In primary care we see a high volume of upper and lower respiratory infections. Too often we prescribe antibiotics unnecessarily. However, sometimes these patients actually have community acquired, hospital or healthcare associated pneumonia. Some of these patients have pneumosepsis.
So where should we turn to find the current treatment guidelines. For years, the American Thoracic Society (ATS) and the Infectious Disease Society of America (IDSA) have issued joint guidelines for the treatment of pneumonia. Additionally, the IDSA has published treatment guidelines for pediatric pneumonia.
When I ask our resident and fellows to find me the current recommendations some turn to UpToDate, others to Dynamed Plus or Essential Evidence Plus, some simply try to Google the guidelines or open an antibiotic app such as the John Hopkins Abx Guide or the Sanford Guide. All of these are reasonable and contain similar information, but wouldn’t it be nice to have all of that information in one spot—adult and pediatric guidelines together?
Thankfully, there is a wonderful medical app designed to assist providers in making these complicated decisions. For years, I have used Dr Joshua Steinberg’s medical applications. He has designed a variety of useful point of care apps including PreopEval14, PFT Eval, EFM Guide and PE & DVT Dx Tool. His most recent app was a redo of the venerable OB Wheel. Of all his apps, I probably use his Pneumonia Guide the most often.
The content of the Pneumonia Guide app is based on a number of published guidelines. Primarily the 2007 IDSA/ATS pneumonia guideline and the 2011 IDSA pneumonia guidelines. Additional studies are referenced regarding prognosis calculators, treatment of resistant organisms such as MRSA, and more. All of this information has been distilled to a very user friendly point of care app.
Let’s walk through the app via a clinical case. A 65 year-old male with a past medical history of Type II diabetes, hypertension, hyperlipidemia presented to the ER with a 3 day history of productive cough, shortness of breath, chills, and fever of 102.5 fahrenheit. Chest radiography revealed a left upper lobe infiltrate. The ER consulted us for admission. I asked the team whether or not this patient needed to be admitted, where in the hospital he should go, and what antibiotics to use. I challenged them to use this app and find me the answers in 30 seconds or less.
When you first open the app, it immediately pops up an instruction window describing how the app will work and what primary references it uses. Once dismissed, the app asks you what kind of pneumonia you are treating and lists the most common adult pneumonias as well as including pediatric pneumonias. Pediatric pneumonia was previously not included in the app. The first screen also includes the currently accepted definitions for these different types of pneumonia. The interface isn’t glamorous, but it is intuitive and gets things done.
It appears that our patient has adult community acquired pneumonia. Clicking on that option, the app opens to another series of topics ranging from treatment setting to diagnostic testing to antibiotics and conclusion of care. This allows more advanced providers to quickly get the information they want. More junior providers can start at the top with treatment setting and work down from there. Clicking on treatment setting, we have the choice of inpatient or outpatient.
The app uses CRB-65 as the decision support tool and includes a good amount of evidence why that particular tool was utilized. It can be calculated by hand easily, which is a good thing since the app doesn’t include any built in calculators. If you must use a calculator or prefer the Pneumonia Severity Index, then check out QxCalculate. Working through the app’s treatment setting calculator, we next determine where in the hospital the patient requires inpatient therapy — ICU versus hospital floor. Using the data from the guidelines, the app helps us determine our patient can be treated on the floor.