Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia

6 January 2009 | Volume 150 Issue 1 | Pages 19-26

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.

Editors' Notes Context Pneumonia in patients who were recently hospitalized, reside in a long-term health facility, or are receiving hemodialysis or intravenous chemotherapy is known as "health care–associated pneumonia." Health care–associated pneumonia seems to differ from pneumonia that occurs in patients without these characteristics. Contribution This study of 362 patients hospitalized with pneumonia showed that the 25% who had health care–associated pneumonia had more severe clinical courses than those with community-acquired pneumonia and a mortality rate close to that of patients with hospital-acquired pneumonia. Receipt of antibiotics not recommended by guidelines was associated with death from health care–associated pneumonia. Caution These findings may not apply to pneumonia that does not require hospitalization. —The Editors

 

Author and Article Information

From the University of Rome, Rome, Italy, and Università degli Studi di Palermo, Palermo, Italy.

Acknowledgment: The authors thank Professor Pier Mannuccio Mannucci, Milan, Italy, for his activity as Chief of the Italian Society of Internal Medicine group for independent clinical research. They also thank Sohita Dhillon and Rod McNab of Wolters Kluwer Health for English-language assistance in the preparation of this manuscript.

Potential Financial Conflicts of Interest: Consultancies: M. Venditti (Glaxo Wellcome, Gilead, Angelini, Novartis, Pfizer, Bayer, Wyeth). Grants received: M. Falcone (Pfizer).

Reproducible Research Statement: Study protocol: Available at http://www.simi.it. Statistical code: Available from Dr. Corrao (s.corrao{at}unipa.it). Data set: Not available.

Requests for Single Reprints: Mario Venditti, MD, Dipartimento di Medicina Clinica—Policlinico Umberto I, Università di Roma "La Sapienza," Viale dell'Università 37, 00161 Rome, Italy; e-mail, mario.venditti{at}uniroma1.it.

Current Author Addresses: Drs. Venditti, Falcone, and Serra: Dipartimento di Medicina Clinica—Policlinico Umberto I, Università di Roma "La Sapienza," Viale dell'Università 37, 00161 Rome, Italy.

Drs. Corrao and Licata: Dipartimento Biomedico di Medicina Interna e Specialistica, Università degli Studi di Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy.

Author Contributions: Conception and design: M. Venditti, M. Falcone, P. Serra.

Analysis and interpretation of the data: M. Venditti, M. Falcone, S. Corrao.

Drafting of the article: M. Venditti, M. Falcone.

Critical revision of the article for important intellectual content: S. Corrao, G. Licata, P. Serra.

Final approval of the article: S. Corrao, G. Licata, P. Serra.

Provision of study materials or patients: G. Licata.

Statistical expertise: S. Corrao.

Obtaining of funding: G. Licata.

Administrative, technical, or logistic support: G. Licata.

Collection and assembly of data: M. Falcone, S. Corrao.

^* For a complete list of study group members, see the Appendix.

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