Chest
Volume 135, Issue 3, March 2009, Pages 633-640
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Original Research
Respiratory Infection
Health-Care-Associated Pneumonia Among Hospitalized Patients in a Japanese Community Hospital

https://doi.org/10.1378/chest.08-1357Get rights and content

Background

Health-care-associated pneumonia (HCAP) is a relatively new concept. Epidemiologic studies are limited, and initial empirical antibiotic treatment is still under discussion. This study aimed to reveal the differences in mortality and pathogens between HCAP and community-acquired pneumonia (CAP) in each severity class, and to clarify the strategy for the treatment of HCAP.

Methods

We conducted a retrospective observational study of patients with HCAP and CAP who were hospitalized between November 2005 and January 2007, and compared baseline characteristics, severity, pathogen distribution, antibiotic regimens, and outcomes. In each severity class (mild, moderate, and severe) assessed using the A-DROP scoring system (ie, age, dehydration, respiratory failure, orientation disturbance, and low BP), we investigated the in-hospital mortality and occurrence of potentially drug-resistant (PDR) pathogens.

Results

A total of 371 patients (141 HCAP patients, 230 CAP patients) were evaluated. The proportion of patients in the severe class was higher in the HCAP patients than in CAP patients. In the moderate class, the in-hospital mortality proportion of HCAP patients was significantly higher than that of CAP patients (11.1% vs 1.9%, respectively; p = 0.008). In moderate-class patients in whom pathogens were identified, PDR pathogens were isolated more frequently from HCAP patients than from CAP patients (22.2% vs 1.9%, respectively; p = 0.002). The occurrence of PDR pathogens was associated with initial treatment failure and inappropriate initial antibiotic treatment.

Conclusions

The present study provides additional evidence that HCAP should be distinguished from CAP, and suggests that the therapeutic strategy for HCAP in the moderate class holds the key to improving mortality. Physicians may need to consider PDR pathogens in selecting the initial empirical antibiotic treatment of HCAP.

Section snippets

Study Design and Patient Population

We conducted a retrospective observational study of patients with pneumonia hospitalized at Handa City Hospital (a 500-bed community hospital in Handa City, Aichi, Japan) between November 1, 2005, and January 31, 2007. Patients with HAP were excluded. We categorized the study patients into HCAP or CAP groups, and compared baseline characteristics, disease severity, pathogen distribution, antibiotic regimens, and outcomes between the pneumonia groups. We adhered to the Japanese ethical

Patient Characteristics

A total of 371 patients were evaluated during the study period, comprising 141 patients with HCAP (38.0%) and 230 patients with CAP (62.0%). The backgrounds of the 141 HCAP patients are shown in Table 1, and the baseline characteristics of patients with HCAP and CAP are presented in Table 2.

Pathogen Distribution

The microbes identified in the HCAP and CAP groups are shown in Table 3. Laboratory cultures were obtained from the respiratory tracts of 132 of 141 HCAP patients (93.6%) and 224 of 230 CAP patients (97.4%).

Discussion

This retrospective study has shown differences in baseline characteristics, disease severity, identified pathogens, initial antibiotic regimens, and clinical outcomes between HCAP and CAP patients. We especially focused on differences in mortality and identified pathogens in each severity class between HCAP and CAP patients. We found significant differences in the in-hospital mortality and occurrence of PDR pathogens in the moderate class between HCAP and CAP patients, but not in the severe

Acknowledgment

We thank Professor Michio Ohta (Department of Molecular Bacteriology, Nagoya University Graduate School of Medicine, Nagoya, Japan) for his comments on the microbiological evaluation.

References (33)

  • LA Mandell et al.

    Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults

    Clin Infect Dis

    (2003)
  • Committee for the Japanese Respiratory Society Guidelines for the Management of Respiratory Infections

    Antibacterial therapy of hospital-acquired pneumonia

    Respirology

    (2004)
  • Committee for the Japanese Respiratory Society Guidelines for the Management of Respiratory Infections

    Appendix I: nursing-home acquired pneumonia

    Respirology

    (2004)
  • British Thoracic Society

    Guidelines for the management of community-acquired pneumonia in adults: 2004 Update

  • JM Mylotte

    Nursing home-acquired pneumonia: update on treatment options

    Drugs Aging

    (2006)
  • WS Lim et al.

    A prospective comparison of nursing home acquired pneumonia with community acquired pneumonia

    Eur Respir J

    (2001)
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    The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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