has also developed an assessment tool that institutions can use to evaluate their environment against the AACN standards.

Evidence that a healthy work environment helps improve job satisfaction is emerging. Reports from hospitals that have implemented changes to create a healthy work environment have shown that the changes led to a more engaged nursing staff, greater job satisfaction, low turnover, and high retention. The changes have included the following [154,155,156,157]:

- Creating a culture of uninterrupted meal breaks

- Developing strategies to manage patient volumes

- Reorganizing schedules to reduce stress

- Creating a serenity area

- Enhancing nurse-physician relationships

- Addressing unprofessional behavior and bullying

- Establishing a hospital wellness program

- Offering regular fun activities

- Implementing training and education initiatives

- Developing reward and recognition programs

Improve Issues Related to Staffing and Work Hours

Nurses' work schedules and appropriate staffing should be the highest priority for reducing burnout. Defining "appropriate staffing" has been subject to debate, however. Some have argued for specific patient-nurse ratios, while others have advocated for hospitals to establish staffing committees, with nurses as members, charged with creating staffing plans that reflect the specific needs of the institution [144]. The ANA supports the committee approach [144]. The Registered Nurse Safe Staffing Act, which calls for the committee approach to safe staffing, has been introduced in Congress several times since 2010, but no action has been taken [158,186]. As of 2018, 14 states have passed laws or regulations addressing nurse staffing: California, Connecticut, Illinois, Massachusetts, Minnesota, Nevada, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Vermont, and Washington [144]. Of these, seven states have laws or regulations requiring staffing policies that are developed by committees. Hospital administrators and nursing leaders should be familiar with staffing ratios mandated in their state.

Institutions should also implement staffing policies that address nurse fatigue. In 2014, the ANA revised its position statement on nurse fatigue and noted the following evidence-based recommendations [127]:

- Employers should include nurse input when designing work schedules and implement a "regular and predictable schedule" that allows nurses to plan for work and personal obligations.

- Nurses should work no more than 40 hours in a seven-day period and limit work shifts to 12 hours in a 24-hour period, including on-call hours worked.

- Employers should stop using mandatory overtime as a "staffing solution."

- Employers should encourage "frequent, uninterrupted rest breaks during work shifts."

- Employers should adopt official policy that gives RNs the "right to accept or reject a work assignment" to prevent risks from fatigue. The policy should be clear that rejecting an assignment under these conditions is not patient abandonment and that RNs will not be retaliated against or face negative consequences for rejecting such an assignment.

- Employers should encourage nurses to be proactive about managing their health and rest, including getting seven to nine hours of sleep per day; managing stress effectively; developing healthy nutrition and exercise habits; and using naps according to employer policy.

These recommendations echo those developed by the Joint Commission and specialty nurse associations [128,132,146,147,159]. The ANA also opposes mandatory overtime [145]. Fourteen states have laws restricting mandatory overtime, and two have regulations [145].

Institutions should also consider implementing innovative measures to ensure that nurses take breaks and meal periods. Some interventions that have been successful are encouraging going outside for breaks, setting longer meal periods, adding shorter shifts to cover meal periods, a buddy system for breaks, tuning off cell phones and pagers during breaks, nurse managers' coverage of breaks, and monitoring and documentation of breaks to ensure they are taken [154,160].

Enhance Nurse Autonomy and Control

Administration and nursing managers can help increase job satisfaction and nurse retention by implementing strategies to enhance nurse autonomy and control. These strategies should be based on setting clear expectations and supporting measures to increase the knowledge and expertise of nurses [161]. Nurses should be involved in participative decision making, especially as it relates to their practice.

Enhance Effectiveness of Nursing Leadership

Given the link between ineffective management and leadership and job dissatisfaction and burnout, institutions should ensure that nursing leadership is strong and supportive [109,129,161]. Nurse managers should be accessible to staff, provide a supportive environment, and work to foster better relationships among nurse peers and between nurses and physicians. Nurse leaders should also empower nurses by providing them with information, resources, and opportunities. These factors have been shown to reduce work-related stress and burnout among nurses [109,129,183].

One challenge for nurse managers is that they themselves are often burned out or fatigued. Nurse managers should ensure that they practice self-care, set realistic goals, be clear about boundaries, and schedule time off [128,182].

Foster Interpersonal Relationships

The importance of positive interpersonal relationships with peers and physicians to both nurses' job satisfaction and patient outcomes requires a commitment from administrators and nursing leadership to foster better collaboration and communication within the working environment. Enhancing peer support systems and group cohesion has been identified as an important aspect of a healthy work environment [162]. And, as noted earlier, enhancing communication and collaboration between nurses and physicians is an essential element of a healthy work environment [153,156,157,183]. Thus, institutions should offer training programs that focus on effective communication between nurses and physicians and forums that allow healthcare professionals to interact outside of the patient's bedside [163,164]. Simulation training in decision making, interdisciplinary rounds, patient care seminars, continuing education lectures, and hospital committees can provide opportunities for nurses and physicians to collaborate on projects and gain a better understanding and respect for each other [164,165,166]. Developing mutual respect early in the career may be of value; medical students who were required (as part of their curriculum) to shadow a nurse for one day gained a better appreciation of the nurse's role [167].

Nurses should be encouraged to participate in workshops that address challenges such as overcoming cultural and language barriers, responding to emotions, and dealing with angry patients and their families. Training has been advocated primarily for nurses in oncology and has been shown to improve some areas of communication skills, to help alleviate stress, and to improve the coping skills of patients with cancer [168,169,170,171].

Enhance Psychosocial Well-Being

Another priority is to make available programs designed to help nurses manage the emotional demands of the job and enhance their psychosocial well-being. However, developing effective programs can be a challenge. A meta-analysis of staff-support interventions showed that stress management training offers some benefit in reducing work-related stress and increasing job satisfaction among health workers, but the benefit is not maintained over the long term [172]. High-intensity stress management training interventions did have a beneficial effect in terms of reducing burnout [172]. More research is needed to determine if longer term interventions or refresher sessions will help improve the effectiveness of these programs [172]. Nurses in all settings can benefit from programs designed to enhance coping techniques, to facilitate work-related grief and bereavement [90,173,174].

8. CASE STUDY: A TALE OF TWO NURSES

Ms. C and Ms. M had been best friends growing up, and they shared a lifelong dream of becoming nurses. Various family and other commitments separated them after college, and they began their nursing careers at different hospitals in different states. As new graduates on medical-surgical units, both were energetic and enthusiastic nurses, committed to excellence in caring for their patients.

Over the course of her first year, the hospital where Ms. C worked dealt with budget cuts and resources began to decline. Staffing on her unit decreased, and Ms. C's daily patient load went from four patients to seven patients. She struggled to keep up with the increasing workload and found herself unable to spend as much time as she wanted with her patients. The hospital instituted mandatory overtime to help overcome the staffing shortage, and Ms. C soon began working a few hours beyond her usual 12-hour shifts and often worked six or seven days in a row. She was tired all the time and frequently found it difficult to focus, especially near the end of her shift. Her personal life was affected; she called her family less often and never seemed to have time for her friends.

Ms. C has many of the personal risk factors for burnout: she is young, early in her career, single, and highly educated. Her unsupportive work environment, however, is the key, with work overload leading her to become frustrated and disappointed with her job. Ms. C is among the approximately 65% of nurses who work 12 hours or more per day. As a result, she is experiencing the first stage of burnout, characterized by mental and physical exhaustion. Unless she addresses her stress and job dissatisfaction, the subsequent stages of burnout will evolve.

Ms. C did make time for a phone call from her friend Ms. M and couldn't believe how happy Ms. M was in her job. Ms. M listened as Ms. C described all her dissatisfactions with her work. Ms. M sympathized with her situation and talked enthusiastically about her own recent transfer to the medical intensive care unit. She urged Ms. C to transfer to the intensive care unit at her hospital because of the professional challenges and lower patient load. "You'll really feel like you're making a difference," Ms. M told her. Encouraged, Ms. C submitted a request for a transfer to the medical intensive care unit.

Ms. C gained renewed interest and energy during her orientation and training in the intensive care unit. She enjoyed the technical challenges of the more complex patient care, and she again looked forward to work. However, after she was fully oriented to the unit, her patient load increased and she again found herself working long hours and overtime. She went home every day with a headache and backache, she never felt fully rested, and she experienced extreme mood swings. She again withdrew from family and friends and found herself frequently overeating. She also began to have a glass or two of wine every night as a way to cope with her stress. The "last straw" for Ms. C was a medication error she made. No substantial harm came to the patient, but the patient's physician yelled at Ms. C and several other nurses in the unit. As a result, Ms. C felt like a professional failure and questioned her decision to become a nurse. She distanced herself even further from her colleagues, her family, and her friends.

Changing the work setting is a frequent response to job dissatisfaction. However, different environments can have the same inherent stress factors, which means that the potential for burnout can continue. Within nursing environments, work overload brought on by inadequate staffing is the most common source of stress and burnout. High levels of fatigue brought on by work schedule factors have been associated with an increased risk of errors, and these errors frequently cause moral distress for nurses. In addition, difficulties in nurse-physician relationships also affect nurses' morale, and job satisfaction decreases when nurse-physician collaboration is poor. Ms. C is moving through the next stages of burnout, marked by indifference and feelings of failure as a professional.

Ms. M surprised Ms. C with a visit and was distressed about what had happened to Ms. C. Her friend had dark circles under her eyes, was overweight, and lacked her usual passion for life. Ms. M forced Ms. C to tell her about her situation at work. When Ms. M heard about Ms. C's work schedule and patient load, she became angry at the situation and told Ms. C that she needed to take better care of herself and become an advocate for change at her hospital. Ms. M explained that not all hospitals are the same, and she described her own positive work environment. In her unit, the nurses have a weekly get-together during which they talk about their most challenging patients and how they cope with loss. The Human Resources department sends out flyers about stress management programs, and the supervisors rearrange schedules to allow nurses to attend. Although there can be heavy workloads, the head nurse works with the staff as she develops the schedule so nurses have some say in the shifts and the number of days they work. The head nurse also anticipates needs and requests per diem nurses to help keep the patient load low.

Ms. C was surprised at the differences between her hospital and Ms. M's hospital. But she expressed doubt that she could change how her hospital functioned. Ms. M acknowledged that it is difficult to change organizations but she encouraged her to talk with other nurses about the situation and to band together to approach administration and request changes in scheduling and to emphasize the detrimental effect of heavy patient load on patient outcomes and quality of care. Ms. M noted that, equally as important as working for change in her hospital, Ms. C must make changes in her personal and professional lifestyles to help her better manage stress and avoid burning out completely. Ms. M told her about the importance of finding healthier ways to cope with stress, evaluating her work/life satisfaction, seeking support from friends and family, working "smarter," and engaging in nonwork activities. Ms. M also reminded Ms. C about how excited the two of them had always been about becoming nurses.

Because it is difficult to change organizational structure, individuals must make changes in themselves to avoid stress and burnout. Attention to personal and professional lifestyle habits are integral steps in preventing and managing stress effectively. Self-care, time management, and strong interpersonal relationships are key elements for maintaining physical and psychosocial well-being.

Maintaining a healthy lifestyle, with proper diet, exercise, and sleep, is vital to avoiding the physical effects of stress, as is seeking activities that help to disengage individuals from their professional routine and provide enjoyment. Self-reflection as a way to remind oneself why he or she entered the healthcare profession and remaining "connected" to people are also important in managing stress and preventing burnout. Adequate time away from work is essential for maintaining a positive work/life satisfaction and has been the most common suggestion about how to avoid stress and burnout.

Working smarter refers to taking frequent "mini-breaks" to escape work stresses, varying daily work routines, and setting realistic goals. Nurses can also increase their sense of control by advocating for changes in the work environment and for adherence to institution policies, state and federal laws and regulations, and nursing association statements and principles.

Over the next few months, Ms. C starts to pay better attention to her health by eating a balanced diet and finding time for regular exercise, including a twice-weekly yoga class. She starts an informal support group with her peers on her unit, and the number of participants increases as the sessions become more popular. She also visits with the Human Resources staff to ask about workshops in stress management techniques. In addition, Ms. C leads a small group of her peers in approaching their nursing supervisor to discuss their concerns about the quality of patient care and staffing. With time, Ms. C has a renewed sense of purpose at work and has become involved in a multidisciplinary committee that is addressing quality of care. She also has become more active in her personal life, spending more time with friends and family and volunteering as a coach for a youth soccer team. She has scheduled her first vacation in two years, planning a 10-day cruise with her best friend, Ms. M.

9. CONCLUSION

Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment. Levels of burnout are high among healthcare professionals, and the effects of burnout have serious consequences in the nursing profession. In addition to the detrimental physical, psychologic, and interpersonal/social effects, high levels of burnout among nurses have led to an ongoing nursing shortage that poses a threat to patient safety and quality of patient care.

At the root of burnout is job dissatisfaction. If left unaddressed, this dissatisfaction can lead to prolonged stress and subsequent burnout. Several sources of job dissatisfaction among nurses have been identified, including staffing inadequacy, work schedule, lack of involvement in decision making, lack of support from nursing leadership and administration, interpersonal conflict (interactions with physicians and peers), and inadequate pay. These sources of dissatisfaction can be correlated with four of the mismatches (work overload, lack of control, insufficient reward, and absence of community) identified by Maslach, the foremost authority on burnout. By far the most-often cited source of dissatisfaction is inadequate staffing, which creates a cycle of increased job dissatisfaction, burnout, and turnover. The rate of burnout has been found to increase 23% for every additional patient per nurse, and patient-nurse volumes have also been related to an increased frequency of adverse events, nursing errors, and higher patient mortality.

Because studies have shown that factors within the work environment are the greatest predictors of job dissatisfaction and stress, it is incumbent on nursing management and administration, as well as individual nurses themselves, to address issues of job dissatisfaction to prevent burnout early in the cycle. Nurses must maintain personal and professional lifestyle habits that will keep them healthy, engaged in pursuits other than their profession, and connected with family, friends, and colleagues. In addition, nurses should seek supportive relationships with colleagues and ensure a work/life balance that fits their overall priorities.

Institutions and organizations should focus on creating a healthy work environment in which nurses feel supported by their peers, their supervisors, and physicians. In addition, organizations should make available stress management workshops and other educational programs that target nurses' psychosocial well-being and interpersonal skills. Above all, organizations must ensure that safe nurse staffing patterns are in place.

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