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Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia

Mario Venditti, MD; Marco Falcone, MD; Salvatore Corrao, MD; Giuseppe Licata, MD; Pietro Serra, MD, the Study Group of the Italian Society of Internal Medicine
[+] Article and Author Information

For a complete list of study group members, see the Appendix.


From the University of Rome, Rome, Italy, and Università degli Studi di Palermo, Palermo, Italy.


Acknowledgment: The authors thank Professor Pier Mannuccio Mannucci, Milan, Italy, for his activity as Chief of the Italian Society of Internal Medicine group for independent clinical research. They also thank Sohita Dhillon and Rod McNab of Wolters Kluwer Health for English-language assistance in the preparation of this manuscript.

Potential Financial Conflicts of Interest:Consultancies: M. Venditti (Glaxo Wellcome, Gilead, Angelini, Novartis, Pfizer, Bayer, Wyeth). Grants received: M. Falcone (Pfizer).

Reproducible Research Statement:Study protocol: Available at http://www.simi.it. Statistical code: Available from Dr. Corrao (s.corrao@unipa.it). Data set: Not available.

Requests for Single Reprints: Mario Venditti, MD, Dipartimento di Medicina Clinica—Policlinico Umberto I, Università di Roma “La Sapienza,” Viale dell'Università 37, 00161 Rome, Italy; e-mail, mario.venditti@uniroma1.it.

Current Author Addresses: Drs. Venditti, Falcone, and Serra: Dipartimento di Medicina Clinica—Policlinico Umberto I, Università di Roma “La Sapienza,” Viale dell'Università 37, 00161 Rome, Italy.

Drs. Corrao and Licata: Dipartimento Biomedico di Medicina Interna e Specialistica, Università degli Studi di Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy.

Author Contributions: Conception and design: M. Venditti, M. Falcone, P. Serra.

Analysis and interpretation of the data: M. Venditti, M. Falcone, S. Corrao.

Drafting of the article: M. Venditti, M. Falcone.

Critical revision of the article for important intellectual content: S. Corrao, G. Licata, P. Serra.

Final approval of the article: S. Corrao, G. Licata, P. Serra.

Provision of study materials or patients: G. Licata.

Statistical expertise: S. Corrao.

Obtaining of funding: G. Licata.

Administrative, technical, or logistic support: G. Licata.

Collection and assembly of data: M. Falcone, S. Corrao.


Ann Intern Med. 2009;150(1):19-26. doi:10.7326/0003-4819-150-1-200901060-00005
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Background: Traditionally, pneumonia has been classified as either community- or hospital-acquired. Although only limited data are available, health care–associated pneumonia has been recently proposed as a new category of respiratory infection. “Health care–associated pneumonia” refers to pneumonia in patients who have recently been hospitalized, had hemodialysis, or received intravenous chemotherapy or reside in a nursing home or long-term care facility.

Objective: To ascertain the epidemiology and outcome of community-acquired, health care–associated, and hospital-acquired pneumonia in adults hospitalized in internal medicine wards.

Design: Multicenter, prospective observational study.

Setting: 55 hospitals in Italy comprising 1941 beds.

Patients: 362 patients hospitalized with pneumonia during two 1-week surveillance periods.

Measurements: Cases of radiologically and clinically assessed pneumonia were classified as community-acquired, health care–associated, or hospital-acquired and rates were compared.

Results: Of the 362 patients, 61.6% had community-acquired pneumonia, 24.9% had health care–associated pneumonia, and 13.5% had hospital-acquired pneumonia. Patients with health care–associated pneumonia had higher mean Sequential Organ Failure Assessment scores than did those with community-acquired pneumonia (3.0 vs. 2.0), were more frequently malnourished (11.1% vs. 4.5%, and had more frequent bilateral (34.4% vs. 19.7%) and multilobar (27.8% vs. 21.5%) involvement on a chest radiograph. Patients with health care–associated pneumonia also had higher fatality rates (17.8% [CI, 10.6% to 24.9%] vs. 6.7% [CI, 2.9% to 10.5%]) and longer mean hospital stay (18.7 days [CI, 15.9 to 21.5 days] vs. 14.7 days [CI, 13.4 to 15.9 days]). Logistic regression analysis revealed that depression of consciousness (odds ratio [OR], 3.2 [CI, 1.06 to 9.8]), leukopenia (OR, 6.2 [CI, 1.01 to 37.6]), and receipt of empirical antibiotic therapy not recommended by international guidelines (OR, 6.4 [CI, 2.3 to 17.6]) were independently associated with increased intrahospital mortality.

Limitations: The number of patients with health care–associated pneumonia was relatively small. Microbiological investigations were not always homogeneous. The study included only patients with pneumonia that required hospitalization; results may not apply to patients treated as outpatients.

Conclusion: Health care–associated pneumonia should be considered a distinct subset of pneumonia associated with more severe disease, longer hospital stay, and higher mortality rates. Physicians should differentiate between patients with health care–associated pneumonia and those with community-acquired pneumonia and provide more appropriate initial antibiotic therapy.

Funding: None.

Figures

Grahic Jump Location
Figure 1.
Geographic distribution of participating centers.
Grahic Jump Location

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Comments

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No Title
Posted on January 26, 2009
Renzo Rozzini
Dept. Internal Medicine & Geriatrics
Conflict of Interest: None Declared
No Comment
Health care associated pneumonia and outcomes
Posted on February 6, 2009
Meritxell Salvadó
Hospital Universitari Mútua de Terrassa
Conflict of Interest: None Declared

We have read with interest the paper of Venditti et al (1) in the Journal. The authors show similar results than previously reported in terms of severity of disease and mortality in the health care related (HCR) group. (2,3,4) We miss the data on the etiology of pneumonia. The association between multiresistant pathogens and HCR- infections has been well established previously (2,3). The high mortality rate that the authors found in HCR pneumonia (HCRP) could be due in part to the greater risk of inappropriate therapy in this group. It is therefore surprising that mortality was not associated with HCR or hospital acquired (HA) categories in multivariate analysis.

Recently, we examined the clinical characteristics and outcomes of a homogenous group of patients with bacteremic pneumococcal pneumonia (BPP) and their relation with the health care system (HCRS) (unpublished data). From Jan 2004 to June 2007, all consecutive adult patients with BPP seen in our hospital were prospectively enrolled. Data obtained included demographics, co morbidities, Pitt score, presence of shock, relation with the HCS and in-hospital mortality. 140 episodes of BPP were identified. Community acquired pneumonia (CAP) was diagnosed in 106 (75%) patients, HCRP in 25 (18%) and HA pneumonia (HAP) in 9 patients (6.4%); mean age was 66.8 (SD 18), 57 (SD 20) and 75 years (SD 12), respectively (p<0.001). Patients with HCRP and HAP presented more commonly with coma and had an increased LOS. Fatality rates in HCRP were similar to HAP (32% vs. 33.3%)and higher than CAP mortality (9.3%, p=0.005). Patients with pneumococcal HCRP presented the highest early mortality (within 72 h of admission) (87.5% vs. 50% in CAP, p<0.001). Few patients received inappropriate therapy and, interestingly enough, it was equally represented among groups.

Multiresistance and inappropriate therapy have been well recognized as risk factors for mortality; however the fact that early mortality was clearly superior in the HCRP group strongly suggests that host related factors are crucial in terms of mortality in BPP. P> References

(1) Venditti M, Falcone M, Corrao S, Licata G, Serra P; Study Group of the Italian Society of Internal Medicine. Outcomes of patients hospitalized with community-acquired, health care-associated, and hospital -acquired pneumonia. Ann Intern Med. 2009; 150:19-26.

(2) Micek ST, Kollef KE, Reichley RM, Roubinian N, Kollef MH. Health care-associated pneumonia and community-acquired pneumonia: a single-center experience. Antimicrob Agents Chemother. 2007; 51:3568-73.

(3) Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest. 2005; 128:3854-62.

(4) Carratalà J, Mykietiuk A, Fernández-Sabé N, Suárez C, Dorca J, Verdaguer R,Manresa F, Gudiol F. Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med. 2007; 167:1393-9.

Conflict of Interest:

None declared

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Summary for Patients

Outcomes in Patients Who Acquired Pneumonia in Various Settings

The summary below is from the full report titled “Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia.” It is in the 6 January 2009 issue of Annals of Internal Medicine (volume 150, pages 19-26). The authors are M. Venditti, M. Falcone, S. Corrao, G. Licata, P. Serra, and the Study Group of the Italian Society of Internal Medicine.

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