ABSTRACT
Healthcare-associated pneumonia (HCAP) is a category of nosocomial pneumonia defined
by the 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA)
guidelines to include any patient who has been hospitalized in an acute care hospital
for 2 or more days within the past 90 days; residents of a nursing home or long-term
care facility; recipients of recent intravenous antibiotic therapy, chemotherapy,
or wound care within the past 30 days; or patients who have attended a hospital or
hemodialysis clinic. In creating this relatively new category the ATS/IDSA acknowledged
that these patients are at increased risk for infection with antibiotic-resistant
organisms and that initial inadequate antibiotic coverage leads to increased mortality.
Risk factors for the development of pneumonia and the development of pneumonia caused
by drug-resistant pathogens, primarily methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, are not the same among the subgroups of HCAP (i.e., dialysis patients have different
risks than nursing home patients). Furthermore there is significant heterogeneity
of risk factors for HCAP within the subgroups due to variations in contextual factors
such as local microbiology and methods of health care delivery and variations of individual
risk factors such as functional status or prior antibiotic exposure. This review examines
the evidence for the creation of the category of HCAP, including the risk factors
for drug-resistant pneumonia in each of the subgroups that constitute HCAP. This review
demonstrates that the guidelines have effectively targeted a population at greater
risk for pneumonia caused by drug-resistant pathogens. However, within the broad range
of HCAP infections, there is significant heterogeneity in terms of the magnitude of
the risk as well as the type of risk (i.e., risk for MRSA, multidrug-resistant gram-negative
bacilli (MDR-GNB), or both).
KEYWORDS
Healthcare-associated pneumonia - pneumonia - drug-resistant bacteria -
Staphylococcus aureus
- MRSA - pneumonia epidemiology
REFERENCES
- 1
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
- 2
Micek S T, Lloyd A E, Ritchie D J et al..
Pseudomonas aeruginosa bloodstream infection: importance of appropriate initial antimicrobial treatment.
Antimicrob Agents Chemother.
2005;
49
1306-1311
- 3
Ibrahim E H, Ward S, Sherman G et al..
A comparative analysis of patients with early-onset vs late-onset nosocomial pneumonia
in the ICU setting.
Chest.
2000;
117
1434-1442
- 4
Kollef M H.
Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized
patients.
Clin Infect Dis.
2000;
31(Suppl 4)
S131-S138
- 5
Luna C M, Vujacich P, Niederman M S et al..
Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.
Chest.
1997;
111
676-685
- 6
Alvarez-Lerma F.
Modification of empiric antibiotic treatment in patients with pneumonia acquired in
the intensive care unit. ICU-Acquired Pneumonia Study Group.
Intensive Care Med.
1996;
22
387-394
- 7
Rello J, Gallego M, Mariscal D et al..
The value of routine microbial investigation in ventilator-associated pneumonia.
Am J Respir Crit Care Med.
1997;
156
196-200
- 8
Kollef M H, Ward S.
The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic
management of ventilator-associated pneumonia.
Chest.
1998;
113
412-420
- 9
Ibrahim E H, Ward S, Sherman G et al..
Experience with a clinical guideline for the treatment of ventilator-associated pneumonia.
Crit Care Med.
2001;
29
1109-1115
- 10
Morin C A, Hadler J L.
Population-based incidence and characteristics of community-onset Staphylococcus aureus infections with bacteremia in 4 metropolitan Connecticut areas, 1998.
J Infect Dis.
2001;
184
1029-1034
- 11
Friedman N D, Kaye K S, Stout J E et al..
Health care–associated bloodstream infections in adults: a reason to change the accepted
definition of community-acquired infections.
Ann Intern Med.
2002;
137
791-797
- 12
Arancibia F, Bauer T T, Ewig S et al..
Community-acquired pneumonia due to gram-negative bacteria and Pseudomonas aeruginosa: incidence, risk, and prognosis.
Arch Intern Med.
2002;
162
1849-1858
- 13
Pop-Vicas A E, D'Agata E M.
The rising influx of multidrug-resistant gram-negative bacilli into a tertiary care
hospital.
Clin Infect Dis.
2005;
40
1792-1798
- 14
Carratala J, Mykietiuk A, Fernandez-Sabe N et al..
Healthcare-associated pneumonia requiring hospital admission: epidemiology, antibiotic
therapy, and clinical outcomes.
Arch Intern Med.
2007;
167
1393-1399
- 15
Micek S T, Kollef K E, Reichley R M, Roubinian N, Kollef M H.
Healthcare-associated pneumonia and community-acquired pneumonia: a single center
experience.
Antimicrob Agents Chemother.
2007;
51
3568-3573
- 16
Kollef M H, Shorr A, Tabak Y P et al..
Epidemiology and outcomes of health-care-associated pneumonia: results from a large
US database of culture-positive pneumonia.
Chest.
2005;
128
3854-3862
- 17
Marrie T J, Blanchard W.
A comparison of nursing home-acquired pneumonia patients with patients with community-acquired
pneumonia and nursing home patients without pneumonia.
J Am Geriatr Soc.
1997;
45
50-55
- 18
Janssens J P, Gauthey L, Herrmann F et al..
Community-acquired pneumonia in older patients.
J Am Geriatr Soc.
1996;
44
539-544
- 19
Muder R R.
Pneumonia in residents of long-term care facilities: epidemiology, etiology, management,
and prevention.
Am J Med.
1998;
105
319-330
- 20
Loeb M B, Craven S, McGeer A J et al..
Risk factors for resistance to antimicrobial agents among nursing home residents.
Am J Epidemiol.
2003;
157
40-47
- 21
El Solh A A, Sikka P, Ramadan F et al..
Etiology of severe pneumonia in the very elderly.
Am J Respir Crit Care Med.
2001;
163
645-651
- 22
El Solh A A, Aquilina A T, Dhillon R S et al..
Impact of invasive strategy on management of antimicrobial treatment failure in institutionalized
older people with severe pneumonia.
Am J Respir Crit Care Med.
2002;
166
1038-1043
- 23
Sund-Levander M, Ortqvist A, Grodzinsky E et al..
Morbidity, mortality and clinical presentation of nursing home-acquired pneumonia
in a Swedish population.
Scand J Infect Dis.
2003;
35
306-310
- 24
MacArthur R D, Lehman M H, Currie-McCumber C A et al..
The epidemiology of gentamicin-resistant Pseudomonas aeruginosa on an intermediate care unit.
Am J Epidemiol.
1988;
128
821-827
- 25
Wingard E, Shlaes J H, Mortimer E A et al..
Colonization and cross-colonization of nursing home patients with trimethoprim-resistant
gram-negative bacilli.
Clin Infect Dis.
1993;
16
75-81
- 26
Washio M, Nishisaka S, Kishikawa K et al..
Incidence of methicillin-resistant Staphylococcus aureus (MRSA) isolation in a skilled nursing home: a third report on the risk factors for
the occurrence of MRSA infection in the elderly.
J Epidemiol.
1996;
6
69-73
- 27
Muder R R, Brennen C, Drenning S D et al..
Multiply antibiotic-resistant gram-negative bacilli in a long-term-care facility:
a case-control study of patient risk factors and prior antibiotic use.
Infect Control Hosp Epidemiol.
1997;
18
809-813
- 28
Terpenning M S, Bradley S F, Wan J Y et al..
Colonization and infection with antibiotic-resistant bacteria in a long-term care
facility.
J Am Geriatr Soc.
1994;
42
1062-1069
- 29
Gaynes R P, Weinstein R A, Chamberlin W et al..
Antibiotic-resistant flora in nursing home patients admitted to the hospital.
Arch Intern Med.
1985;
145
1804-1807
- 30
Trick W E, Weinstein R A, DeMarais P L et al..
Colonization of skilled-care facility residents with antimicrobial-resistant pathogens.
J Am Geriatr Soc.
2001;
49
270-276
- 31
Ewig S, Torres A, El-Ebiary M et al..
Bacterial colonization patterns in mechanically ventilated patients with traumatic
and medical head injury: incidence, risk factors, and association with ventilator-associated
pneumonia.
Am J Respir Crit Care Med.
1999;
159
188-198
- 32
Lim W S, Macfarlane J T.
A prospective comparison of nursing home acquired pneumonia with community acquired
pneumonia.
Eur Respir J.
2001;
18
362-368
- 33
El Solh A A, Pietrantoni C, Bhat A et al..
Indicators of potentially drug-resistant bacteria in severe nursing home-acquired
pneumonia.
Clin Infect Dis.
2004;
39
474-480
- 34
Yakovlev S V, Stratchounski L S, Woods G L et al..
Ertapenem versus cefepime for initial empirical treatment of pneumonia acquired in
skilled-care facilities or in hospitals outside the intensive care unit.
Eur J Clin Microbiol Infect Dis.
2006;
25
633-641
- 35
Maruyama T, Niederman M S, Kobayashi T et al..
A prospective comparison of nursing home-acquired pneumonia with hospital-acquired
pneumonia in non-intubated elderly.
Respir Med.
2008;
102
1287-1295
- 36
Slinin Y, Foley R N, Collins A J.
Clinical epidemiology of pneumonia in hemodialysis patients: the USRDS waves 1, 3,
and 4 study.
Kidney Int.
2006;
70
1135-1141
- 37
Sarnak M J, Jaber B L.
Pulmonary infectious mortality among patients with end-stage renal disease.
Chest.
2001;
120
1883-1887
- 38
Vanholder R, Ringoir S.
Infectious morbidity and defects of phagocytic function in end-stage renal disease:
a review.
J Am Soc Nephrol.
1993;
3
1541-1554
- 39
Cendoroglo M, Jaber B L, Balakrishnan V S et al..
Neutrophil apoptosis and dysfunction in uremia.
J Am Soc Nephrol.
1999;
10
93-100
- 40
von Baum H, Ober J F, Wendt C et al..
Antibiotic-resistant bloodstream infections in hospitalized patients: specific risk
factors in a high-risk population?.
Infection.
2005;
33
320-326
- 41
Glasmacher A, von Lilienfeld-Toal M, Schulte S et al..
An evidence-based evaluation of important aspects of empirical antibiotic therapy
in febrile neutropenic patients.
Clin Microbiol Infect.
2005;
11(Suppl 5)
17-23
- 42
Maschmeyer G, Braveny I.
Review of the incidence and prognosis of Pseudomonas aeruginosa infections in cancer patients in the 1990s.
Eur J Clin Microbiol Infect Dis.
2000;
19
915-925
- 43
Freifeld A, Marchigiani D, Walsh T et al..
A double-blind comparison of empirical oral and intravenous antibiotic therapy for
low-risk febrile patients with neutropenia during cancer chemotherapy.
N Engl J Med.
1999;
341
305-311
- 44
Neuburger S, Maschmeyer G.
Update on management of infections in cancer and stem cell transplant patients.
Ann Hematol.
2006;
85
345-356
- 45
Hachem R, Raad I.
Prevention and management of long-term catheter related infections in cancer patients.
Cancer Invest.
2002;
20
1105-1113
- 46
Patel P J, Leeper Jr K V, McGowan Jr J E.
Epidemiology and microbiology of hospital-acquired pneumonia.
Semin Respir Crit Care Med.
2002;
23
415-425
- 47
Sopena N, Sabria M.
Multicenter study of hospital-acquired pneumonia in non-ICU patients.
Chest.
2005;
127
213-219
- 48
Craven D E.
What is healthcare-associated pneumonia, and how should it be treated?.
Curr Opin Infect Dis.
2006;
19
153-160
- 49
Cook D J, Walter S D, Cook R J et al..
Incidence of and risk factors for ventilator-associated pneumonia in critically ill
patients.
Ann Intern Med.
1998;
129
433-440
- 50
Laheij R J, Sturkenboom M C, Hassing R J et al..
Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs.
JAMA.
2004;
292
1955-1960
David S PochM.D.
Department of Pulmonary and Critical Care Medicine, NYU Medical Center
SKI 9 N, 550 1st Ave., New York, NY 10016
Email: pochd01@med.nyu.edu