Lung DOI 10.1007/s00408-013-9541-x

Comparison of Severe Healthcare-Associated Pneumonia with Severe Community-Acquired Pneumonia Byeong-Ho Jeong • Eun Ju Jeon • Hongseok Yoo • Won-Jung Koh • Gee Young Suh • Man Pyo Chung O Jung Kwon • Kyeongman Jeon



Received: 9 July 2013 / Accepted: 14 November 2013 Ó Springer Science+Business Media New York 2013

Abstract Background We compared the demographic characteristics and outcomes of patients with severe healthcare-associated pneumonia (HCAP) to those with severe community-acquired pneumonia (CAP). Methods This was a retrospective study of prospectively collected data from all consecutive patients with severe pneumonia who were admitted to the hospital through the emergency department between January 2008 and December 2010. Results During the study period, 247 patients had severe pneumonia; of these, 107 had severe CAP and 140 had severe HCAP. There was no significant difference in demographic characteristics between the two groups, except for comorbidities. Although the incidence of potentially drug-resistant pathogens was higher in patients with severe HCAP than in those with severe CAP (34 vs. 6 %, P = 0.004), there was no statistically significant difference in the rate of inappropriate antibiotic treatment (16 vs. 3 %, P = 0.143). Finally, clinical outcomes, such as intensive care unit admission, length of hospital stay, and in-hospital mortality, were not different between the two groups. In a multiple logistic regression analysis, a Byeong-Ho Jeong and Eun Ju Jeon contributed equally to this work. B.-H. Jeong  E. J. Jeon  H. Yoo  W.-J. Koh  G. Y. Suh  M. P. Chung  O. J. Kwon  K. Jeon (&) Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Korea e-mail: [email protected] G. Y. Suh  K. Jeon Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

higher PSI score (adjusted OR 1.01; 95 % CI 1.00–1.02; P = 0.024) and the need for mechanical ventilation (adjusted OR 2.62; 95 % CI 1.37–5.00; P = 0.004) were independently associated with in-hospital mortality. However, the type of pneumonia was not associated with inhospital mortality after adjusting for potential confounding factors. Conclusions The severity of illness rather than the type of pneumonia might be associated with in-hospital mortality in patients with severe pneumonia. Keywords Pneumonia  Critical illness  Hospital  Community-acquired  Outcomes

Introduction Healthcare-associated pneumonia (HCAP) is pneumonia that occurs outside of the hospital in patients with contact or exposure to the healthcare environment [1]. Previous studies have demonstrated that patients with HCAP are at an increased risk of infection with antibiotic-resistant organisms, and initial inadequate antibiotic coverage increases the mortality rate of these patients [2–4]. Consequently, it has been recommended that patients with HCAP should receive broad-spectrum antimicrobial therapy directed against drug-resistant healthcare-acquired pathogens [1]. However, recent validation studies do not support this concept [5–7]. Compared with patients with community-acquired pneumonia (CAP), patients with HCAP are older and have more comorbidities. Therefore, the severity of their illness is often greater [2–6]. These findings suggest the possibility that mortality is simply higher in more severely ill patients as well as in those who receive inappropriate initial

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antibiotic treatment. Therefore, a study comparing the demographic characteristics and outcomes of patients with severe CAP and severe HCAP may be of interest. However, the information on severe HCAP is limited. Therefore, we compared the demographic characteristics and outcomes of patients with severe HCAP to those with severe CAP and evaluated whether there would be a significant difference between the in-hospital mortality of CAP and HCAP patients with severe pneumonia.

Methods This retrospective observational study with prospectively collected data was conducted at Samsung Medical Center (a 1,961-bed, university-affiliated, tertiary referral hospital in Seoul, South Korea) between January 2008 and December 2010. Over the study period, all consecutive patients admitted to the hospital through the emergency department with a clinical diagnosis of pneumonia were prospectively registered. Some of the clinical data were also included in a study that evaluated the performance of severity scoring systems in patients with HCAP [8]. The study was approved by the Institutional Review Board of Samsung Medical Center to review and publish information obtained from patient records. Informed consent was waived because of the retrospective nature of the study. Study Population Over the study period, all consecutive patients admitted to the hospital through the emergency department with pneumonia were prospectively registered. The patients with hospital-acquired pneumonia (HAP) that developed after being hospitalized for more than 72 h or within 10 days of leaving the hospital were not included [6]. The patients who had been transferred from other hospitals after hospitalization for more than 48 h were also excluded. In addition, immunocompromised patients, such as those with neutropenia (absolute neutrophil count \1,500/mm3) after chemotherapy, human immunodeficiency virus (HIV) infection, or immunosuppressive therapy (e.g., the use of prednisolone [20 mg/day as equivalent or any other immunosuppressant in the previous 4 weeks), and those who had undergone transplantations were excluded. Definitions A clinical diagnosis of pneumonia required the presence of new radiographic infiltrates and at least two of the following clinical criteria: fever ([38 °C) or hypothermia (B35 °C), new cough with or without sputum production, pleuritic chest pain, dyspnea, and altered breath sounds on

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auscultation [9]. The patients with pneumonia were classified into CAP and HCAP groups. HCAP was defined as a diagnosis of pneumonia in patients admitted to the hospital who met at least one of the following criteria: (1) a recent history of hospitalization for C2 days in the preceding 90 days; (2) residence in a nursing home or long-term-care facility; (3) recent antibiotic therapy, intravenous chemotherapy, or wound care within the preceding 30 days of the current infection; and (4) attendance at a hospital or hemodialysis clinic [6, 10, 11]. CAP was defined as a diagnosis of pneumonia in patients who did not meet any of the criteria for HCAP. A clinical diagnosis of severe pneumonia was made according to the presence of one of two major criteria (requirement of mechanical ventilation and presence of septic shock) or two or three minor criteria (systolic blood pressure \90 mmHg, multilobar involvement, and PaO2/ FiO2 \250) [12]. Based on patient demographics and baseline clinical data that were prospectively registered, the severity of pneumonia was also evaluated using the pneumonia severity index (PSI) and the CURB-65 (confusion, urea nitrogen, respiratory rate, blood pressure, age C65 years) [13, 14]. Functional status was assessed using the system developed by the Eastern Cooperative Oncology Group (ECOG) [15]. Microbiological Data and Antibiotic Therapy An etiologic diagnosis was considered when a respiratory pathogen was isolated from a usually sterile specimen, pneumococcal antigen was detected in urine, or a predominant microorganism was isolated from adequate sputum ([25 neutrophils and \10 squamous epithelial cells per low-power field) or bronchial washing fluids with compatible Gram staining, as previously reported [10]. Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas species, Acinetobacter species, Stenotrophomonas maltophilia, and extended-spectrum b-lactamaseproducing Enterobacteriaceae were considered potentially drug-resistant (PDR) pathogens [16]. Initial antibiotic therapy during the study period recommended a combination of b-lactams plus macrolides for patients with CAP and a combination of antipseudomonal b-lactams plus fluoroquinolones for patients with HCAP or those with a high risk of pseudomonal infection. At our institution, additional vancomycin or linezolid was not recommended for initial treatment of CAP or HCAP because of the low occurrence of MRSA in patients with CAP or HCAP. The appropriateness of antibiotic therapy was analyzed for all cases with an etiologic diagnosis according to susceptibility test criteria for lower respiratory tract pathogens. Antibiotic therapy was classified as being

Lung Table 1 Criteria for healthcare-associated pneumonia (n = 140) Criterion

No. of patients (%)

Previous hospitalization for 2 days or more in the preceding 90 days

82 (59)

Prior antibiotic therapy in the 30 days before pneumonia

62 (44)

Chemotherapy in the 30 days before pneumonia

43 (31)

Nursing home residency

11 (8)

Hemodialysis

8 (6)

Wound care within 30 days

2 (1)

Cases are duplicated

Fig. 1 Flowchart of patient selection. HAP hospital-acquired pneumonia, CAP community-acquired pneumonia, HCAP healthcareassociated pneumonia

inappropriate if the initially prescribed antibiotics were not active against the identified pathogens based on in vitro susceptibility testing [3]. Statistical Analyses The data are presented as median and interquartile range for continuous variables and as number (percent) for categorical variables. The data were compared using the Mann–Whitney U test for the continuous variables and Pearson’s v2 test or Fisher’s exact test for the categorical variables. To estimate whether the type of pneumonia was associated with mortality in patients with severe pneumonia, we performed multivariable logistic regression analysis to adjust for age, gender, type of pneumonia, and factors with P \0.25 on univariate analysis [17]. To reduce the risk of multicolinearity, one variable from a group of closely correlated variables was selected as a candidate for inclusion in the final model. All of the statistical analyses were performed using PASW Statistics 18 (SPSS Inc., Chicago, IL, USA). A two-sided P value \ 0.05 was considered significant.

Results During the study period, 1,585 consecutive patients with pneumonia were hospitalized through the emergency department. Of these patients, 347 patients with HAP, 245 immunocompromised patients, and 55 patients transferred

from other hospitals after hospitalization [48 h were excluded. Of the 938 consecutive patients with CAP or HCAP, 247 patients had severe pneumonia, with 107 patients with severe CAP and 140 patients with severe HCAP (Fig. 1). The severe HCAP group included (Table 1) patients who had a previous hospitalization for C2 days in the preceding 90 days (59 %), prior antibiotic therapy within 30 days (44 %), and chemotherapy within 30 days (31 %). Patient Characteristics As shown in Table 2, patients with severe HCAP were younger, were more likely to be male, and had a lower body mass index. However, these findings had no statistical significance. Patients with severe HCAP had more comorbidities, especially malignancy and a worse functional status assessed by the ECOG. There were no significant differences among patients with severe pneumonia in radiological findings, severity of illness assessed using the PSI and CURB-65, and clinical conditions such as shock and need for mechanical ventilation at the time of presentation. During the study period, the limitation-ofcare decision had been made in 2 (1.9 %) patients with severe CAP and in 7 (5.0 %) patients with severe HCAP (P = 0.306). Pathogen Distribution The bacterial pathogen that caused severe pneumonia was identified in 31 (29 %) patients with severe CAP and in 50 (36 %) patients with severe HCAP (P = 0.263). The methods and results of the etiologic diagnosis are listed in Table 3. In patients with severe HCAP, blood for culture was obtained in 107 (100 %), pleural fluid in 8 (7 %), adequate sputum in 96 (90 %), bronchoalveolar lavage fluid in 9 (8 %), bronchial washing fluid in 4 (4 %), and urine for antigen testing in 97 (91 %). Corresponding figures for patients with severe CAP were 140 (100 %), 4

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Lung Table 2 Comparison of baseline characteristics between patients with severe community-acquired pneumonia (CAP) and severe healthcare-associated pneumonia (HCAP)

Characteristics

Severe CAP (n = 107)

Age (years)

69 (62–77)

Gender, male (%)

67 (63)

BMI (kg/m2)

21.5 (18.3–24.2)

Use of antibiotics within the previous 90 days Comorbidities

Severe HCAP (n = 140)

P value

67 (61–73)

0.076

103 (74)

0.066

20.4 (17.8–23.1)

0.069

6 (6)

92 (66)

\0.001

92 (86)

138 (99)

\0.001

Malignancy

27 (25)

75 (54)

Chronic lung disease

46 (43)

61 (44)

Diabetes

25 (23)

24 (17)

Cerebrovascular disease

15 (14)

18 (13)

Chronic heart disease

18 (17)

11 (8)

8 (7) 4 (4)

15 (11) 6 (4)

Chronic kidney disease Chronic liver disease Functional status, ECOG scores

2 (1–2)

2 (1–3)

0.002

Criteria for severe pneumonia Major criteria Mechanical ventilation

45 (42)

55 (39)

0.660

Septic shock

28 (26)

43 (31)

0.434

Minor criteria Systolic BP \90 mmHg (not septic shock) CAP community-acquired pneumonia, HCAP healthcareassociated pneumonia, BMI body mass index, ECOG Eastern Cooperative Oncology Group, BP blood pressure, PSI pneumonia severity index, CURB-65 confusion-urearespiratory rate-blood pressureage 65

13/79 (16)

16/97 (16)

0.994

Multilobar involvement

84 (79)

118 (84)

0.243

PaO2/FiO2 \250

87 (81)

103 (74)

0.153

124 (102–141)

0.462

Severity of illness PSI score

29 (27)

21 (15)

PSI risk class 4

32 (30)

59 (42)

46 (43) 2 (1–3)

60 (43) 2 (1–2)

PSI risk class 5 CURB-65 score

(3 %), 129 (92 %), 10 (7 %), 2 (1 %), and 111 (79 %). The distribution of pathogens for severe HCAP and severe CAP is given in Table 3. Streptococcus pneumoniae was the most commonly isolated pathogen in both groups but was more common in patients with severe CAP. S. aureus was the second most common pathogen in both groups. The ratio of MRSA to methicillin-sensitive S. aureus was higher in the severe HCAP group (9/14, 64 %) than in the severe CAP group (1/5, 20 %); however, these findings had no statistical significance (P = 0.141). The presence of a PDR pathogen was more common in patients with severe HCAP than in those with severe CAP (34 vs. 6 %, P = 0.004).

Antimicrobial Treatment and Clinical Outcomes Antimicrobial treatment and outcomes of patients with severe CAP and severe HCAP are given in Table 4. The combination of antipseudomonal b-lactams and fluoroquinolones for initial therapy, which is recommended for

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120 (88–150)

PSI risk class B3

0.234

patients with HCAP or suspected to have a pseudomonal infection, was prescribed more commonly for patients with severe HCAP (57 %) than for those with severe CAP (36 %, P = 0.001). On the other hand, the combination of b-lactams and macrolides, which is recommended for patients with CAP, was prescribed more commonly for patients with severe CAP (40 %) than for those with severe HCAP (13 %, P \0.001). Of the 247 patients, only 17 (7 %) were initially treated with additional vancomycin, and no patient was initially treated with additional linezolid. Inappropriate initial antimicrobial treatment was higher in patients with severe HCAP (8/50, 16 %) than in those with severe CAP (1/31, 3 %), although it was not statistically significant (P = 0.143). There was no significant difference between the two severe pneumonia groups in the rate of intensive care unit (ICU) admission and early-case fatality rate within 48 h after admission. Finally, there was a trend of higher inhospital mortality in patients with severe HCAP (31 %) than in patients with severe CAP (21 %), although it was not statistically significant (P = 0.073).

Lung Table 3 Methods and results of etiological diagnosis of patients with severe community-acquired pneumonia (CAP) and severe healthcareassociated pneumonia (HCAP) Severe CAP (n = 107)

Severe HCAP (n = 140)

P value

Blood

6/107 (6)

11/140 (8)

0.489

Pleural fluid

0/8 (0)

1/4 (25)

0.333

Adequate sputum

19/96 (20)

40/129 (31)

0.059

Bronchoalveolar lavage fluid

2/9 (22)

3/10 (30)

1.000

Bronchial washing fluid

0/4 (0)

1/2 (50)

0.333

Pneumococcal antigen test

14/97 (14)

11/111 (10)

0.317

Sterile specimen

Respiratory specimen

Pathogen identified

31 (29)

50 (36)

0.263

Streptococcus pneumoniae

17 (55)

15 (30)

0.026

Streptococci other than S. pneumoniaea

3 (10)

5 (10)

0.999

Staphylococcus aureus

5 (16)

14 (28)

0.220

Pseudomonas aeruginosa

1 (3)

8 (16)

0.143

Haemophilus influenza

1 (3)

2 (4)

0.999

Klebsiella pneumoniae

3 (10)

4 (8)

0.999

Anaerobeb

2 (6)

2 (4)

0.635

2/31 (6)

17/50 (34)

0.004

PDR pathogen

PDR potentially drug resistant, included methicillin-resistant Staphylococcus aureus, Pseudomonas species, Acinetobacter species, Stenotrophomonas maltophilia, and extended-spectrum b-lactamase producing Enterobacteriaceae

Predictors of In-Hospital Mortality in Patients with Severe Pneumonia According to univariate analysis of the clinical characteristics of survivors and nonsurvivors (Table 5), the type of pneumonia was not significantly associated with in-hospital mortality (P = 0.073). However, severity of illness assessed by PSI (P = 0.001), the need for mechanical ventilation (P \0.001), septic shock at presentation (P = 0.001), and ICU admission (P \0.001) were significantly associated with in-hospital mortality. Moreover, neither the presence of a PDR pathogen (P = 0.349) nor inappropriate antibiotic treatment (P = 0.439) was associated with increased in-hospital mortality. By multiple logistic regression analysis, after adjusting for potential confounding factors (Table 6), a higher PSI score (adjusted odds ratio [OR] per 1 score increase 1.01; 95 % CI 1.00–1.02; P = 0.024) and the need for mechanical ventilation (adjusted OR 2.62; 95 % CI 1.37–5.00; P = 0.004) were independently associated with in-hospital mortality. However, the type of pneumonia was not associated with in-hospital mortality after adjusting for potential confounding factors (adjusted OR 1.71; 95 % CI 0.90–3.24; P = 0.104).

Discussion

a

S. mitis/oralis (n = 2) and b-hemolytic Streptococcus group C (n = 1) in patients with severe CAP; S. mitis/oralis (n = 2), b-hemolytic Streptococcus group A (n = 2), and b-hemolytic Streptococcus group C (n = 1) in patients with severe HCAP b

Peptostreptococcus and Micrococcus luteus/lylae in patients with severe CAP, Parvimonas micra and Peptostreptococcus in patients with severe HCAP

Table 4 Antibiotic treatment and clinical outcomes between patients with severe community-acquired pneumonia and severe healthcare-associated pneumonia

To our knowledge, this is the first report to compare the demographic characteristics and outcomes of patients with severe CAP and severe HCAP, and our results demonstrated significant differences related to comorbidities and the presence of a PDR pathogen. However, there was no

Treatment and outcomes

Severe CAP (n = 107)

Severe HCAP (n = 140)

P value

Initial antibiotic therapy b-Lactams ? macrolides

43 (40)

b-Lactams ? fluoroquinolones

2 (2)

Anti-pseudomonal b-lactams ? macrolides

2 (2)

Anti-pseudomonal b-lactams ? fluoroquinolones Additional vancomycin/linezolid Others Inappropriate antibiotic treatment Length of antibiotic therapy (days)

18 (13) 0 6 (4)

\0.001 0.187 0.472

39 (36)

80 (57)

0.001

5 (5)

12 (9)

0.230

24 (17)

0.643

16 (15) 1/31 (3)

8/50 (16)

0.143

14 (9–16)

14 (10–20)

0.179

ICU admission Early case-fatality rate (\48 h)

56 (52) 6 (6)

71 (51) 7 (5)

0.800 0.832

In-hospital mortality

22 (21)

43 (31)

0.073

Length of hospital stay (days)

11 (8–19)

14 (9–22)

0.114

Clinical outcomes

ICU intensive care unit

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Lung Table 5 Comparisons of clinical characteristics between survivors and nonsurvivors with severe pneumonia

Characteristics Age (years)

Survivors (n = 182) 69 (63–73)

Gender, male

119 (65)

BMI (kg/m2)

20.3 (17.8–23.7)

HCAP Comorbidities

Nonsurvivors (n = 65)

P value

67 (60–76)

0.508

51 (78) 21.5 (18.3–23.6)

97 (53)

43 (66)

0.073

168 (92)

62 (95)

0.571

Malignancy

65 (36)

37 (57)

Chronic lung disease

80 (44)

27 (42)

Diabetes

40 (22)

9 (14)

Cerebrovascular disease

26 (14)

7 (11)

Chronic heart disease

23 (13)

6 (9)

Chronic kidney disease Chronic liver disease

16 (9) 4 (2)

7 (11) 6 (9)

Functional status, ECOG scores

0.051 0.338

2 (1–2)

2 (1–3)

0.008

Radiologic findings BMI body mass index, ECOG Eastern Cooperative Oncology Group, HCAP healthcareassociated pneumonia, PSI pneumonia severity index, CURB-65 confusion-urearespiratory rate-blood pressureage 65, ICU intensive care unit, PDR potentially drug resistant, included methicillin-resistant Staphylococcus aureus, Pseudomonas species, Acinetobacter species, Stenotrophomonas maltophilia, and extended-spectrum b-lactamase producing Enterobacteriaceae

Multilobar infiltration Pleural effusion

54 (83)

0.753

53 (29)

17 (26)

0.649

Severity of illness PSI score CURB-65 score

119 (90–140) 2 (1–2)

134 (108–169) 2 (1–3)

0.001 0.171

Clinical conditions at presentation ICU admission

78 (43)

49 (75)

\0.001

Need for mechanical ventilation

59 (32)

41 (63)

\0.001

Septic shock

42 (23)

29 (45)

0.001

12 (7)

5 (8)

0.779

57 (31)

24 (37)

0.409

15 (26) 5 (9)

4 (17) 4 (17)

0.349 0.439

Bacteremia Pathogen identified PDR pathogen Inappropriate antibiotic treatment

difference in clinical outcome between these groups. Furthermore, according to multiple logistic regression analysis, the type of pneumonia was not associated with inhospital mortality in patients with severe pneumonia. However, the severity of disease assessed by PSI and the need for mechanical ventilation were independently associated with in-hospital mortality. HCAP has been studied extensively and clarified in terms of its etiology and management. However, it remains unclear whether the poor outcomes observed in patients with HCAP are related to the presence of additional comorbidities, the high severity of illness, an increased incidence of multidrugresistant pathogens, or inappropriate empirical antibiotic therapy. In a study comparing pneumococcal HCAP and pneumococcal CAP, the differences in outcomes were associated with differences in advanced age and comorbidities, which affected the therapeutic decision to limit admission to the ICU [18]. In the present study, however, approximately half of the patients with HCAP and CAP were admitted to the ICU with no difference in the rate of ICU

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148 (81)

admission or outcomes. Therefore, the severity of illness may be the most important factor associated with poor outcomes in patients with severe pneumonia. The term HCAP has been introduced to identify patients at greater risk for infection with antibiotic-resistant organisms [2]. In previous reports, patients with HCAP were more likely to receive inappropriate initial antibiotic treatment and demonstrated a greater risk of hospital mortality [3]. A recent large European cohort study on severe healthcare-associated infections, including pneumonia, also demonstrated that the risk of death was associated with drug resistance in HCAP. However, that study also showed that the presence of drug resistance had a low additional effect on patient outcomes [19]. In the present study, although PDR pathogens were significantly more likely to be present in patients with severe HCAP, we did not find an association between inappropriate initial antibiotic treatment and in-hospital mortality. This finding could be explained by the difference in prevalence of drugresistant pathogens compared to that in previous reports

Lung Table 6 Multiple logistic regression analysis for risk factors of in-hospital mortality in patients with severe pneumonia Univariable logistic regression OR (95 % CI)

Multivariable logistic regression P value

Adjusted OR (95 % CI)

P value 0.333

Age (years)

1.00 (0.98–1.02)

0.767

0.99 (0.96–1.01)

Gender, male

1.93 (0.99–3.75)

0.053

1.39 (0.67–2.87)

0.380

HCAP

1.71 (0.95–3.09)

0.074

1.71 (0.90–3.24)

0.104

PSI

1.02 (1.01–1.02)

\0.001

1.01 (1.00–1.02)

0.024

Need for mechanical ventilation

3.56 (1.97–6.44)

\0.001

2.62 (1.37–5.00)

0.004

Septic shock at presentation

2.69 (1.48–4.89)

0.001

1.58 (0.80–3.10)

0.186

OR odds ratio, CI confidence interval, HCAP healthcare-associated pneumonia, PSI pneumonia severity index

[2, 3]. In addition, the majority of patients with severe HCAP were empirically treated with antipseudomonal b-lactams and fluoroquinolones. As a result, the frequency of inappropriate initial antibiotic treatment was relatively low in patients with HCAP and that underpowered the study to detect a potential association between inappropriate initial antibiotic treatment and in-hospital mortality. There are several potential limitations to our study that should be acknowledged. First, given its retrospective nature, there is always the possibility that selection bias might have influenced the significance of our findings. However, the data were collected prospectively from all consecutive patients with severe pneumonia who were admitted to the hospital through the emergency department. Furthermore, our study was from a single institution with a comprehensive cancer center, which had a large number of cancer patients receiving chemotherapy. Although immunosuppressed patients with neutropenia that developed after chemotherapy were excluded from the HCAP group, this situation could limit the generalizability of our findings to other hospitals with smaller numbers of cancer patients with risk factors for HCAP. In conclusion, the results of this study demonstrated that there was no significant difference in severity scores, radiologic findings, and clinical conditions between the two severe pneumonia groups. In addition, there was no difference in clinical outcome such as ICU admission, length of hospital stay, and in-hospital mortality, bearing in mind that the majority of patients received initially appropriate antibiotics in our study. The severity of illness rather than the type of pneumonia might be associated with in-hospital mortality in patients with severe pneumonia.

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Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest. 11.

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Comparison of severe healthcare-associated pneumonia with severe community-acquired pneumonia.

We compared the demographic characteristics and outcomes of patients with severe healthcare-associated pneumonia (HCAP) to those with severe community...
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