Epidemiology and Outcomes of Health-care–Associated Pneumonia: Results From a Large US Database of Culture-Positive Pneumonia

doi:10.1378/chest.128.6.3854

Chest

Volume 128, Issue 6, December 2005, Pages 3854-3862

https://doi.org/10.1378/chest.128.6.3854 Get rights and content

Context:

Traditionally, pneumonia developing in patients outside the hospital is categorized as community acquired, even if these patients have been receiving health care in an outpatient facility. Accumulating evidence suggests that health-care–associated infections are distinct from those that are truly community acquired.

Objective:

To characterize the microbiology and outcomes among patients with culture-positive community-acquired pneumonia (CAP), health-care–associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP).

Design and setting:

A retrospective cohort study based on a large US inpatient database.

Patients:

A total of 4,543 patients with culture-positive pneumonia admitted into 59 US hospitals between January 1, 2002, and December 31, 2003, and recorded in a large, multi-institutional database of US acute-care hospitals (Cardinal Health-Atlas Research Database; Cardinal Health Clinical Knowledge Services; Marlborough, MA).

Main measures:

Culture data (respiratory and blood), in-hospital mortality, length of hospital stay (LOS), and billed hospital charges.

Results:

Approximately one half of hospitalized patients with pneumonia had CAP, and > 20% had HCAP. Staphylococcus aureus was a major pathogen in all pneumonia types, with its occurrence markedly higher in the non-CAP groups than in the CAP group. Mortality rates associated with HCAP (19.8%) and HAP (18.8%) were comparable (p > 0.05), and both were significantly higher than that for CAP (10%, all p < 0.0001) and lower than that for VAP (29.3%, all p < 0.0001). Mean LOS varied significantly with pneumonia category (in order of ascending values: CAP, HCAP, HAP, and VAP; all p < 0.0001). Similarly, mean hospital charge varied significantly with pneumonia category (in order of ascending value: CAP, HCAP, HAP, and VAP; all p < 0.0001).

Conclusions:

The present analysis justified HCAP as a new category of pneumonia. S aureus was a major pathogen of all pneumonias with higher rates in non-CAP pneumonias. Compared with CAP, non-CAP was associated with more severe disease, higher mortality rate, greater LOS, and increased cost.

Section snippets

Study Design

A retrospective cohort analysis was performed to characterize the epidemiology, microbiology, and clinical/economic outcomes of patients with culture-positive CAP, HCAP, HAP, and VAP in the first 5 days of hospital admission. Data were obtained for all patients with pneumonia admitted to 59 US hospitals between January 1, 2002, and December 31, 2003.

Data Source

Data for the present analysis were obtained from a large, multi-institutional database of US acute-care hospitals, the Atlas database (Cardinal

Patient Characteristics

A total of 4,543 patients met the inclusion criteria and were analyzed in the present study. Among these patients, there were 2,221 patients with CAP (48.9%), 988 patients with HCAP (21.7%), 835 patients with HAP (18.4%), and 499 patients with VAP (11%) [Table 2]. Gender differences were statistically nonsignificant among the four pneumonia types. HCAP patients (78.1%) were more likely to be white than were patients with VAP (71.7%). A significantly lower proportion of patients with HCAP were

Comment

To our knowledge, this is the first multi-institutional study defining HCAP as a distinct type of pneumonia. The unique microbiology, epidemiology, and outcomes for patients with CAP, HCAP, HAP, and VAP demonstrated in the present study support a new, refined classification scheme categorizing pneumonias into these four subtypes. Compared with CAP, non-CAP, including HCAP, was associated with more severe disease, higher mortality rate, greater LOS, and increased cost. Our study also suggests

References (33)

JS Garner et al.
CDC definitions for nosocomial infections, 1988
Am J Infect Control
(1988)
J Rello et al.
Epidemiology and outcomes of ventilator-associated pneumonia in a large US database
Chest
(2002)
DE Craven et al.
Healthcare-associated pneumonia in adults: management principles to improve outcomes
Infect Dis Clin North Am
(2004)
J Chastre et al.
Ventilator-associated pneumonia
Am J Respir Crit Care Med
(2002)
MJ Fine et al.
Prognosis and outcomes of patients with community-acquired pneumonia: a meta-analysis
JAMA
(1996)
M Wilkinson et al.
Guidelines for community-acquired pneumonia in the ICU
Curr Opin Crit Care
(2004)
MH Kollef et al.
Clinical cure and survival in Gram-positive ventilator-associated pneumonia: retrospective analysis of two double-blind studies comparing linezolid with vancomycin
Intensive Care Med
(2004)
J Rello et al.
The value of routine microbial investigation in ventilator-associated pneumonia
Am J Respir Crit Care Med
(1997)
PA Tambyah et al.
Community-acquired methicillin-resistantStaphylococcus aureusinfection in Singapore is usually “healthcare associated.”
Infect Control Hosp Epidemiol
(2003)
BM Farr et al.
Would active surveillance cultures help control healthcare-related methicillin-resistantStaphylococcus aureusinfections?
Infect Control Hosp Epidemiol
(2002)

BD Cookson

Methicillin-resistantStaphylococcus aureusin the community: new battlefronts, or are the battles lost?

Infect Control Hosp Epidemiol

(2000)

ND Friedman et al.

Health care-associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections

Ann Intern Med

(2002)

E Tacconelli et al.

Methicillin-resistantStaphylococcus aureusbacteraemia diagnosed at hospital admission: distinguishing between community-acquired versus healthcare-associated strains

J Antimicrob Chemother

(2004)

TS Naimi et al.

Comparison of community- and health care-associated methicillin-resistantStaphylococcus aureusinfection

JAMA

(2003)

CA Morin et al.

Population-based incidence and characteristics of community-onsetStaphylococcus aureusinfections with bacteremia in 4 metropolitan Connecticut areas, 1998

J Infect Dis

(2001)

Hospital-Acquired Pneumonia Guideline Committee of the American Thoracic Society et al.

Guidelines for the management of adults with hospital-acquired pneumonia, ventilator-associated pneumonia, and healthcare-associated pneumonia

Am J Respir Crit Care Med

(2005)

Cited by (859)

Increasing the precision of simulated percutaneous dilatational tracheostomy—a pilot prototype device development study
2024, iScience
Percutaneous dilatational tracheostomy (PDT) is a bedside medical procedure which sites a new tracheostomy tube in the front of the neck. The critical first step is accurate placement of a needle through the neck tissues into the trachea. Misplacement occurs in around 5% of insertions, causing morbidity, mortality, and delays to recovery. We aimed to develop and evaluate a prototype medical device to improve precision of initial PDT-needle insertion. The Guidance for Tracheostomy (GiFT) system communicates the relative locations of intra-tracheal target sensor and PDT-needle sensor to the operator. In simulated “difficult neck” models, GiFT significantly improved accuracy (mean difference 10.0 mm, ANOVA p < 0.001) with ten untrained laboratory-based participants and ten experienced medical participants. GiFT resulted in slower time-to-target (mean difference 56.1 s, p < 0.001) than unguided attempts, considered clinically insignificant. Our proof-of-concept study highlights GiFT’s potential to significantly improve PDT accuracy, reduce procedural complications and offer bedside PDT to more patients.
Epidemiology and outcomes of infections during extracorporeal membrane oxygenation in adult patients with COVID-19 ARDS- A single center study
2024, Indian Journal of Medical Microbiology
There is a scarcity of data regarding nosocomial infections in patients with COVID-19 treated with ECMO. This observational study from India aims to describe the epidemiology and microbiology of infections in patients with COVID-19 associated ECMO.
This is an ambi-directional observational study of COVID-19 ECMO patients admitted from April 2021 to June 2022 in a tertiary care hospital. The total number of sepsis episodes for each patient was recorded and were categorized as bloodstream infections (BSI), pneumonias, skin and soft tissue infections (SSTI), invasive candidiasis (IC), catheter associated urinary tract infection (CAUTI), intra-abdominal infections (IAI), and Clostridioides difficile infections. Details regarding each infection including the microbiological profile and outcomes were recorded.
29 patients who received ECMO for COVID-19 pneumonia during the study period were identified. Of the 29 patients, there were a total of 185 septic episodes. The incidence of septic episodes was 72.4 per 1000 ECMO days.
Of the 185 sepsis events, 82 (44.3%) were BSI, 72 (39%) were pneumonia, 19 (10.3%) were SSTI, 7 (3.8%) were CAUTI and 5 (2.7%) were IAIs. Of these 29 patients, 16 (55.2%) patients were discharged and 13 (44.8%) died.
The most common infections in our patients were bloodstream infections followed by pneumonia. High rates of gram negative infections, including those caused by carbapenem resistant bacteria, reflect the Indian critical care unit epidemiology in general. Despite these high infection rates with antimicrobial resistant set of micro-organisms, we had a successful outcome in 55.2% of patients.
Predictors of hospital mortality and multidrug-resistant pathogens in hospitalized pneumonia patients residing in the community: Predictors of mortality and MDR pathogens
2023, Heliyon
The 2019 ATS/ADSA guidelines for adult community-acquired pneumonia (CAP) eliminated healthcare-associated pneumonia (HCAP) and considered it to be a form of CAP. This concept, however, was based on studies with relatively small sample sizes.
We investigated the risk factors of 30-day mortality, and methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa infections in patients with pneumonia coming from the community using the Diagnosis Procedure Combination database, a nationwide discharge database of acute care hospitals. Furthermore, we compared these factors between CAP and HCAP.
A total of 272,337 patients aged ≥20 years with pneumonia were grouped into 145,082 CAP patients and 127,255 HCAP patients. The 30-day mortality rate (8.9 % vs.3.3 %), MRSA infection (2.4 % vs. 1.4 %), and Pseudomonas aeruginosa infection (1.6 % vs. 1.0 %) were significantly higher in HCAP than in CAP patients. Multivariable logistic regression analysis showed that 12 of 13 identified predictors of mortality (i.e., high age, male, underweight, non-ambulatory status, bedsore, dehydration, respiratory failure, consciousness disturbance, hypotension, admitted in critical care, comorbidity of heart failure, and chronic obstructive pulmonary disease) were identical in CAP and HCAP patients. Similarly, five of six distinct risk factors for MRSA infection, and three of three for Pseudomonas aeruginosa infection were identical between the patients.
The risk factors for mortality and MRSA or Pseudomonas aeruginosa infection were almost identical in patients with CAP and HCAP. The assessment of individual risk factors for mortality and MRSA or Pseudomonas aeruginosa infection in CAP and abandoning categorization as HCAP can improve and simplify empiric therapy.
DnaJ-induced miRNA-146a negatively regulates the expression of IL-8 in macrophages
2023, Microbial Pathogenesis
As a member of the damage-associated molecular patterns, heat shock proteins (HSPs) are widely recognized for their role in initiating innate immune responses. These highly conserved proteins are expressed ubiquitously in both prokaryotes and eukaryotes. In this study, our aim was to investigate how DnaJ, a HSP40 homolog derived from Pseudomonas aeruginosa (P. aeruginosa), influences the regulation of IL-8 expression in macrophages. Treatment with DnaJ served as a stimulus, inducing a more robust expression of IL-8 compared to other HSP homologs, including DnaK, GroEL, and HtpG. This effect was achieved through the activation of the NF-κB signaling pathway. Interestingly, DnaJ treatment also significantly increased the expression of microRNA-146a (miR-146a), which appears to play a role in modulating the expression of innate defense genes. As a consequence, pre-treatment with DnaJ led to a reduction in the extent of IL-8 induction in response to P. aeruginosa treatment. Notably, this reduction was counteracted by transfection of a miR-146a inhibitor, highlighting the involvement of miR-146a in P. aeruginosa-mediated induction of IL-8 expression. Therefore, this study uncovers the role of DnaJ in triggering the expression of miR-146a, which, in turn, modulates the excessive expression of IL-8 induced by P. aeruginosa infection.
Pleural infections
2022, Medicine (Spain)
La infección pleural es la invasión de las membranas pleurales y el espacio entre ambas por diferentes microorganismos, bien de forma directa o indirecta. De entre ellas destacan la infección paraneumónica y la tuberculosa por su frecuencia y tratamientos específicos. La prueba de imagen de elección en el momento actual es la ecografía torácica, tanto para el diagnóstico como para guiar la toracocentesis, detectar complicaciones locales y realizar el seguimiento. Es necesario el análisis bioquímico y microbiológico del líquido pleural para confirmar la infección, identificar las complicaciones y guiar el tratamiento. La demora en el inicio del tratamiento antibiótico se relaciona con una alta morbilidad y mortalidad, por lo que este se iniciará de forma empírica en la mayoría de los casos. Si el derrame pleural está complicado, se debe valorar la realización de técnicas invasivas sobre la cavidad pleural como: la colocación de drenajes pleurales, la instilación en el espacio pleural de fármacos fibrinolíticos y fármacos antiviscosos y el tratamiento quirúrgico en presencia de tabiques en el espacio pleural, ausencia de reexpansión pulmonar o complicaciones no controladas con tratamiento previo. El retraso en la realización de estos tratamientos también aumenta la morbilidad y mortalidad de la enfermedad.
Pleural infection is an invasion of the pleural membranes and the space between them by different microorganisms either directly or indirectly. Of note among them are parapneumonic infection and tuberculosis, given their frequency and specific treatments. The imaging test of choice at present is a chest ultrasound, both for the diagnosis and for guiding the thoracentesis, detecting local complications, and providing follow-up. A biochemical and microbiological analysis of the pleural fluid are necessary for confirming the infection, identifying complications, and guiding treatment. Delays in starting antibiotic treatment are related to high morbidity and mortality. Therefore, treatment will be started empirically in most cases. If the pleural effusion is complicated, performing invasive techniques in the pleural cavity should be evaluated. These techniques include the placement of pleural drainage, instillation of fibrinolytic drugs and viscosity-reducing drugs in the pleural space, and surgical treatment if there are septi in the pleural space, an absence of pulmonary re-expansion, or uncontrolled complications of previous treatment. A delay in providing these treatments also increases the disease's morbidity and mortality.
Molecular detection of respiratory pathogens in community-acquired pneumonia involving adults
2022, Journal of Microbiology, Immunology and Infection
Community-acquired pneumonia (CAP) causes substantial morbidity and mortality in adults worldwide. The etiology of CAP often remains uncertain, and therapy is empirical. Thus, there is still room for improvement in the diagnosis of pneumonia.
Adults aged >20 years who presented at the outpatient or emergency departments of Linkou and Keelung Chang Gung Memorial Hospital with CAP were prospectively included between November 2016 and December 2018. We collected respiratory specimens for culture and molecular testing and calculated the incidence rates of CAP according to pathogens.
Of 212 hospitalized adult patients with CAP, 69.3% were male, and the median age of the patients was 67.8 years. Bacterial pathogens were detected in 106 (50%) patients, viruses in 77 (36.3%), and fungal pathogens in 1 patient (0.5%). The overall detection rate (culture and molecular testing method) was 70.7% (n = 150). Traditional microbial culture yielded positive results in 36.7% (n = 78), molecular testing in 61.3% (n = 130). The most common pathogens were influenza (16.1%), followed by Klebsiella pneumoniae (14.1%), Pseudomonas aeruginosa (13.6%), human rhinovirus (11.8%), and Streptococcus pneumoniae (9.9%). Multiple pathogen co-infections accounted for 28.7% (n = 61), of which co-infection with K. pneumoniae and human rhinovirus comprised the largest proportion.
Molecular diagnostic testing could detect 23.6% more pathogens than traditional culture techniques. However, despite the current diagnostic tests, there is still the possibility that no pathogen was detected.

View all citing articles on Scopus

: This study was supported by a research grant from Pfizer Inc.

View full text

Chest

Clinical InvestigationsINFECTIONEpidemiology and Outcomes of Health-care–Associated Pneumonia: Results From a Large US Database of Culture-Positive Pneumonia

Context:

Objective:

Design and setting:

Patients:

Main measures:

Results:

Conclusions:

Section snippets

Study Design

Data Source

Patient Characteristics

Comment

Am J Infect Control

Chest

Infect Dis Clin North Am

Ventilator-associated pneumonia

Am J Respir Crit Care Med

Prognosis and outcomes of patients with community-acquired pneumonia: a meta-analysis

JAMA

Guidelines for community-acquired pneumonia in the ICU

Curr Opin Crit Care

Clinical cure and survival in Gram-positive ventilator-associated pneumonia: retrospective analysis of two double-blind studies comparing linezolid with vancomycin

Intensive Care Med

The value of routine microbial investigation in ventilator-associated pneumonia

Am J Respir Crit Care Med

Community-acquired methicillin-resistantStaphylococcus aureusinfection in Singapore is usually “healthcare associated.”

Infect Control Hosp Epidemiol

Would active surveillance cultures help control healthcare-related methicillin-resistantStaphylococcus aureusinfections?

Infect Control Hosp Epidemiol

Methicillin-resistantStaphylococcus aureusin the community: new battlefronts, or are the battles lost?

Infect Control Hosp Epidemiol

Health care-associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections

Ann Intern Med

Methicillin-resistantStaphylococcus aureusbacteraemia diagnosed at hospital admission: distinguishing between community-acquired versus healthcare-associated strains

J Antimicrob Chemother

Comparison of community- and health care-associated methicillin-resistantStaphylococcus aureusinfection

JAMA

Population-based incidence and characteristics of community-onsetStaphylococcus aureusinfections with bacteremia in 4 metropolitan Connecticut areas, 1998

J Infect Dis

Guidelines for the management of adults with hospital-acquired pneumonia, ventilator-associated pneumonia, and healthcare-associated pneumonia

Am J Respir Crit Care Med

Clinical Investigations
INFECTION
Epidemiology and Outcomes of Health-care–Associated Pneumonia: Results From a Large US Database of Culture-Positive Pneumonia