CW CHOW, LR LEE-PACK, N SENATHI RA GAH, M RAWJI, M CHAN, CK CHAN. Com mu nity ac quired, nurs ing home acquired and hos pi tal ac quired pneu mo nia:A five-year re view of the clini cal, bac te rio logi cal and ra dio logi cal char ac ter is tics. Can J In fect Dis 1995;6(6):317-325. PUR POSE:To as sess the con tem po rary clini cal, bac te rio logi cal and ra dio graphic fea tures of hos pi tal ized pa tients with com mu nity ac quired (CA), nurs ing home ac quired (NA) and hos pi tal ac quired pneu mo nia (HA) and to ex am ine pa tient out come. PATIENTS AND METH ODS: All hos pi tal rec ords of pa tients with pneu mo nia over a five-year pe riod from April 1987 to March 1992 were re viewed ret ro spec tively. Pa tients in cluded in the study were all those with a di ag no sis of pneu mo nia as iden ti fied by com puter rec ords of di ag nos tic codes at dis charge; pa tients with a spe cific di ag no sis of Pneu mo cys tis carinii pneu mo nia were ex cluded. Of 74,435 dis charges over the five-year pe riod, 1782 pa tients met the in clu sion cri te ria. RESULTS: Charts of 1622 of the to tal 1782 cases were re viewed. Mean age was 64.4 years with 59.4% men and 40.6% women. Sixty-three per cent were CA, 28.5% were HA and 8.5% were NA. A to tal of 1542 pa tients (95%) had at least one con comi tant medi cal con di tion. Chest roent ge no gram was ab nor mal in 97%. Com mon or gan isms iso lated over all were Hae mo phi lus in flu en zae (from 204 pa tients), Staphy lo coc cus aureas (from 152 pa tients), Strep to coc cus pneu mo niae (from 143 pa tients ), Escheri chia coli (from 113 pa tients) and Pseu do mo nas ae rugi nosa (from 111 pa tients). H in flu enzae and S pneu mo niae were most com mon in CA pneu mo nia, whereas S au reus and Gram-negative or gan isms were more com mon in the HA group and Gram-negative agents in the NA group. One hun dred and four pa tients de vel oped com pli ca tions. Fif teen per cent re quired in ten sive care unit ad mis sion. The av er age length of hos pi tali za tion in the CA and NA groups was 17 days and in the HA group, 43 days. At time of dis charge 1261 pa tients (78%) were cured or improved, and 361 pa tients (22%) died dur ing the ad mis sion. CON CLU SIONS: These re sults sug gest that hos pi tali za tion for pneu mo nia in the 1990s is pri mar ily for eld erly pa tients with sig nifi cant co-morbidity. Al though mi cro bi ol ogy ap pears un changed com pared with ear lier re ports, the con tem po rary popu la tion is sig nifi cantly sicker than pre vi ous co horts. This may ac count for the per sis tently high mor bid ity and mor tality de spite bet ter or newer an ti bi ot ics. was by August Hirsch in 1881 (1), in which he de scribed pneu mo nia to oc cur in epi dem ics and to be more preva lent in the eld erly, the sick and those of low so cio eco nomic status. This re port had fol lowed the first suc cess ful cul ture of a bac terial or gan ism from a pa tient with pneu mo nia by Louis Pas teur, who aptly named the or gan ism Strep to coc cus pneu mo niae. Hirsch'...

OBJECTIVES: To review the epidemiology of community acquired, nursing home acquired and nosocomial pneumonia in terms of clinical. bacteriological and radiological features and to examine the spectrum of and response to antimicrobial agents used in its management.DESIGN: A retrospective review of all hospital records with pneumonia coded in the discharge diagnoses over a five-year period from April 1987 to March 1993.SETTING: University-affiliated, community-based hospital with a mixed primary to tertiary referral base.PATIENT SELECTION: Patients included in the study were all patients with a diagnosis of pneumonia as identified by computer records of diagnostic codes of all discharges: patients with a specific diagnosis of Pneumocystis carinii pneumonia were excluded. One thousand seven hundred and eighty-two patients out of 74.435 discharges over the five-year period met the inclusion criteria.RESULTS: The initial 1300 of the 1782 cases of pneumonia are included in this interim report. Mean age was 65 years (range 16 to 103) wilh 60% men and 40% women. Sixty-two percent of all cases were community acquired, 29% were hospital acquired and 9% were nursing home acquired. One thousand two hundred and sixty (97%) patients had al least one concomitant medical condition. mainly cardiac disease. alcoholism and chronic obstructive lung disease. Chest roentgenogram was abnormal in 98%. Cultures of sputum, bronchoalveolar lavage fluid, blood and/or serology revealed positive results in 785. The most common pathogens were Streptococcus pneumoniae (154). Haemophilus influenzae (147). Staphylococcus aureus (111) and Pseudomonas aeruginosa (100). In the group with community acquired pneumonia, S pneumoniae and H influenzae predominated. In the hospital acquired pneumonia group S aureus and P aeruginosa were more common. although S pneumoniae remains a significant pathogen. In the nursing home acquired pneumonia group. Gram-negative agents were the most common. The pattern of antimicrobial agents used, usually begun empirically when culture results are pending. showed that the majority of patients was treated with combination antibiotics for both Gram-positive and Gram-negative coverage. Ceftriaxone was usually prescribed with either erythromycin or clindamycin. In about half the patients. the ceftriaxone dose was 1 g per clay. Ninety-six (7%) patients developed complications of pneumonia and 207 (16%) patients required intensive care unit admission. Nine hundred and fifty-nine (73%) patients were cured or improved at time of discharge, 21 ( 1.5%) patients discharged themselves against medical advice and 320 (25%) patients died during admission to hospital, of whom 165 cases had pneumonia listed as a cause on the death certificate.CONCLUSIONS: Pneumonia remains a significant illness with high morbidity and mortality. Those affected and requiring hospitalization are elderly and ill. The most common pathogens overall continue to be S pneumoniae and H influenzae, although Gram-negative organisms and S aureus were also significant agents in nosocomial and nursing home acquired pneumonia. The high percentage of Gram-negative infections in the community acquired group has not been previously described and may represent a change in the pattern of pathogens affecting this group. Three of the 53 community acquired cases in whom P aeruginosa was implicated were detected on blood cultures and were definitely pathogens. Ten of the 53 patients had underlying bronchiectasis or cystic fibrosis and one patient had a history of hematogenous malignancy. Whether the finding of P aeruginosa represents true pathogenicity or colonization in the 53 cases is difficult to differentiate in a retrospective fashion. However. all but two received antibiotic therapy. and 10 of the 40 survivors in this subgroup received adequate coverage for pseudomonas. Although yield from routine investigations is only 60% (785 of 1300 patients in this study), cultures of blood and sputum should be sent in all patients as it may help to narrow choice of antimicrobial agents and aid in oral step-down selection . Only in select patients should serum serology and more costly and invasive procedures such as bronchoscopy and thoracocentesis be done. It appears that the current pattern of antimicrobial use is appropriate for management of pneumonia given the pattern of offending organisms seen. In the present study, pragmatic use of ceftriaxone at 1 g/24h in these sick patients appeared to result in a therapeutic outcome similar to other antibiotic combination therapy.