From the Guidelines
Healthcare-associated pneumonia (HCAP) should no longer be used as a category to guide selection of extended antibiotic coverage in adults with community-acquired pneumonia, and instead, individual risk factors for resistant organisms should be considered. HCAP was previously defined as pneumonia that occurs in patients who have been hospitalized for 2 or more days within the past 90 days, reside in nursing homes or long-term care facilities, have received recent intravenous antibiotic therapy, chemotherapy, or wound care within the past 30 days, or attend hospital or hemodialysis clinics 1. However, recent guidelines recommend abandoning the HCAP designation and instead emphasizing individual risk factors for resistant organisms, such as Methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, to guide empiric antibiotic therapy 1.
Key Points
- HCAP is no longer a recommended category for guiding antibiotic therapy
- Individual risk factors for resistant organisms should be considered when selecting empiric antibiotic therapy
- Patients with risk factors for MRSA or Pseudomonas aeruginosa should receive broader-spectrum antibiotics, such as vancomycin or piperacillin-tazobactam, respectively 1
- The concept of HCAP emerged due to the higher risk of poor outcomes and the need for different empiric antibiotic approaches in patients with healthcare exposures, but recent guidelines have moved away from this designation in favor of a more individualized approach 1
Definition and Diagnosis
The definition of HCAP has been a topic of debate, and recent guidelines have moved away from using this term to guide antibiotic therapy 1. Instead, the focus is on identifying individual risk factors for resistant organisms and selecting empiric antibiotic therapy accordingly. The diagnosis of pneumonia is typically based on the presence of new lung infiltrate plus clinical evidence of an infectious origin, such as fever, purulent sputum, leukocytosis, and decline in oxygenation 1.
Treatment and Management
The treatment of pneumonia in patients with risk factors for resistant organisms typically requires broader-spectrum antibiotics, such as vancomycin or piperacillin-tazobactam, to cover for MRSA and Pseudomonas aeruginosa, respectively 1. The selection of empiric antibiotic therapy should be based on individual risk factors and local epidemiology, and should be tailored to the results of lower respiratory tract cultures and the clinical response of the patient 1.
From the Research
Definition of Healthcare-Associated Pneumonia
Healthcare-associated pneumonia (HCAP) is defined as pneumonia that develops in patients with a history of recent hospitalization, hemodialysis as an outpatient, residence in a nursing home, outpatient intravenous therapy, and home wound care 2. It is a new category of respiratory infection that includes a spectrum of adult patients who have close association with acute care hospitals or reside in chronic care settings that increase their risk for pneumonia caused by multi-drug-resistant bacteria 3.
Key Characteristics of HCAP
- Pneumonia developing before hospital admission in patients in close contact with the health system 4
- Recent hospitalization within 90 days before pneumonia, attending a dialysis clinic, and residing in a nursing home are common criteria for HCAP 4, 2
- Patients with HCAP are older, have greater co-morbidity, and are more likely to have aspiration pneumonia and pneumonia caused by antibiotic-resistant pathogens compared to those with community-acquired pneumonia (CAP) 4, 2
- HCAP is distinct from CAP in terms of its epidemiology, etiology, and risk for infection with multidrug-resistant (MDR) pathogens 5
Diagnosis and Treatment of HCAP
- HCAP should be differentiated from CAP to promote a targeted approach when selecting initial antibiotic therapy 4
- Patients with HCAP are more likely to receive inappropriate initial antibiotic therapy, which may result in poorer outcomes in terms of patient morbidity, mortality, and increased length of hospital stay 3
- Empiric treatment strategies for HCAP should take into account the potential for MDR pathogens, and treatment regimens such as piperacillin/tazobactam and meropenem may be effective 6