Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia
Publication: Annals of Internal Medicine
Volume 150, Number 1
Submit a Comment
Contributors must reveal any conflict of interest. Comments are moderated. Please see our information for authorsregarding comments on an Annals publication.
Abstract
Background:
Traditionally, pneumonia has been classified as either community- or hospital-acquired. Although only limited data are available, health care–associated pneumonia has been recently proposed as a new category of respiratory infection. “Health care–associated pneumonia” refers to pneumonia in patients who have recently been hospitalized, had hemodialysis, or received intravenous chemotherapy or reside in a nursing home or long-term care facility.
Objective:
To ascertain the epidemiology and outcome of community-acquired, health care–associated, and hospital-acquired pneumonia in adults hospitalized in internal medicine wards.
Design:
Multicenter, prospective observational study.
Setting:
55 hospitals in Italy comprising 1941 beds.
Patients:
362 patients hospitalized with pneumonia during two 1-week surveillance periods.
Measurements:
Cases of radiologically and clinically assessed pneumonia were classified as community-acquired, health care–associated, or hospital-acquired and rates were compared.
Results:
Of the 362 patients, 61.6% had community-acquired pneumonia, 24.9% had health care–associated pneumonia, and 13.5% had hospital-acquired pneumonia. Patients with health care–associated pneumonia had higher mean Sequential Organ Failure Assessment scores than did those with community-acquired pneumonia (3.0 vs. 2.0), were more frequently malnourished (11.1% vs. 4.5%, and had more frequent bilateral (34.4% vs. 19.7%) and multilobar (27.8% vs. 21.5%) involvement on a chest radiograph. Patients with health care–associated pneumonia also had higher fatality rates (17.8% [CI, 10.6% to 24.9%] vs. 6.7% [CI, 2.9% to 10.5%]) and longer mean hospital stay (18.7 days [CI, 15.9 to 21.5 days] vs. 14.7 days [CI, 13.4 to 15.9 days]). Logistic regression analysis revealed that depression of consciousness (odds ratio [OR], 3.2 [CI, 1.06 to 9.8]), leukopenia (OR, 6.2 [CI, 1.01 to 37.6]), and receipt of empirical antibiotic therapy not recommended by international guidelines (OR, 6.4 [CI, 2.3 to 17.6]) were independently associated with increased intrahospital mortality.
Limitations:
The number of patients with health care–associated pneumonia was relatively small. Microbiological investigations were not always homogeneous. The study included only patients with pneumonia that required hospitalization; results may not apply to patients treated as outpatients.
Conclusion:
Health care–associated pneumonia should be considered a distinct subset of pneumonia associated with more severe disease, longer hospital stay, and higher mortality rates. Physicians should differentiate between patients with health care–associated pneumonia and those with community-acquired pneumonia and provide more appropriate initial antibiotic therapy.
Funding:
None.
Get full access to this article
View all available purchase options and get full access to this article.
References
1.
Marrie TJ, Wu L. Factors influencing in-hospital mortality in community-acquired pneumonia: a prospective study of patients not initially admitted to the ICU. Chest. 2005;127:1260-70. [PMID: 15821203]
2.
Friedman ND, Kaye KS, Stout JE, McGarry SA, Trivette SL, Briggs JP, et al. Health care–associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections. Ann Intern Med. 2002;137:791-7. [PMID: 12435215]
3.
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. [PMID: 15699079]
4.
Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; for the Healthcare Infection Control Practices Advisory Committee. CDC. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53:1-36. [PMID: 15048056]
5.
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;128:3854-62. [PMID: 16354854]
6.
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;51:3568-73. [PMID: 17682100]
7.
Carratalà J, Mykietiuk A, Fernández-Sabé N, Suárez C, Dorca J, Verdaguer R, et al. Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med. 2007;167:1393-9. [PMID: 17620533]
8.
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;336:243-50. [PMID: 8995086]
9.
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;58:377-82. [PMID: 12728155]
10.
Physical Status: The Use and Interpretation of Anthropometry. World Health Organization Technical Report Series 854. Geneva: World Health Organization; 1995. Accessed at whqlibdoc.who.int/trs/WHO_TRS_854.pdf on 24 October 2008.
11.
Mykietiuk A, Carratalà J, Domínguez A, Manzur A, Fernández-Sabé N, Dorca J, et al. Effect of prior pneumococcal vaccination on clinical outcome of hospitalized adults with community-acquired pneumococcal pneumonia. Eur J Clin Microbiol Infect Dis. 2006;25:457-62. [PMID: 16773389]
12.
Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al; Infectious Diseases Society of America. 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 S27-72. [PMID: 17278083]
13.
Arancibia F, Bauer TT, Ewig S, Mensa J, Gonzalez J, Niederman MS, et al. Community-acquired pneumonia due to gram-negative bacteria and Pseudomonas aeruginosa: incidence, risk, and prognosis. Arch Intern Med. 2002;162:1849-58. [PMID: 12196083]
14.
Hosmer DW, Lemeshow S. Applied Logistic Regression. New York: J Wiley; 2002.
15.
Morin CA, Hadler JL. Population-based incidence and characteristics of community-onset Staphylococcus aureus infections with bacteremia in 4 metropolitan Connecticut areas, 1998. J Infect Dis. 2001;184:1029-34. [PMID: 11574918]
16.
Scanvic A, Denic L, Gaillon S, Giry P, Andremont A, Lucet JC. Duration of colonization by methicillin-resistant Staphylococcus aureus after hospital discharge and risk factors for prolonged carriage. Clin Infect Dis. 2001;32:1393-8. [PMID: 11317238]
17.
Abrahamian FM, Deblieux PM, Emerman CL, Kollef MH, Kupersmith E, Leeper KV Jr, et al. Health care-associated pneumonia: identification and initial management in the ED. Am J Emerg Med. 2008;26:1-11. [PMID: 18603170]
18.
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:S296-334; quiz 335-8. [ 18429676]
Comments
Sign In to Submit A CommentInformation & Authors
Information
Published In
Annals of Internal Medicine
Volume 150 • Number 1 • 6 January 2009
Pages: 19 - 26
History
Published online: 6 January 2009
Published in issue: 6 January 2009
Keywords
Copyright
© 2009 American College of Physicians.
Authors
Metrics & Citations
Metrics
Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. For an editable text file, please select Medlars format which will download as a .txt file. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
Download article citation data for:
Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia. Ann Intern Med.2009;150:19-26. [Epub 6 January 2009]. doi:10.7326/0003-4819-150-1-200901060-00005
Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia. Ann Intern Med.2009;150:19-26. [Epub 6 January 2009]. doi:10.7326/0003-4819-150-1-200901060-00005
View More
Login Options:
Purchase
You will be redirected to acponline.org to sign-in to Annals to complete your purchase.
Access to EPUBs and PDFs for FREE Annals content requires users to be registered and logged in. A subscription is not required. You can create a free account below or from the following link. You will be redirected to acponline.org to create an account that will provide access to Annals. If you are accessing the Free Annals content via your institution's access, registration is not required.
Create your Free Account
You will be redirected to acponline.org to create an account that will provide access to Annals.
Health care associated pneumonia and outcomes
We have read with interest the paper of Venditti et al (1) in the Journal. The authors show similar results than previously reported in terms of severity of disease and mortality in the health care related (HCR) group. (2,3,4) We miss the data on the etiology of pneumonia. The association between multiresistant pathogens and HCR- infections has been well established previously (2,3). The high mortality rate that the authors found in HCR pneumonia (HCRP) could be due in part to the greater risk of inappropriate therapy in this group. It is therefore surprising that mortality was not associated with HCR or hospital acquired (HA) categories in multivariate analysis.
Recently, we examined the clinical characteristics and outcomes of a homogenous group of patients with bacteremic pneumococcal pneumonia (BPP) and their relation with the health care system (HCRS) (unpublished data). From Jan 2004 to June 2007, all consecutive adult patients with BPP seen in our hospital were prospectively enrolled. Data obtained included demographics, co morbidities, Pitt score, presence of shock, relation with the HCS and in-hospital mortality. 140 episodes of BPP were identified. Community acquired pneumonia (CAP) was diagnosed in 106 (75%) patients, HCRP in 25 (18%) and HA pneumonia (HAP) in 9 patients (6.4%); mean age was 66.8 (SD 18), 57 (SD 20) and 75 years (SD 12), respectively (p<0.001). Patients with HCRP and HAP presented more commonly with coma and had an increased LOS. Fatality rates in HCRP were similar to HAP (32% vs. 33.3%)and higher than CAP mortality (9.3%, p=0.005). Patients with pneumococcal HCRP presented the highest early mortality (within 72 h of admission) (87.5% vs. 50% in CAP, p<0.001). Few patients received inappropriate therapy and, interestingly enough, it was equally represented among groups.
Multiresistance and inappropriate therapy have been well recognized as risk factors for mortality; however the fact that early mortality was clearly superior in the HCRP group strongly suggests that host related factors are crucial in terms of mortality in BPP. P> References
(1) 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.
(2) 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; 51:3568-73.
(3) 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; 128:3854-62.
(4) Carratalà J, Mykietiuk A, Fernández-Sabé N, Suárez C, Dorca J, Verdaguer R,Manresa F, Gudiol F. Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med. 2007; 167:1393-9.
Conflict of Interest:
None declared