Healthcare-Associated Pneumonia

This issue is devoted to the topic of healthcare-associated pneumonia (HCAP). International experts have contributed to this issue with timely and concise manuscripts. Nosocomial pneumonia is one of the most common nosocomial infections occurring in hospitalized patients. The frequent occurrence of this disease is, in part, due to advances in medical technology, particularly the use of mechanical ventilation. However, it is also apparent that increasing numbers of patients are being cared for outside of the hospital setting but have frequent contact with healthcare settings (e.g., hospitals, nursing homes, home wound or infusion therapy, hemodialysis). This has resulted in a new category of patients having healthcare-associated infections, of which pneumonia is one of the most common.

First, Nitin Anand and I provide an overview of HCAP and differentiate it from other types of nosocomial pneumonia, including hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). The article also highlights some of the patient acuity differences that exist within the category of nursing home-associated pneumonia (NHAP), a subgroup of HCAP.

Marya Zilberberg and Andrew Shorr then provide an interesting discussion of the epidemiology of HCAP, again focusing on its differentiation from other types of nosocomial pneumonia as well as community-acquired pneumonia (CAP).

Ali El Solh, a world expert on NHAP, provides a detailed overview of this important category of infection. Increasingly, clinicians are faced with the dilemma of making treatment decisions for patients arriving at the hospital with pneumonia. The presence of risk factors for healthcare-acquired infection dictates that broader-spectrum antimicrobial therapy be initially prescribed to cover more antibiotic-resistant bacteria.

David Ost and his colleague David Poch provide a review of the important risk factors for HCAP, which will assist clinicians in making these important therapeutic decisions.

Eva Polverino and Antoni Torres then provide an insightful review on the diagnosis of HCAP, drawing useful conclusions from the available literature on HAP and VAP.

Peter DeBlieux and his colleagues Ellen Slaven and Jairo Santanilla discuss the importance of HCAP in the emergency department. Increasingly in the United States and abroad, patients are seeking their initial healthcare in an emergency department setting. The importance of this is highlighted by numerous investigations demonstrating that initial antimicrobial therapy of pneumonia, as well as other serious infections in the emergency department, dictates the outcome for the patient. This article will assist those working in the emergency department to differentiate patients with HCAP from those with CAP to provide more timely and directed antimicrobial treatment.

Anna Lam and Richard Wunderink describe the important role of methicillin-resistant Staphylococcus aureus (MRSA) in HCAP. MRSA is increasingly being recognized as an important pathogen in pneumonia, and these authors provide a logical approach for the evaluation of patients with possible MRSA pneumonia, as well as recommendations on appropriate treatment.

Marcos Restrepo and Antonio Anzueto review gram-negative bacteria as a cause of HCAP and highlight the important implications of increasing antimicrobial resistance within this group of pathogens.

Although atypical pathogens have primarily been associated with CAP, Sarah Forgie and Thomas Marrie provide an overview on the role of these pathogens in HCAP. Again, this information will have useful therapeutic implications for clinicians treating patients with HCAP.

As with all infections, there needs to be an emphasis on the prevention of HCAP. HCAP being the newest category of pneumonia suggests that there may not be much information related to its prevention as for CAP, HAP, and VAP. Nevertheless, Lee Morrow describes the logical measures that should be undertaken to minimize the occurrence of HCAP using information derived from the successful prevention of HAP and VAP.

The cornerstone for the treatment of HCAP, as well as other serious infections, is timely and appropriate antimicrobial therapy. Given the increasing resistance of gram-positive and gram-negative bacteria to our current antimicrobial agents, Elizabeth Neuner, David Ritchie, and Scott Micek describe new antibiotics that have the potential for improved treatment of HCAP. This includes the description of several novel cephalosporin agents with activity against both gram-positive and gram-negative bacteria.

Joseph Kuti and colleagues then take on the issue of implementing guidelines for the management of nosocomial pneumonia in the hospital setting.

Finally, Drs. Eagye, Nicolau, and Kuti describe the impact of nosocomial infections on hospital lengths of stay and medical care costs.

We hope that this issue will provide valuable information to clinicians caring for patients with HCAP, as well as other types of nosocomial pneumonia. It is evident that the population at risk for healthcare-acquired infections is increasing as our population ages, becomes more immunosuppressed, and is exposed to infectious threats that increasingly are becoming more virulent and more resistant to existing antimicrobial agents.