Healthcare-associated pneumonia
Encyclopedia
In medicine
, healthcare-associated pneumonia (HCAP) is a category of pneumonia
in patients with recent close contact with the health care system.
HCAP is a condition in patients who are not hospitalised (similar to community-acquired pneumonia
, CAP) but its causes, prognosis, prevention and treatment are more similar to hospital-acquired pneumonia
(HAP). The category was introduced because healthcare has increasingly shifted from hospital-based to home care, and more people are residing in nursing home
s or extended care facilities.
Nursing home-acquired pneumonia is an important subgroup of HCAP. Residents of long term care facilities may become infected through their contacts with the healthcare system; as such, the microbes responsible for their pneumonias may be different from those traditionally seen in community-dwelling patients, requiring therapy with different antibiotics. Other groups include patients who are admitted as a day case for regular hemodialysis
or intravenous infusion (for example, chemotherapy
). Especially in the very old and in demented
patients, HCAP is likely to present with atypical symptoms.
Compared to subjects with CAP, the pneumonia in HCAP is more likely to be caused by bacteria
resistant to first line antibiotics, such as methicillin-resistant Staphylococcus aureus
(MRSA) or Pseudomonas aeruginosa
. The optimal antibiotic strategy for the treatment of HCAP remains controversial. Influenza vaccines have been shown to reduce the risk of pneumonia in nursing home residents. The pneumococcal polysaccharide vaccine
is also recommended, although the evidence for its preventative role against pneumonia is more conflicting.
HCAP was first suggested as a novel category of pneumonia in 2005 by the American Thoracic Society
and Infectious Diseases Society of America
.
Although patients with HCAP may have more severe disease than those with classic CAP, disease severity does not determine if a patient has HCAP or not; the label HCAP is merely an indicator of risk factors for multi-drug resistant bacteria.
A recent study defined HCAP as admittance to a hospital or underwent surgery in the past 180 days, based on the observation that colonization with hospital-acquired bacteria can occur for extended periods.
(S. aureus) and Pseudomonas aeruginosa
, and less Streptococcus pneumoniae
and Haemophilus influenzae
. It is well known that nursing home residents have high rates of colonization with MRSA. However, not all studies have found high rates of S. aureus and gram-negative bacteria. One factor responsible for these differences is the reliance on sputum samples and the strictness of the criteria to discriminate between colonising or disease-causing bacteria. Moreover, sputum samples might be less frequently obtained in the elderly.
Aspiration
(both of microscopic drops and macroscopic amounts of nose and throat
secretions) is thought to be the most important cause of HCAP. Dental plaque
might also be a reservoir for bacteria in HCAP.
In 2002, an expert panel made recommendations about the evaluation and treatment of probable nursing home-acquired pneumonia. They defined probably pneumonia, emphasized expedite antibiotic treatment (which is known to improve survival) and drafted criteria for the hospitalization of willing patients.
For initial treatment in the nursing home, a fluoroquinolone antibiotic suitable for respiratory infections (moxifloxacin
, for example), or amoxicillin with clavulanic acid plus a macrolide
has been suggested. In a hospital setting, injected (parenteral
) fluoroquinolones or a second- or third-generation cephalosporin
plus a macrolide could be used. Other factors that need to be taken into account are recent antibiotic therapy (because of possible resistance caused by recent exposure), known carrier state or risk factors for resistant organisms (for example, known carrier of MRSA or presence of bronchiectasis
predisposing to Pseudomonas aeruginosa
), or suspicion of possible Legionella pneumophila
infection (legionnaires disease).
In 2005, the American Thoracic Society
and Infectious Diseases Society of America
have published guidelines suggesting antibiotics specifically for HCAP. The guidelines recommend combination therapy with an agent from each of the following groups to cover for both Pseudomonas aeruginosa and MRSA. This is based on studies using sputum
samples and intensive care patients, in whom these bacteria were commonly found.
In one observational study, empirical antibiotic treatment that was not according to international treatment guidelines was an independent predictor of worse outcome among HCAP patients.
Guidelines from Canada suggest that HCAP can be treated like community-acquired pneumonia with antibiotics targeting Streptococcus pneumoniae
, based on studies using blood culture
s in different settings which have not found high rates of MRSA or Pseudomonas.
Besides prompt antibiotic treatment, supportive measure for organ failure (such as cardiac decompensation) are also important. Another consideration goes to hospital referral; although more severe pneumonia requires admission to an acute care facility, this also predisposes to hazards of hospitalization such as delirium
, urinary incontinence
, depression
, falls
, restraint use, functional decline, adverse drug effects and hospital infections
. Therefore, mild pneumonia might be better dealt with inside the long term care facility. In patients with a limited life expectancy (for example, those with advanced dementia), end-of-life pneumonia also requires recognition and appropriate, palliative care
.
(fast breathing) or a high white cell count (leukocytosis
), the prognosis seems to be influenced by the underlying associated diseases (comorbidities
) and functional capacities (for example, the ADL score
). Many patients have a decreased health condition after the episode.
, heart failure and diabetes).
The number of residents in long term care facilities is expected to rise dramatically over the next 30 years. These older adults are known to develop pneumonia 10 times more than their community-dwelling peers, and hospital admittance rates are 30 times higher.
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
, healthcare-associated pneumonia (HCAP) is a category of pneumonia
Pneumonia
Pneumonia is an inflammatory condition of the lung—especially affecting the microscopic air sacs —associated with fever, chest symptoms, and a lack of air space on a chest X-ray. Pneumonia is typically caused by an infection but there are a number of other causes...
in patients with recent close contact with the health care system.
HCAP is a condition in patients who are not hospitalised (similar to community-acquired pneumonia
Community-acquired pneumonia
Community-acquired pneumonia is a term used to describe one of several diseases in which individuals who have not recently been hospitalized develop an infection of the lungs . CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever,...
, CAP) but its causes, prognosis, prevention and treatment are more similar to hospital-acquired pneumonia
Hospital-acquired pneumonia
Hospital-acquired pneumonia or nosocomial pneumonia refers to any pneumonia contracted by a patient in a hospital at least 48–72 hours after being admitted. It is usually caused by a bacterial infection, rather than a virus....
(HAP). The category was introduced because healthcare has increasingly shifted from hospital-based to home care, and more people are residing in nursing home
Nursing home
A nursing home, convalescent home, skilled nursing unit , care home, rest home, or old people's home provides a type of care of residents: it is a place of residence for people who require constant nursing care and have significant deficiencies with activities of daily living...
s or extended care facilities.
Nursing home-acquired pneumonia is an important subgroup of HCAP. Residents of long term care facilities may become infected through their contacts with the healthcare system; as such, the microbes responsible for their pneumonias may be different from those traditionally seen in community-dwelling patients, requiring therapy with different antibiotics. Other groups include patients who are admitted as a day case for regular hemodialysis
Hemodialysis
In medicine, hemodialysis is a method for removing waste products such as creatinine and urea, as well as free water from the blood when the kidneys are in renal failure. Hemodialysis is one of three renal replacement therapies .Hemodialysis can be an outpatient or inpatient therapy...
or intravenous infusion (for example, chemotherapy
Chemotherapy
Chemotherapy is the treatment of cancer with an antineoplastic drug or with a combination of such drugs into a standardized treatment regimen....
). Especially in the very old and in demented
Dementia
Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging...
patients, HCAP is likely to present with atypical symptoms.
Compared to subjects with CAP, the pneumonia in HCAP is more likely to be caused by bacteria
Bacteria
Bacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...
resistant to first line antibiotics, such as methicillin-resistant Staphylococcus aureus
Methicillin-resistant Staphylococcus aureus
Methicillin-resistant Staphylococcus aureus is a bacterium responsible for several difficult-to-treat infections in humans. It is also called multidrug-resistant Staphylococcus aureus and oxacillin-resistant Staphylococcus aureus...
(MRSA) or Pseudomonas aeruginosa
Pseudomonas aeruginosa
Pseudomonas aeruginosa is a common bacterium that can cause disease in animals, including humans. It is found in soil, water, skin flora, and most man-made environments throughout the world. It thrives not only in normal atmospheres, but also in hypoxic atmospheres, and has, thus, colonized many...
. The optimal antibiotic strategy for the treatment of HCAP remains controversial. Influenza vaccines have been shown to reduce the risk of pneumonia in nursing home residents. The pneumococcal polysaccharide vaccine
Pneumococcal polysaccharide vaccine
Pneumococcal polysaccharide vaccine — the latest version is known as Pneumovax 23 — is the first pneumococcal vaccine, the first vaccine derived from a capsular polysaccharide, and an important landmark in medical history...
is also recommended, although the evidence for its preventative role against pneumonia is more conflicting.
HCAP was first suggested as a novel category of pneumonia in 2005 by the American Thoracic Society
American Thoracic Society
American Thoracic Society , established in 1905, is an independently incorporated, international, educational and scientific society, serving its 18,000 members worldwide who are dedicated in respiratory and critical care medicine...
and Infectious Diseases Society of America
Infectious Diseases Society of America
The Infectious Diseases Society of America is a medical association representing physicians, scientists and other health care professionals who specialize in infectious diseases. As of 2010, IDSA had approximately 9,000 members...
.
Definition
Healthcare-associated pneumonia can be defined as pneumonia in a patient with at least one of the following risk factors:- hospitalization in an acute care hospitalHospitalA hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
for two or more days in the last 90 days; - residence in a nursing home or long-term care facility in the last 90 days
- receiving outpatient intravenous therapy (like antibiotics or chemotherapyChemotherapyChemotherapy is the treatment of cancer with an antineoplastic drug or with a combination of such drugs into a standardized treatment regimen....
) within the past 30 days - receiving home wound care within the past 30 days
- attending a hospital clinic or dialysisDialysisIn medicine, dialysis is a process for removing waste and excess water from the blood, and is primarily used to provide an artificial replacement for lost kidney function in people with renal failure...
center in the last 30 days - having a family member with known multi-drug resistant pathogenPathogenA pathogen gignomai "I give birth to") or infectious agent — colloquially, a germ — is a microbe or microorganism such as a virus, bacterium, prion, or fungus that causes disease in its animal or plant host...
s
Although patients with HCAP may have more severe disease than those with classic CAP, disease severity does not determine if a patient has HCAP or not; the label HCAP is merely an indicator of risk factors for multi-drug resistant bacteria.
A recent study defined HCAP as admittance to a hospital or underwent surgery in the past 180 days, based on the observation that colonization with hospital-acquired bacteria can occur for extended periods.
Causes
The bacteria found in patients with HCAP are more similar to HAP than to CAP; compared to CAP, they have higher rates of Staphylococcus aureusStaphylococcus aureus
Staphylococcus aureus is a facultative anaerobic Gram-positive coccal bacterium. It is frequently found as part of the normal skin flora on the skin and nasal passages. It is estimated that 20% of the human population are long-term carriers of S. aureus. S. aureus is the most common species of...
(S. aureus) and Pseudomonas aeruginosa
Pseudomonas aeruginosa
Pseudomonas aeruginosa is a common bacterium that can cause disease in animals, including humans. It is found in soil, water, skin flora, and most man-made environments throughout the world. It thrives not only in normal atmospheres, but also in hypoxic atmospheres, and has, thus, colonized many...
, and less Streptococcus pneumoniae
Streptococcus pneumoniae
Streptococcus pneumoniae, or pneumococcus, is Gram-positive, alpha-hemolytic, aerotolerant anaerobic member of the genus Streptococcus. A significant human pathogenic bacterium, S...
and Haemophilus influenzae
Haemophilus influenzae
Haemophilus influenzae, formerly called Pfeiffer's bacillus or Bacillus influenzae, Gram-negative, rod-shaped bacterium first described in 1892 by Richard Pfeiffer during an influenza pandemic. A member of the Pasteurellaceae family, it is generally aerobic, but can grow as a facultative anaerobe. H...
. It is well known that nursing home residents have high rates of colonization with MRSA. However, not all studies have found high rates of S. aureus and gram-negative bacteria. One factor responsible for these differences is the reliance on sputum samples and the strictness of the criteria to discriminate between colonising or disease-causing bacteria. Moreover, sputum samples might be less frequently obtained in the elderly.
Aspiration
Aspiration pneumonia
Aspiration pneumonia is bronchopneumonia that develops due to the entrance of foreign materials into the bronchial tree, usually oral or gastric contents...
(both of microscopic drops and macroscopic amounts of nose and throat
Nasopharynx
The nasopharynx is the uppermost part of the pharynx. It extends from the base of the skull to the upper surface of the soft palate; it differs from the oral and laryngeal parts of the pharynx in that its cavity always remains patent .-Lateral:On its lateral wall is the pharyngeal ostium of the...
secretions) is thought to be the most important cause of HCAP. Dental plaque
Dental plaque
Dental plaque is a biofilm, usually a pale yellow, that develops naturally on the teeth. Like any biofilm, dental plaque is formed by colonizing bacteria trying to attach themselves to a smooth surface...
might also be a reservoir for bacteria in HCAP.
Treatment
Patients with HCAP are more likely than those with community-acquired pneumonia to receive inappropriate antibiotics that do not target the bacteria causing their disease.In 2002, an expert panel made recommendations about the evaluation and treatment of probable nursing home-acquired pneumonia. They defined probably pneumonia, emphasized expedite antibiotic treatment (which is known to improve survival) and drafted criteria for the hospitalization of willing patients.
For initial treatment in the nursing home, a fluoroquinolone antibiotic suitable for respiratory infections (moxifloxacin
Moxifloxacin
Moxifloxacin is a fourth-generation synthetic fluoroquinolone antibacterial agent developed by Bayer AG . It is marketed worldwide under the brand names Avelox, Avalox, and Avelon for oral treatment. In most countries, the drug is also available in parenteral form for intravenous infusion...
, for example), or amoxicillin with clavulanic acid plus a macrolide
Macrolide
The macrolides are a group of drugs whose activity stems from the presence of a macrolide ring, a large macrocyclic lactone ring to which one or more deoxy sugars, usually cladinose and desosamine, may be attached. The lactone rings are usually 14-, 15-, or 16-membered...
has been suggested. In a hospital setting, injected (parenteral
Parenteral
Parenteral is a route of administration that involves piercing the skin or mucous membrane. Parenteral nutrition refers to providing nutrition via the veins.-Etymology:...
) fluoroquinolones or a second- or third-generation cephalosporin
Cephalosporin
The cephalosporins are a class of β-lactam antibiotics originally derived from Acremonium, which was previously known as "Cephalosporium".Together with cephamycins they constitute a subgroup of β-lactam antibiotics called cephems.-Medical use:...
plus a macrolide could be used. Other factors that need to be taken into account are recent antibiotic therapy (because of possible resistance caused by recent exposure), known carrier state or risk factors for resistant organisms (for example, known carrier of MRSA or presence of bronchiectasis
Bronchiectasis
Bronchiectasis is a disease state defined by localized, irreversible dilation of part of the bronchial tree caused by destruction of the muscle and elastic tissue. It is classified as an obstructive lung disease, along with emphysema, bronchitis, asthma, and cystic fibrosis...
predisposing to Pseudomonas aeruginosa
Pseudomonas aeruginosa
Pseudomonas aeruginosa is a common bacterium that can cause disease in animals, including humans. It is found in soil, water, skin flora, and most man-made environments throughout the world. It thrives not only in normal atmospheres, but also in hypoxic atmospheres, and has, thus, colonized many...
), or suspicion of possible Legionella pneumophila
Legionella pneumophila
Legionella pneumophila is a thin, ærobic, pleomorphic, flagellated, non-spore forming, Gram-negative bacterium of the genus Legionella. L. pneumophila is the primary human pathogenic bacterium in this group and is the causative agent of legionellosis or Legionnaires' disease.-Characterization:L...
infection (legionnaires disease).
In 2005, the American Thoracic Society
American Thoracic Society
American Thoracic Society , established in 1905, is an independently incorporated, international, educational and scientific society, serving its 18,000 members worldwide who are dedicated in respiratory and critical care medicine...
and Infectious Diseases Society of America
Infectious Diseases Society of America
The Infectious Diseases Society of America is a medical association representing physicians, scientists and other health care professionals who specialize in infectious diseases. As of 2010, IDSA had approximately 9,000 members...
have published guidelines suggesting antibiotics specifically for HCAP. The guidelines recommend combination therapy with an agent from each of the following groups to cover for both Pseudomonas aeruginosa and MRSA. This is based on studies using sputum
Sputum
Sputum is mucus that is coughed up from the lower airways. It is usually used for microbiological investigations of respiratory infections....
samples and intensive care patients, in whom these bacteria were commonly found.
- cefepimeCefepimeCefepime is a fourth-generation cephalosporin antibiotic developed in 1994. Cefepime has an extended spectrum of activity against Gram-positive and Gram-negative bacteria, with greater activity against both Gram-negative and Gram-positive organisms than third-generation agents...
, ceftazidimeCeftazidimeCeftazidime is a third-generation cephalosporin antibiotic. Like other third-generation cephalosporins, it has broad spectrum activity against Gram-positive and Gram-negative bacteria. Unlike most third-generation agents, it is active against Pseudomonas aeruginosa, however it has weaker activity...
, imipenemImipenemImipenem is an intravenous β-lactam antibiotic developed in 1980. It has an extremely broad spectrum of activity.Imipenem belongs to the subgroup of carbapenems. It is derived from a compound called thienamycin, which is produced by the bacterium Streptomyces cattleya...
, meropenemMeropenemMeropenem is an ultra-broad spectrum injectable antibiotic used to treat a wide variety of infections, including meningitis and pneumonia. It is a beta-lactam and belongs to the subgroup of carbapenem, similar to imipenem and ertapenem. Meropenem was originally developed by Sumitomo Pharmaceuticals...
or piperacillin–tazobactamPiperacillin/tazobactamPiperacillin/tazobactam is a combination antibiotic containing the extended-spectrum penicillin antibiotic piperacillin and the β-lactamase inhibitor tazobactam. It is marketed as Kilbac by Morepen and Tazocin or, in the USA, as Zosyn by Wyeth Pharms Inc .-External links:*...
; plus - ciprofloxacinCiprofloxacinCiprofloxacin is a synthetic chemotherapeutic antibiotic of the fluoroquinolone drug class.It is a second-generation fluoroquinolone antibacterial. It kills bacteria by interfering with the enzymes that cause DNA to rewind after being copied, which stops synthesis of DNA and of...
, levofloxacinLevofloxacinLevofloxacin is a synthetic chemotherapeutic antibiotic of the fluoroquinolone drug class and is used to treat severe or life-threatening bacterial infections or bacterial infections that have failed to respond to other antibiotic classes. It is sold under various brand names, such as Levaquin and...
, amikacinAmikacinAmikacin is an aminoglycoside antibiotic used to treat different types of bacterial infections. Amikacin works by binding to the bacterial 30S ribosomal subunit, causing misreading of mRNA and leaving the bacterium unable to synthesize proteins vital to its growth.-Administration:Amikacin may be...
, gentamicinGentamicinGentamicin is an aminoglycoside antibiotic, used to treat many types of bacterial infections, particularly those caused by Gram-negative organisms. However, gentamicin is not used for Neisseria gonorrhoeae, Neisseria meningitidis or Legionella pneumophila...
, or tobramycin; plus - linezolidLinezolidLinezolid is a synthetic antibiotic used for the treatment of serious infections caused by Gram-positive bacteria that are resistant to several other antibiotics...
or vancomycinVancomycinVancomycin INN is a glycopeptide antibiotic used in the prophylaxis and treatment of infections caused by Gram-positive bacteria. It has traditionally been reserved as a drug of "last resort", used only after treatment with other antibiotics had failed, although the emergence of...
In one observational study, empirical antibiotic treatment that was not according to international treatment guidelines was an independent predictor of worse outcome among HCAP patients.
Guidelines from Canada suggest that HCAP can be treated like community-acquired pneumonia with antibiotics targeting Streptococcus pneumoniae
Streptococcus pneumoniae
Streptococcus pneumoniae, or pneumococcus, is Gram-positive, alpha-hemolytic, aerotolerant anaerobic member of the genus Streptococcus. A significant human pathogenic bacterium, S...
, based on studies using blood culture
Blood culture
Blood culture is a microbiological culture of blood. It is employed to detect infections that are spreading through the bloodstream...
s in different settings which have not found high rates of MRSA or Pseudomonas.
Besides prompt antibiotic treatment, supportive measure for organ failure (such as cardiac decompensation) are also important. Another consideration goes to hospital referral; although more severe pneumonia requires admission to an acute care facility, this also predisposes to hazards of hospitalization such as delirium
Delirium
Delirium or acute confusional state is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior...
, urinary incontinence
Urinary incontinence
Urinary incontinence is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners...
, depression
Depression (mood)
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless...
, falls
Falls in older adults
Every year, many older people suffer from falls. These falls in older adults are a significant cause of morbidity and mortality, and can have a serious effect on the person who falls...
, restraint use, functional decline, adverse drug effects and hospital infections
Nosocomial infection
A nosocomial infection , also known as a hospital-acquired infection or HAI, is an infection whose development is favoured by a hospital environment, such as one acquired by a patient during a hospital visit or one developing among hospital staff...
. Therefore, mild pneumonia might be better dealt with inside the long term care facility. In patients with a limited life expectancy (for example, those with advanced dementia), end-of-life pneumonia also requires recognition and appropriate, palliative care
Palliative care
Palliative care is a specialized area of healthcare that focuses on relieving and preventing the suffering of patients...
.
Prognosis
Healthcare-associated pneumonia seems to have fatality rates similar to hospital-acquired pneumonia, worse than community-acquired pneumonia but less severe than pneumonia in ventilated patients. Besides clinical markers like tachypneaTachypnea
Tachypnea means rapid breathing. Any rate between 12-20 breaths per minute is normal. Tachypnea is a respiration rate greater than 20 breaths per minute. - Distinction from other breathing terms :...
(fast breathing) or a high white cell count (leukocytosis
Leukocytosis
Leukocytosis is a raised white blood cell count above the normal range in the blood. It is frequently a sign of an inflammatory response, most commonly the result of infection, and is observed in certain parasitic infections...
), the prognosis seems to be influenced by the underlying associated diseases (comorbidities
Comorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...
) and functional capacities (for example, the ADL score
Activities of daily living
Activities of Daily Living is a term used in healthcare to refer to daily self-care activities within an individual's place of residence, in outdoor environments, or both...
). Many patients have a decreased health condition after the episode.
Epidemiology
Several studies found that healthcare-associated pneumonia is the second most common type of pneumonia, occurring less commonly than community-acquired pneumonia but more frequently than hospital-acquired pneumonia and ventilator-associated pneumonia. In a recent observational study, the rates for CAP, HCAP and HAP were 60%, 25% and 15% respectively. Patients with HCAP are older and more commonly have simultaneous health problems (such as previous strokeStroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
, heart failure and diabetes).
The number of residents in long term care facilities is expected to rise dramatically over the next 30 years. These older adults are known to develop pneumonia 10 times more than their community-dwelling peers, and hospital admittance rates are 30 times higher.