Tuberc Respir Dis.  2014 Feb;76(2):66-74. 10.4046/trd.2014.76.2.66.

Healthcare-Associated Pneumonia among Hospitalized Patients: Is It Different from Community Acquired Pneumonia?

• Seong GM
• Kim M
• Lee J
• Lee JH
• Jeong SY
• Choi Y
• Kim WJ

• KMID: 1877343
• DOI: http://doi.org/10.4046/trd.2014.76.2.66

Abstract

BACKGROUND
The increasing number of outpatients with multidrug-resistant (MDR) pathogens has led to a new category of pneumonia, termed healthcare-associated pneumonia (HCAP). We determined the differences in etiology and outcomes between patients with HCAP and those with community-acquired pneumonia (CAP) to clarify the risk factors for HCAP mortality.
METHODS
A retrospective study comparing patients with HCAP and CAP at Jeju National University Hospital. The primary outcome was 30-day mortality.
RESULTS
A total of 483 patients (208 patients HCAP, 275 patients with CAP) were evaluated. Patients with HCAP were older than those with CAP (median, 74 years; interquartile range [IQR], 65-81 vs. median, 69 years; IQR, 52-78; p<0.0001). Streptococcus pneumoniae was the major pathogen in both groups, and MDR pathogens were isolated more frequently from patients with HCAP than with CAP (18.8% vs. 4.9%, p<0.0001). Initial pneumonia severity was greater in patients with HCAP than with CAP. The total 30-day mortality rate was 9.9% and was higher in patients with HCAP based on univariate analysis (16.3% vs. 5.1%; odds ratio (OR), 3.64; 95% confidence interval (CI), 1.90-6.99; p<0.0001). After adjusting for age, sex, comorbidities, and initial severity, the association between HCAP and 30-day mortality became non-significant (OR, 1.98; 95% CI, 0.94-4.18; p=0.167).
CONCLUSION
HCAP was a common cause of hospital admissions and was associated with a high mortality rate. This increased mortality was related primarily to age and initial clinical vital signs, rather than combination antibiotic therapy or type of pneumonia.

Keyword

Pneumonia; Anti-Bacterial Agents; Drug Resistance; Mortality

MeSH Terms

Anti-Bacterial Agents
Comorbidity
Drug Resistance
Humans
Mortality
Odds Ratio
Outpatients
Pneumonia*
Retrospective Studies
Risk Factors
Streptococcus pneumoniae
Vital Signs
Anti-Bacterial Agents

Figure

• 

  Figure 1 Flow diagram of the study population. *Including overlapping cases. HAP: hospital-acquired pneumonia; HIV: human immunodeficiency virus.

Reference

1. Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest. 2005; 128:3854–3862.

2. American Thoracic Society. Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005; 171:388–416.

3. Manell LA, Wunderink R. Chapter 257. Pneumonia. In : Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, editors. Harrison's principles of internal medicine. 18th ed. New York: McGraw-Hill Co. Inc.;2012. p. 2130–2141.

4. Carratala J, Fernandez-Sabe N, Ortega L, Castellsague X, Roson B, Dorca J, et al. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients. Ann Intern Med. 2005; 142:165–172.

5. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007; 44:Suppl 2. S27–S72.

6. Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003; 58:377–382.

7. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997; 336:243–250.

8. Mylotte JM. Nursing home-acquired pneumonia. Clin Infect Dis. 2002; 35:1205–1211.

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

10. Lim WS, Macfarlane JT. A prospective comparison of nursing home acquired pneumonia with community acquired pneumonia. Eur Respir J. 2001; 18:362–368.

11. Micek ST, Kollef KE, Reichley RM, Roubinian N, Kollef MH. Health care-associated pneumonia and community-acquired pneumonia: a single-center experience. Antimicrob Agents Chemother. 2007; 51:3568–3573.

12. Schreiber MP, Chan CM, Shorr AF. Resistant pathogens in nonnosocomial pneumonia and respiratory failure: is it time to refine the definition of health-care-associated pneumonia? Chest. 2010; 137:1283–1288.

13. Zilberberg MD, Shorr AF, Micek ST, Mody SH, Kollef MH. Antimicrobial therapy escalation and hospital mortality among patients with health-care-associated pneumonia: a single-center experience. Chest. 2008; 134:963–968.

14. Fujitani S, Sun HY, Yu VL, Weingarten JA. Pneumonia due to Pseudomonas aeruginosa: part I: epidemiology, clinical diagnosis, and source. Chest. 2011; 139:909–919.

15. Carratala J, Mykietiuk A, Fernandez-Sabe N, Suarez C, Dorca J, Verdaguer R, et al. Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med. 2007; 167:1393–1399.

16. Lim WS, Baudouin SV, George RC, Hill AT, Jamieson C, Le Jeune I, et al. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009; 64 Suppl 3. iii1–iii55.

17. Woodhead M, Blasi F, Ewig S, Huchon G, Ieven M, Ortqvist A, et al. Guidelines for the management of adult lower respiratory tract infections. Eur Respir J. 2005; 26:1138–1180.

18. Chalmers JD, Taylor JK, Singanayagam A, Fleming GB, Akram AR, Mandal P, et al. Epidemiology, antibiotic therapy, and clinical outcomes in health care-associated pneumonia: a UK cohort study. Clin Infect Dis. 2011; 53:107–113.

19. Kollef MH, Morrow LE, Baughman RP, Craven DE, McGowan JE Jr, Micek ST, et al. Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes: proceedings of the HCAP Summit. Clin Infect Dis. 2008; 46:Suppl 4. S296–S334.

20. Lambert ML, Suetens C, Savey A, Palomar M, Hiesmayr M, Morales I, et al. Clinical outcomes of health-care-associated infections and antimicrobial resistance in patients admitted to European intensive-care units: a cohort study. Lancet Infect Dis. 2011; 11:30–38.

21. Venditti M, Falcone M, Corrao S, Licata G, Serra P. Study Group of the Italian Society of Internal Medicine. Outcomes of patients hospitalized with community-acquired, health care-associated, and hospital-acquired pneumonia. Ann Intern Med. 2009; 150:19–26.

22. Shindo Y, Sato S, Maruyama E, Ohashi T, Ogawa M, Hashimoto N, et al. Health-care-associated pneumonia among hospitalized patients in a Japanese community hospital. Chest. 2009; 135:633–640.

23. Kollef MH. Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients. Clin Infect Dis. 2000; 31:Suppl 4. S131–S138.

24. Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999; 115:462–474.

25. Garnacho-Montero J, Garcia-Garmendia JL, Barrero-Almodovar A, Jimenez-Jimenez FJ, Perez-Paredes C, Ortiz-Leyba C. Impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis. Crit Care Med. 2003; 31:2742–2751.

26. Rello J, Lujan M, Gallego M, Valles J, Belmonte Y, Fontanals D, et al. Why mortality is increased in health-care-associated pneumonia: lessons from pneumococcal bacteremic pneumonia. Chest. 2010; 137:1138–1144.

27. Kett DH, Cano E, Quartin AA, Mangino JE, Zervos MJ, Peyrani P, et al. Implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an observational, multicentre cohort study. Lancet Infect Dis. 2011; 11:181–189.

28. Grenier C, Pepin J, Nault V, Howson J, Fournier X, Poirier MS, et al. Impact of guideline-consistent therapy on outcome of patients with healthcare-associated and community-acquired pneumonia. J Antimicrob Chemother. 2011; 66:1617–1624.

29. El Solh AA, Pietrantoni C, Bhat A, Bhora M, Berbary E. Indicators of potentially drug-resistant bacteria in severe nursing home-acquired pneumonia. Clin Infect Dis. 2004; 39:474–480.

30. Micek ST, Reichley RM, Kollef MH. Health care-associated pneumonia (HCAP): empiric antibiotics targeting methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa predict optimal outcome. Medicine (Baltimore). 2011; 90:390–395.

31. Jensen PA, Lambert LA, Iademarco MF, Ridzon R. CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005; 54:1–141.

32. Feng JY, Fang WF, Wu CL, Yu CJ, Lin MC, Ku SC, et al. Concomitant pulmonary tuberculosis in hospitalized healthcare-associated pneumonia in a tuberculosis endemic area: a multi-center retrospective study. PLoS One. 2012; 7:e36832.

33. Park HK, Song JU, Um SW, Koh WJ, Suh GY, Chung MP, et al. Clinical characteristics of health care-associated pneumonia in a Korean teaching hospital. Respir Med. 2010; 104:1729–1735.

34. Jung JY, Park MS, Kim YS, Park BH, Kim SK, Chang J, et al. Healthcare-associated pneumonia among hospitalized patients in a Korean tertiary hospital. BMC Infect Dis. 2011; 11:61.