Healthcare-associated pneumonia: is there any reason to continue to utilize this label in 2019?

Abstract

Background: There is an ongoing controversy on the role of the healthcare-associated pneumonia (HCAP) label in the treatment of patients with pneumonia. Objective: To provide an update of the literature on patients meeting criteria for HCAP between 2014 and 2018. Sources: The review is based on a systematic literature search using PubMed-Central full-text archive of biomedical and life sciences literature at the U.S. National Institutes of Health's National Library of Medicine (NIH/NLM). Content: Studies compared clinical characteristics of patients with HCAP and community-acquired pneumonia (CAP). HCAP patients were older and had a higher comorbidity. Mortality rates in HCAP varied from 5% to 33%, but seemed lower than those cited in the initial reports. Criteria behind the HCAP classification differed considerably within populations. Microbial patterns differed in that there was a higher incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, and, to a lesser extent, enterobacteriaceae. Definitions and rates of multidrug-resistant (MDR) pneumonia also varied considerably. Broad-spectrum guideline-concordant treatment did not reduce mortality in four observational studies. The HCAP criteria performed poorly as a predictive tool to identify MDR pneumonia or pathogens not covered by treatment for CAP. A new score (Drug Resistance in Pneumonia, DRIP) outperformed HCAP in the prediction of MDR pathogens. Comorbidity and functional status, but not different microbial patterns, seem to account for increased mortality. Implications: HCAP should no longer be used to identify patients at risk of MDR pathogens. The use of validated predictive scores along with implementation of de-escalation strategies and careful individual assessment of comorbidity and functional status seem superior strategies for clinical management.

International Perspective on the New 2019 American Thoracic Society/Infectious Diseases Society of America Community-Acquired Pneumonia Guideline

“…There was broad consensus that the positive predictive value of the HCAP definition was far too low to justify empiric antibiotic regimens covering multidrug-resistant (MDR) bacteria, and data clearly demonstrate that this classification resulted in overtreatment of patients with CAP, and may be associated with adverse outcomes including increased mortality. [5][6][7][8][9] The alternative concept of "strong risk factors," for example, known colonization of methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa, has been suggested by international experience and was well received by the present expert panel. 10 However, an overemphasis on these two specific pathogens-MRSA and P. aeruginosa-misses emerging data on extended-spectrum b-lactamase-containing…”

“…There was broad consensus that the positive predictive value of the HCAP definition was far too low to justify empiric antibiotic regimens covering multidrug-resistant (MDR) bacteria, and data clearly demonstrate that this classification resulted in overtreatment of patients with CAP, and may be associated with adverse outcomes including increased mortality. 5 , 6 , 7 , 8 , 9 …”

Extended-spectrum antibiotics for community-acquired pneumonia with a low risk for drug-resistant pathogens

“…(American Thoracic and Infectious Diseases Society of America, 2005, Kollef et al, 2008) However, several researchers have raised doubts on the HCAP concept, suggesting that it could increase the unnecessary use of extended-spectrum antibiotics. (Aliberti et al, 2021, Ewig et al, 2019, Webb et al, 2016 Indeed, several studies have revealed an association between the use of extended-spectrum antibiotics and increased mortality in patients with CAP, including HCAP. (Attridge et al, 2011, Jones et al, 2020, Webb et al, 2019 In the last decade, several research groups in different regions have reassessed the essential risk factors of DRPs to be considered when determining the initial antibiotics to be administered after pneumonia diagnosis.…”

Rationale Antibiotikatherapie – Ist weniger mehr?

“…Beispielsweise forderte die American Thoracic Society in der Leitlinie zur Nosokomialen Pneumonie von 2005 jeden Patienten mit einer im Pflegeheim erworbenen Pneumonie eine Dreifach-Therapie bestehend aus 2 Antibiotika mit Pseudomonas-Wirksamkeit und einem MRSA-wirksamen Antibiotikum [3]. Spätere Studien zeigten jedoch, dass 1) MRSA und Pseudomonas aeruginosa bei Pflegeheimpatienten nicht häufiger auftreten als bei anderen Patienten [4] und 2) diese auf maximale Sicherheit bedachte Dreifach-Therapie die Sterblichkeit erhöhte -insbesondere wenn sie nicht indiziert war, also keine multiresistenten Erreger nachgewiesen wurden [5].…”