Healthcare-Associated Pneumonia (HCAP)
The term for pneumonia in a patient hospitalized within the last 30 days is Healthcare-Associated Pneumonia (HCAP), though this classification has evolved and is no longer universally endorsed by all major guidelines. 1
Definition and Criteria
HCAP is defined as pneumonia occurring in patients with specific healthcare exposures, including hospitalization for 2 or more days within the preceding 90 days. 1 The complete criteria include:
- Hospitalization in an acute care hospital for ≥2 days within 90 days prior to infection 1
- Residence in a nursing home or long-term care facility 1
- Receipt of intravenous antibiotic therapy, chemotherapy, or wound care within 30 days 1
- Attendance at a hemodialysis clinic within 30 days 1
Important Guideline Evolution
The 2016 IDSA/ATS guidelines removed the HCAP category, but some regions and healthcare systems continue to use this classification. 1 The Taiwan guidelines specifically retained HCAP as a distinct entity due to their unique medical system with respiratory care wards and hemodialysis clinics covered by universal health insurance. 1
European guidelines similarly do not emphasize HCAP, noting that European data suggest HCAP patients often have similar etiology to community-acquired pneumonia and are frequently not critically ill, unlike U.S. data. 1
Clinical Significance
HCAP patients are at substantially higher risk for multidrug-resistant organisms compared to community-acquired pneumonia patients. 1, 2 Key differences include:
- Higher mortality rates (10.3-34.7% vs 4.3-9.0% for CAP) 3, 4
- More frequent inappropriate initial antibiotic therapy (5.6-28.3% vs 2.0-13.0%) 3, 5
- Greater likelihood of drug-resistant pathogens including methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa 4, 3, 5
- Longer hospital stays (14.4 vs 10.7 days) 4
Practical Application
If using the HCAP classification, patients with recent hospitalization (within 90 days) should receive empiric antibiotic coverage for multidrug-resistant organisms, similar to hospital-acquired pneumonia. 1 However, clinicians should recognize significant heterogeneity exists within HCAP patients—not all require broad-spectrum coverage. 2 Local antibiotic resistance patterns, individual patient risk factors (prior antibiotic exposure, functional status), and severity of illness should guide the intensity of empiric therapy. 2
The key caveat: Recent hospitalization within 30 days places patients in the HCAP category by definition, but current practice increasingly emphasizes individualized risk assessment for multidrug-resistant organisms rather than automatic broad-spectrum coverage based solely on healthcare contact. 1, 2