Clinical Infectious Diseases Advance Access published May 7, 2014 1
Developing local treatment guidelines for healthcare-associated pneumonia
1
Richard Roudebush VA Medical Center, Indianapolis, IN
2
cr ipt
Daniel Livorsi1,2 and Katie Eckerle3
Division of Infectious Diseases, Indiana University School of Medicine
3
Ac
ce
pt ed
M
an
Corresponding author: Daniel Livorsi, MD, MSc, Assistant Professor, Division of Infectious Diseases, Indiana University School of Medicine, 545 Barnhill Drive, EH 421, Indianapolis, IN 46202, Phone number: 317-274-2835, Fax number: 317-274-1587, E-mail: [email protected] Alternate author: Katie Eckerle, MD, Internal Medicine and Pediatric Combined Residency Program, University of Maryland Medical Center, 22 S. Greene St. Baltimore, MD 21201-1595, Phone number: 812-447-8627, E-mail: [email protected]
© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e‐mail: [email protected].
Downloaded from http://cid.oxfordjournals.org/ at UB Kaiserslautern on May 16, 2014
us
University of Maryland, Internal Medicine and Pediatric Combined Residency, Baltimore, MD
2
DEAR EDITOR—We read with interest the meta-analysis by Chalmers et al, which
cr ipt
demonstrates that the healthcare-associated pneumonia (HCAP) definition poorly predicts the presence of resistant pathogens [1]. Based on these findings, Chalmers et al encourage treatment for HCAP to be guided by the local prevalence of multidrug-resistant (MDR) pathogens.
retrospectively identified inpatients treated for pneumonia at our facility, the Richard Roudebush
an
Veterans Affair Medical Center, between 1/1/2011 and 12/31/2012. The Roudebush VAMC is a tertiary-care facility that provides complete medical care for 85,000 adults in Indianapolis, Indiana. Potential cases were identified by the following ICD-9 codes: 480.0-480.9, 481, 482.0-
M
482.9, 483.0-483.8, 484.1-484.8, 485, 486, and 487. All medical records were reviewed, and only cases that met criteria for HCAP were selected for further analysis [2]. A total of 113 cases of HCAP were identified; 98% of cases were men, and the mean age was 71 years. Blood
pt ed
cultures were obtained in 103 patients (91%), sputum cultures in 47 (42%), and bronchoalveolar lavage in 2 (2%). The sputum specimen was graded as good in 15 (32%), fair in 29 (62%), and poor in 3 (6%). At least one microbiologic pathogen was identified by either blood or respiratory samples in only 26 (23%) cases. Enterobacteriaceae were isolated in 10 cases (38%),
ce
methicillin-susceptible Staphylococcus aureus in 5 (19%), Pseudomonas aeruginosa in 4 (15%), Streptococcus pneumoniae in 4 (15%), and methicillin-resistant S.aureus (MRSA) in 3 (12%).
Ac
Despite collecting 2 years of data, our sample size of culture-positive cases (n=26) was
small. The culture-positive rate of 23% is similar to several HCAP studies [3-7]. This low culture-positive rate may reflect 1) the difficulty of collecting sputum samples in non-ventilated patients, and 2) the poor-quality of the samples that were collected [8].
Downloaded from http://cid.oxfordjournals.org/ at UB Kaiserslautern on May 16, 2014
us
In hopes of constructing a local syndromic antibiogram specific to HCAP, we
3 To augment our limited microbiologic data, we’ve also monitored clinical outcomes in patients who had no microbiologic pathogen identified. Of the 87 HCAP patients without a
cr ipt
microbiologic diagnosis, 17 (20%) were entirely treated with a community-acquired pneumonia (CAP) antibiotic regimen and 33 (38%) were de-escalated within 3 days from a HCAP regimen to an empiric oral CAP regimen, e.g. a respiratory fluoroquinolone [9] . Of these 50 patients,
92% had a MRSA-negative nasal swab at admission, and 96% had no prior history of a MDR-
difference in the 30-day mortality rate (15% vs. 6%, p=0.24) or the 30-day readmission rate
empirically treated as CAP.
an
(29% vs. 24%, p=0.79) between culture-positive HCAP cases and culture-negative cases
We agree with Chalmers et al that local microbiologic data will provide more meaningful
M
guidance than a global HCAP definition. However, given the difficulty of establishing a microbiologic diagnosis in this patient population, local guidelines can also be informed by monitoring clinical outcomes in patients who meet the HCAP definition but are empirically
pt ed
treated as if they have CAP.
Ac
ce
The authors have no reported conflicts of interest.
Downloaded from http://cid.oxfordjournals.org/ at UB Kaiserslautern on May 16, 2014
us
infection. The mean duration of antibiotic treatment was 10 days. There was no statistical
4
References:
cr ipt
1. Chalmers JD, Rother C, Salih W, Ewig S. Healthcare‐associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta‐analysis. Clin Infect Dis 2014; 58:330‐9. 2. 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.
pneumonia and pneumonia in immunosuppression. Eur Respir J 2012; 40:1201‐10.
an
4. Jung JY, Park MS, Kim YS, et al. Healthcare‐associated pneumonia among hospitalized patients in a Korean tertiary hospital. BMC Infect Dis 2011; 11:61.
5. Chalmers JD, Taylor JK, Singanayagam A, et al. Epidemiology, antibiotic therapy, and clinical outcomes
M
in health care‐associated pneumonia: a UK cohort study. Clin Infect Dis 2011; 53:107‐13. 6. Aliberti S, Di Pasquale M, Zanaboni AM, et al. Stratifying risk factors for multidrug‐resistant pathogens
pt ed
in hospitalized patients coming from the community with pneumonia. Clin Infect Dis 2012; 54:470‐8. 7. Jeong BH, Koh WJ, Yoo H, et al. Performances of prognostic scoring systems in patients with healthcare‐associated pneumonia. Clin Infect Dis 2013; 56:625‐32. 8. Garcia‐Vazquez E, Marcos MA, Mensa J, et al. Assessment of the usefulness of sputum culture for
ce
diagnosis of community‐acquired pneumonia using the PORT predictive scoring system. Arch Intern Med 2004; 164:1807‐11.
Ac
9. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community‐acquired pneumonia in adults.
Clin Infect Dis 2007; 44 Suppl 2:S27‐72.
Downloaded from http://cid.oxfordjournals.org/ at UB Kaiserslautern on May 16, 2014
us
3. Carrabba M, Zarantonello M, Bonara P, et al. Severity assessment of healthcare‐associated
Developing local treatment guidelines for healthcare-associated pneumonia
1
Richard Roudebush VA Medical Center, Indianapolis, IN
2
cr ipt
Daniel Livorsi1,2 and Katie Eckerle3
Division of Infectious Diseases, Indiana University School of Medicine
3
Ac
ce
pt ed
M
an
Corresponding author: Daniel Livorsi, MD, MSc, Assistant Professor, Division of Infectious Diseases, Indiana University School of Medicine, 545 Barnhill Drive, EH 421, Indianapolis, IN 46202, Phone number: 317-274-2835, Fax number: 317-274-1587, E-mail: [email protected] Alternate author: Katie Eckerle, MD, Internal Medicine and Pediatric Combined Residency Program, University of Maryland Medical Center, 22 S. Greene St. Baltimore, MD 21201-1595, Phone number: 812-447-8627, E-mail: [email protected]
© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e‐mail: [email protected].
Downloaded from http://cid.oxfordjournals.org/ at UB Kaiserslautern on May 16, 2014
us
University of Maryland, Internal Medicine and Pediatric Combined Residency, Baltimore, MD
2
DEAR EDITOR—We read with interest the meta-analysis by Chalmers et al, which
cr ipt
demonstrates that the healthcare-associated pneumonia (HCAP) definition poorly predicts the presence of resistant pathogens [1]. Based on these findings, Chalmers et al encourage treatment for HCAP to be guided by the local prevalence of multidrug-resistant (MDR) pathogens.
retrospectively identified inpatients treated for pneumonia at our facility, the Richard Roudebush
an
Veterans Affair Medical Center, between 1/1/2011 and 12/31/2012. The Roudebush VAMC is a tertiary-care facility that provides complete medical care for 85,000 adults in Indianapolis, Indiana. Potential cases were identified by the following ICD-9 codes: 480.0-480.9, 481, 482.0-
M
482.9, 483.0-483.8, 484.1-484.8, 485, 486, and 487. All medical records were reviewed, and only cases that met criteria for HCAP were selected for further analysis [2]. A total of 113 cases of HCAP were identified; 98% of cases were men, and the mean age was 71 years. Blood
pt ed
cultures were obtained in 103 patients (91%), sputum cultures in 47 (42%), and bronchoalveolar lavage in 2 (2%). The sputum specimen was graded as good in 15 (32%), fair in 29 (62%), and poor in 3 (6%). At least one microbiologic pathogen was identified by either blood or respiratory samples in only 26 (23%) cases. Enterobacteriaceae were isolated in 10 cases (38%),
ce
methicillin-susceptible Staphylococcus aureus in 5 (19%), Pseudomonas aeruginosa in 4 (15%), Streptococcus pneumoniae in 4 (15%), and methicillin-resistant S.aureus (MRSA) in 3 (12%).
Ac
Despite collecting 2 years of data, our sample size of culture-positive cases (n=26) was
small. The culture-positive rate of 23% is similar to several HCAP studies [3-7]. This low culture-positive rate may reflect 1) the difficulty of collecting sputum samples in non-ventilated patients, and 2) the poor-quality of the samples that were collected [8].
Downloaded from http://cid.oxfordjournals.org/ at UB Kaiserslautern on May 16, 2014
us
In hopes of constructing a local syndromic antibiogram specific to HCAP, we
3 To augment our limited microbiologic data, we’ve also monitored clinical outcomes in patients who had no microbiologic pathogen identified. Of the 87 HCAP patients without a
cr ipt
microbiologic diagnosis, 17 (20%) were entirely treated with a community-acquired pneumonia (CAP) antibiotic regimen and 33 (38%) were de-escalated within 3 days from a HCAP regimen to an empiric oral CAP regimen, e.g. a respiratory fluoroquinolone [9] . Of these 50 patients,
92% had a MRSA-negative nasal swab at admission, and 96% had no prior history of a MDR-
difference in the 30-day mortality rate (15% vs. 6%, p=0.24) or the 30-day readmission rate
empirically treated as CAP.
an
(29% vs. 24%, p=0.79) between culture-positive HCAP cases and culture-negative cases
We agree with Chalmers et al that local microbiologic data will provide more meaningful
M
guidance than a global HCAP definition. However, given the difficulty of establishing a microbiologic diagnosis in this patient population, local guidelines can also be informed by monitoring clinical outcomes in patients who meet the HCAP definition but are empirically
pt ed
treated as if they have CAP.
Ac
ce
The authors have no reported conflicts of interest.
Downloaded from http://cid.oxfordjournals.org/ at UB Kaiserslautern on May 16, 2014
us
infection. The mean duration of antibiotic treatment was 10 days. There was no statistical
4
References:
cr ipt
1. Chalmers JD, Rother C, Salih W, Ewig S. Healthcare‐associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta‐analysis. Clin Infect Dis 2014; 58:330‐9. 2. 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.
pneumonia and pneumonia in immunosuppression. Eur Respir J 2012; 40:1201‐10.
an
4. Jung JY, Park MS, Kim YS, et al. Healthcare‐associated pneumonia among hospitalized patients in a Korean tertiary hospital. BMC Infect Dis 2011; 11:61.
5. Chalmers JD, Taylor JK, Singanayagam A, et al. Epidemiology, antibiotic therapy, and clinical outcomes
M
in health care‐associated pneumonia: a UK cohort study. Clin Infect Dis 2011; 53:107‐13. 6. Aliberti S, Di Pasquale M, Zanaboni AM, et al. Stratifying risk factors for multidrug‐resistant pathogens
pt ed
in hospitalized patients coming from the community with pneumonia. Clin Infect Dis 2012; 54:470‐8. 7. Jeong BH, Koh WJ, Yoo H, et al. Performances of prognostic scoring systems in patients with healthcare‐associated pneumonia. Clin Infect Dis 2013; 56:625‐32. 8. Garcia‐Vazquez E, Marcos MA, Mensa J, et al. Assessment of the usefulness of sputum culture for
ce
diagnosis of community‐acquired pneumonia using the PORT predictive scoring system. Arch Intern Med 2004; 164:1807‐11.
Ac
9. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community‐acquired pneumonia in adults.
Clin Infect Dis 2007; 44 Suppl 2:S27‐72.
Downloaded from http://cid.oxfordjournals.org/ at UB Kaiserslautern on May 16, 2014
us
3. Carrabba M, Zarantonello M, Bonara P, et al. Severity assessment of healthcare‐associated
