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In The News Internal Medicine Pneumonia Outcomes in Hospitalized Patients, Based on Classification: CAP, HCAP, HAP
| Pneumonia Outcomes in Hospitalized Patients, Based on Classification: CAP, HCAP, HAP |
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| Posted by Dr. Johanne Perez M.D |
| Tuesday, 10 February 2009 21:01 |
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Healthcare-associated pneumonia is associated with higher mortality than is community-acquired pneumonia, especially when guideline-recommended antibiotic regimens are not initiated empirically.
Patients who were hospitalized with pneumonia during two 1-week surveillance periods in 1 of 55 Italian hospitals were enrolled prospectively. Cases were classified as CAP, HCAP, or HAP. Notably, these investigators used a more liberal definition of recent hospitalization (previous 180 days) than do the ATS/IDSA guidelines (90 days); they did so based on retrospective data that suggested patients remain colonized with resistant organisms as long as 1 year after hospitalization. Patients with HCAP were more ill (based on Pneumonia Severity Index and CURB-65 scores) and had higher inpatient mortality than did those with CAP (18% vs. 7%; P=0.02). Three factors were associated independently with excess inpatient mortality: depressed level of consciousness (odds ratio, 3.2), leukopenia (OR, 6.2), and receipt of an empirical antibiotic that is not guideline recommended (OR, 6.4). Clinicians were much less likely to adhere to guidelines for antibiotic prescribing in patients with HCAP than in patients with either CAP or HAP (27% vs. 59% and 69%; P<0.001). Comment: This is the first prospective multicenter study in which researchers compared epidemiology and outcomes of CAP, HCAP, and HAP in hospitalized medical-ward patients. Its results confirm what we have suspected, based on retrospective data — that patients with HCAP are sicker and more likely to die than are those with CAP. However, clinicians follow antibiotic-prescribing guidelines less often for HCAP than for other pneumonia cases, and this tendency could contribute to higher mortality among inpatients with HCAP. The time might be ripe for us as clinicians to stop making our antibiotic decisions for HCAP patients based on "gestalt" or "how the patient looks" and start applying guideline-recommended antibiotics for all patients who meet HCAP criteria. View Pneumonia Severity Index Algorithm NEJM Image — Daniel D. Dressler, MD, MSc |
| Last Updated on Friday, 13 February 2009 12:14 |
In 2005, the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) proposed a new category of pneumonia — healthcare-associated (HCAP) — for patients who have had recent contact with the healthcare system through nursing homes, hemodialysis clinics, or hospitalization prior to the active admission. Guideline recommendations and retrospective data suggest that patients with HCAP have worse outcomes than do patients with community-acquired pneumonia (CAP); however, prospective evaluation of these groups of patients has not been performed. Researchers sought to identify epidemiologic features and compare outcomes of patients who were hospitalized with CAP, HCAP, or hospital-acquired pneumonia (HAP). Patients with ventilator-associated pneumonia or HIV infections were excluded.
