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Health care associated pneumonia and outcomes
Submit responseWe 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group of patients with bacteremic pneumococcal pneumonia (BPP) and their relation with the health care system (HCRS) (unpublished data).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
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Health Care-Associated Pneumonia: an increasing clinical problem
Submit responsePneumonia 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. Data that validate this proposal are scanty. In this context we read with great interest the paper by Venditti et al entitled “Outcomes of Patients Hospitalized With Community-Acquired (CAP), Health Care–Associated (HCAP), and Hospital-Acquired Pneumonia (HAP)” (1). We would like to contribute to this topic presenting data obtained on a large group of elderly patients admitted to our Department of Internal Medicine and Geriatrics (Poliambulanza General Hospital -Brescia, Italy).
From July 2005 to December 2007, 356 patients with pneumonia were consecutively admitted (mean age = 81.1±8.4 years). Pneumonia was diagnosed by clinical signs and chest radiography and treatment done according to the ATS/ATS-IDSA guidelines (2); its severity was assessed according to CURB-65 (Confusion or dementia, Urea nitrogen, Respiratory rate, Blood pressure, and age 65 years or older) score (3).
Characteristics of patients were obtained after a multidimensional evaluation, including information on demographics (age, sex, living site prior to admission), cognitive status, functional status (i.e. presence of disability two weeks before the acute event), and physical health performed after admission using a standard protocol, by a trained staff of physicians; physical health was evaluated by the detection of single diseases, comorbidity (computed by the Charlson index), and by the evaluation of physiologic severity (computed by the APACHE II score). Number of currently administered drugs was also recorded (4).
We classified patients as having Hospital-Acquired Pneumonia (n=45) if they received their diagnosis after being hospitalized for more than 72 hours or within 10 days of leaving the hospital. Affected by Health Care–Associated Pneumonia (n=76, of whom 33 admitted directly from Nursing Homes) were those patients with pneumonia who have had a recent contact with the health care system through nursing homes, hemodialysis clinics, or hospitalization in previous 6 months. We classified patients as having Community Acquired Pneumonia (n=235) if they did not fit the criteria for either health care–associated or hospital-acquired pneumonia.
In hospital and three months mortality were the outcome measure of our analysis.
Characteristics and the survival of patients of the three pneumonia groups (i.e. CAP, HCAP, and HAP) are shown in table: in comparison with patients affected by CAP, severity of somatic, biological, psychic, and functional conditions was higher in patients affected by HCAP and in those with HAP. In hospital and three-month mortality were 9.8 and 27.7% in patients with CAP, 18.4 and 38.2% in patients with HCRP, and 22.2 and 44.4 % in those with HAP respectively.
Our data agree with those by Venditti et al and provide further evidence supporting that HCRP represents a distinct subset of pneumonia. In fact, also in our study, if compared with elderly patients who have CAP, those with HCRP have more severe disease and a mortality rate close to that of patients with HAP.
In order to provide an optimal clinical management this subset of pneumonia requires not only specific antibiotic therapy but also a multidimensional approach considering frailty, comorbidity, dementia, and disability, all of these independently associated with poor prognosis (5).
Finally, it is important to emphasize that, due to the progressive increase of intermediate elderly care facilities between hospitals and home, that will take place in the next future, the prevalence of HCRP will increase. This fact will stimulate the attention of clinicians to maximize treatment efficacy in a broader number of patients.
References
1. Venditti M, Falcone M, Corrao S, Licata G, Serra P, and the 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. 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.
3. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003; 58:377-82.
4. Rozzini R, Sabatini T, Cassinadri A et al. Relationship between functional loss before hospital admission and mortality in elders with medical illness J Gerontol A Biol Sci Med Sci. 2005; 60:1180-3
5. Rozzini R, Sabatini T, Trabucchi M. Is pneumonia still the old man's friend? Arch Intern Med. 2003; 163:1491-2.
Table. Characteristics, in hospital and 3-months mortality rate of 356 Elderly Patients Hospitalized for Community-Acquired (CAP), Health Care–Associated (HCAP), and Hospital-Acquired Pneumonia (HAP)
CAP
HCAP
HAP
(N=235)
(N=76)
P*
(N=45)
P†
P‡
M+SD/ N (%)
M+SD (%)
M+SD (%)
Age (years)
81.6+8.2
81.2+8.9
0.785
78.7+8.5
0.033
0.118
Gender (males)
115 (48.9)
35 (46.1)
0.380
20 (44.4)
0.349
0.507
Urea Nitrogen (mg/dl)
66.6+39.6
75.7+52.5
0.122
79.1+54.1
0.077
0.741
Creatinine (mg/dl)
1.3+0.8
1.5+1.0
0.095
1.2+0.8
0.638
0.148
CPR (mg/dl)
9.4+10.4
10.3+10.2
0.506
11.7+10.1
0.181
0.478
Serum Albumin (g/dl)
3.4+0.6
3.1+0.6
0.009
2.9+0.6
0.000
0.101
Hemoglobin (g/dl)
12.3+2.2
11.8+2.4
0.086
11.2+2.1
0.003
0.191
Delirium
46 (19.6)
17 (22.4)
0.353
18 (40.0)
0.004
0.032
Dementia
85 (38.6)
37 (51.4)
0.039
24 (58.5)
0.014
0.100
Chronic Obstructive Pulmonary Diseases
117 (49.8)
38 (50.0)
0.540
26 (57.8)
0.206
0.261
Heart failure (NYHA III-IV)
82 (34.9)
35 (46.1)
0.055
15 (33.3)
0.493
0.118
Renal Failure
56 (24.0)
26 (35.6)
0.038
12 (27.9)
0.356
0.259
Malnutrition
41 (17.8)
23 (30.7)
0.015
19 (39.5)
0.002
0.218
Stroke
30 (12.8)
15 (19.7)
0.097
11 (24.4)
0.041
0.349
Cancer
27 (11.5)
12 (15.8)
0.217
8 (17.8)
0.179
0.482
Diseases (n)
3.9+1.9
4.2+1.6
0.248
4.3+1.8
0.136
0.569
Charlson Index
2.9+1.9
3.2+1.8
0.191
4.1+2.9
0.000
0.040
Drugs (n)
6.5+3.2
7.1+3.5
0.244
8.0+3.6
0.009
0.205
Disabled (2 wks before admission)
42 (17.9)
25 (32.9)
0.006
15 (33.3)
0.019
0.557
APACHE II score§
14.9+5.4
17.3+7.0
0.002
17.7+6.4
0.007
0.789
APACHE II-APS subscore||
7.3.9+6.2
9.8+6.9
0.003
10.9+5.9
0.003
0.874
CURB-65 High risk score (Class III)**
118 (50.2)
42 (55.3)
0.263
28 (62.2)
0.094
0.289
Length of stay (days)
6.7+3.4
6.5+3.8
0.811
8.2+5.3
0.013
0.050
In hospital mortality
23 (9.8)
14 (18.4)
0.038
10 (22.2)
0.022
0.389
Total 3 months mortality
65 (27.7)
29 (38.2)
0.011
20 (44.4)
0.021
0.312
§ APACHE II= Acute Physiology and Chronic Health Evaluation II
|| APACHE II-APS= APACHE II-Acute Physiologic Subscore
** CURB-65= Confusion or dementia, Urea nitrogen, Respiratory rate, Blood pressure, and age 65 years or older.
Significant differences between groups were valued using the independent t test and the chi test for continuous and dichotomyc variables respectively:
* for comparison between health care–associated and community-acquired pneumonia.
† for comparison between hospital-acquired and community-acquired pneumonia.
‡ for comparison between hospital-acquired and health care–associated pneumonia.
Conflict of Interest:
None declared