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Semin Respir Crit Care Med 2009; 30(2): 239-248
DOI: 10.1055/s-0029-1202940
© Thieme Medical Publishers

Current Perspective of the HCAP Problem: Is It CAP or Is It HAP?

Eva Polverino1 , Antoni Torres1
  • 1Division of Pulmonary Medicine, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona–Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)–University of Barcelona (UB)–Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Publication History

Publication Date:
18 March 2009 (online)

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ABSTRACT

The number of individuals receiving health care outside the hospital setting, including home wound care or infusion therapy, dialysis, nursing homes, and similar settings is constantly increasing. One of the most frequent causes of hospitalization and mortality in these patients is pneumonia. Hence a new class of pneumonia has been identified: healthcare-associated pneumonia (HCAP).

The last American Thoracic Society/Infectious Disease Society of America (ATS/IDSA) guidelines define specific criteria to identify HCAP; however, the clinical practice suggests that the presence of indwelling devices (permanent catheters, etc.) may also be considered an additional criterion.

Different studies have shown that, in comparison with community-acquired pneumonia (CAP) patients, HCAP patients are significantly older, have a higher number of comorbidities (cerebrovascular diseases, congestive heart failure, dementia, and diabetes mellitus) and show worse functional status before admission. It has also been observed that HCAP differs from CAP in terms of clinical presentation, risk factors, etiology, prognostics, and, likely, therapeutic approach. The clinical presentation of HCAP is often unusual because it is frequently conditioned by advanced age, multiple chronic comorbidities, and neurological disorders. Classic respiratory symptoms of pneumonia are often mild in HCAP, whereas extrapulmonary manifestations, including mental confusion and gastrointestinal disorders, are frequent. HCAP patients, commonly present a worse clinical presentation (hypoxemia, altered consciousness, Fine score, multilobar infiltrates, etc.) than CAP, and a mortality rate close to that of hospital-acquired pneumonia. Many studies have attributed these findings to a nosocomial etiology [methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, etc.] with a high frequency of multidrug-resistant infections (MRIs), even though this remains controversial. Further investigation on microbial composition and MRI risk factors of HCAP is fundamental because no definitive therapeutic indications are currently available.

KEYWORDS

Healthcare-associated pneumonia - healthcare-associated infections - nursing home–acquired pneumonia - long-term care facilities

REFERENCES

  • 1 World Health Organization .The world health report 2001: healthy life expectancy. WHO Statistics. Available at: http://www.un.org/esa/population/publications/wpp2002/WPP2002-HIGHLIGHTSrev1.PDF
  • 2 European Commission .The Stockholm and Barcelona targets: Increasing employment of older workers and delaying the exit from the labour market. Working paper of the Commission Services Employment and Social Affairs Brussels, EMPL/A/1. 2 A.D Brussels; European Commission 2002 Available at: http://ec.europa.eu/employment_social/employment_analysis/work/exit_en.pdf
    Search in Google Scholar
  • 3 European Commission .Employment in Europe 2003: recent trends and prospects. Employment and Social Affairs. Luxembourg; Office for Official Publications of the European Communities 2003 Available at: http://ec.europa.eu/employment_social/news/2003/oct/eie2003_foreword_toc_en.pdf
    Search in Google Scholar
  • 4 Hiramatsu K, Niederman M S. Health-care-associated pneumonia: a new therapeutic paradigm.  Chest. 2005;  128 3784-3787
    CrossrefPubMedSearch in Google Scholar
  • 5 Muder R R. Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention.  Am J Med. 1998;  105 319-330
    CrossrefPubMedSearch in Google Scholar
  • 6 Stevenson K B. Regional data set of infection rates for long-term care facilities: description of a valuable benchmarking tool.  Am J Infect Control. 1999;  27 20-26
    CrossrefPubMedSearch in Google Scholar
  • 7 Mylotte J M. Nursing home-acquired pneumonia.  Clin Infect Dis. 2002;  35 1205-1211
    CrossrefPubMedSearch in Google Scholar
  • 8 Kollef M H, Shorr A, Tabak Y P, Gupta V, Liu L Z, Johannes R S. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia.  Chest. 2005;  128 3854-3862
    CrossrefPubMedSearch in Google Scholar
  • 9 American Thoracic Society . Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.  Am J Respir Crit Care Med. 2005;  171 388-416
    CrossrefPubMedSearch in Google Scholar
  • 10 Tablan O C, Anderson L J, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee.  MMWR Recomm Rep. 2004;  53 1-36
    PubMedSearch in Google Scholar
  • 11 Friedman N D, Kaye K S, Stout J E et al.. Health care–associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections.  Ann Intern Med. 2002;  137 791-797
    CrossrefPubMedSearch in Google Scholar
  • 12 Grossman R F, Rotschafer J C, Tan J S. Antimicrobial treatment of lower respiratory tract infections in the hospital setting.  Am J Med. 2005;  118(Suppl 7A) 29S-38S
    CrossrefPubMedSearch in Google Scholar
  • 13 Lim W S, Macfarlane J T. A prospective comparison of nursing home acquired pneumonia with community acquired pneumonia.  Eur Respir J. 2001;  18 362-368
    CrossrefPubMedSearch in Google Scholar
  • 14 Martinez-Moragón E, Garcia Ferrer L, Serra Sanchis B, Fernández Fabrellas E, Gómez Belda A, Julve Pardo R. Community-acquired pneumonia among the elderly: differences between patients living at home and in nursing homes [in Spanish].  Arch Bronconeumol. 2004;  40 547-552
    PubMedSearch in Google Scholar
  • 15 Carratala J, Mykietiuk A, Fernandez-Sabe N et al.. Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes.  Arch Intern Med. 2007;  167 1393-1399
    CrossrefPubMedSearch in Google Scholar
  • 16 Polverino E, Balasso V, Marcos M A et al.. Nursing home-acquired pneumonia: a 10 years, single-centre, experience [abstract].  Am J Respir Crit Care Med 8 A.D.. 2008;  177 A675
    PubMedSearch in Google Scholar
  • 17 Richards C. Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel.  J Am Geriatr Soc. 2002;  50 570-576
    CrossrefPubMedSearch in Google Scholar
  • 18 Gross J S, Neufeld R R, Libow L S, Gerber I, Rodstein M. Autopsy study of the elderly institutionalized patient: review of 234 autopsies.  Arch Intern Med. 1988;  148 173-176
    CrossrefPubMedSearch in Google Scholar
  • 19 Kerr H D, Byrd J C. Nursing home patients transferred by ambulance to a VA emergency department.  J Am Geriatr Soc. 1991;  39 132-136
    PubMedSearch in Google Scholar
  • 20 Marrie T J, Durant H, Yates L. Community-acquired pneumonia requiring hospitalization: 5-year prospective study.  Rev Infect Dis. 1989;  11 586-599
    PubMedSearch in Google Scholar
  • 21 Marrie T J. Pneumonia in the long-term-care facility.  Infect Control Hosp Epidemiol. 2002;  23 159-164
    CrossrefPubMedSearch in Google Scholar
  • 22 Irvine P W, Van B N, Crossley K. Causes for hospitalization of nursing home residents: the role of infection.  J Am Geriatr Soc. 1984;  32 103-107
    PubMedSearch in Google Scholar
  • 23 Marrie T J, Durant H, Yates L. Community acquired pneumonia requiring hospitalisation: 5-year prospective study.  Rev Infect Dis.. 1989;  11 586-599
    PubMedSearch in Google Scholar
  • 24 Gloth III F M, Burton J R. Autopsies and death certificates in the chronic care setting.  J Am Geriatr Soc. 1990;  38 151-155
    PubMedSearch in Google Scholar
  • 25 Muder R R, Brennen C, Wagener M M, Goetz A M. Bacteremia in a long-term-care facility: a five-year prospective study of 163 consecutive episodes.  Clin Infect Dis. 1992;  14 647-654
    PubMedSearch in Google Scholar
  • 26 Slinin Y, Foley R N, Collins A J. Clinical epidemiology of pneumonia in hemodialysis patients: the USRDS waves 1, 3, and 4 study.  Kidney Int. 2006;  70 1135-1141
    CrossrefPubMedSearch in Google Scholar
  • 27 Guo H, Liu J, Collins A J, Foley R N. Pneumonia in incident dialysis patients: the United States Renal Data System.  Nephrol Dial Transplant. 2008;  23 680-686
    PubMedSearch in Google Scholar
  • 28 Grossman S, Mager D D. Managing the threat of methicillin-resistant Staphylococcus aureus in home care.  Home Healthc Nurse. 2008;  26 356-364
    CrossrefPubMedSearch in Google Scholar
  • 29 Weinstein M P, Towns M L, Quartey S M et al.. The clinical significance of positive blood cultures in the 1990s: a prospective comprehensive evaluation of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults.  Clin Infect Dis. 1997;  24 584-602
    PubMedSearch in Google Scholar
  • 30 Joos L, Tamm M. Breakdown of pulmonary host defense in the immunocompromised host: cancer chemotherapy.  Proc Am Thorac Soc. 2005;  2 445-448
    CrossrefPubMedSearch in Google Scholar
  • 31 Maschmeyer G, Link H, Hiddemann W et al.. Pulmonary infiltrations in febrile patients with neutropenia: risk factors and outcome under empirical antimicrobial therapy in a randomized multicenter study.  Cancer. 1994;  73 2296-2304
    PubMedSearch in Google Scholar
  • 32 Sickles E A, Young V M, Greene W H, Wiernik P H. Pneumonia in acute leukemia.  Ann Intern Med. 1973;  79 528-534
    PubMedSearch in Google Scholar
  • 33 Valdivieso M, Gil-extremera B, Zornoza J, Rodriquez V, Bodey G P. Gram-negative bacillary pneumonia in the compromised host.  Medicine (Baltimore). 1977;  56 241-254
    CrossrefPubMedSearch in Google Scholar
  • 34 Carratala J, Roson B, Fernandez-Sevilla A, Alcaide F, Gudiol F. Bacteremic pneumonia in neutropenic patients with cancer: causes, empirical antibiotic therapy, and outcome.  Arch Intern Med. 1998;  158 868-872
    CrossrefPubMedSearch in Google Scholar
  • 35 Warshawsky B, Hussain Z, Gregson D B et al.. Hospital- and community-based surveillance of methicillin-resistant Staphylococcus aureus: previous hospitalization is the major risk factor.  Infect Control Hosp Epidemiol. 2000;  21 724-727
    CrossrefPubMedSearch in Google Scholar
  • 36 Padiglione A A, Grabsch E, Wolfe R, Gibson K, Grayson M L. The prevalence of fecal colonization with VRE among residents of long-term-care facilities in Melbourne, Australia.  Infect Control Hosp Epidemiol. 2001;  22 576-578
    CrossrefPubMedSearch in Google Scholar
  • 37 Richard P, Delangle M H, Raffi F, Espaze E, Richet H. Impact of fluoroquinolone administration on the emergence of fluoroquinolone-resistant gram-negative bacilli from gastrointestinal flora.  Clin Infect Dis. 2001;  32 162-166
    CrossrefPubMedSearch in Google Scholar
  • 38 Lescure F X, Locher G, Eveillard M et al.. Community-acquired infection with healthcare-associated methicillin-resistant Staphylococcus aureus: the role of home nursing care.  Infect Control Hosp Epidemiol. 2006;  27 1213-1218
    CrossrefPubMedSearch in Google Scholar
  • 39 El Solh A A, Pietrantoni C, Bhat A, Bhora M, Berbary E. Indicators of potentially drug-resistant bacteria in severe nursing home-acquired pneumonia.  Clin Infect Dis. 2004;  39 474-480
    CrossrefPubMedSearch in Google Scholar
  • 40 Finkelstein D M, Cassileth B R, Bonomi P D, Ruckdeschel J C, Ezdinli E Z, Wolter J M. A pilot study of the Functional Living Index-Cancer (FLIC) Scale for the assessment of quality of life for metastatic lung cancer patients. An Eastern Cooperative Oncology Group study.  Am J Clin Oncol. 1988;  11 630-633
    PubMedSearch in Google Scholar
  • 41 El-Solh A A, Sikka P, Ramadan F, Davies J. Etiology of severe pneumonia in the very elderly.  Am J Respir Crit Care Med. 2001;  163 645-651
    PubMedSearch in Google Scholar
  • 42 Vergis E N, Brennen C, Wagener M, Muder R R. Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival.  Arch Intern Med. 2001;  161 2378-2381
    CrossrefPubMedSearch in Google Scholar
  • 43 Niederman M S, Brito V. Pneumonia in the older patient.  Clin Chest Med. 2007;  28 751-771 , vi. Review
    CrossrefPubMedSearch in Google Scholar
  • 44 Berk S L. Bacterial pneumonia in the elderly: the observations of Sir William Osler in retrospect.  J Am Geriatr Soc. 1984;  32 683-685
    PubMedSearch in Google Scholar
  • 45 Donowitz G R, Cox H L. Bacterial community-acquired pneumonia in older patients.  Clin Geriatr Med. 2007;  23 515-534 , vi. Review
    CrossrefPubMedSearch in Google Scholar
  • 46 Fernandez-Sabe N, Carratala J, Roson B et al.. Community-acquired pneumonia in very elderly patients: causative organisms, clinical characteristics, and outcomes.  Medicine (Baltimore). 2003;  82 159-169
    CrossrefPubMedSearch in Google Scholar
  • 47 Metlay J P, Schulz R, Li Y H et al.. Influence of age on symptoms at presentation in patients with community-acquired pneumonia.  Arch Intern Med. 1997;  157 1453-1459
    CrossrefPubMedSearch in Google Scholar
  • 48 Riquelme R, Torres A, El-Ebiary M et al.. Community-acquired pneumonia in the elderly. clinical and nutritional aspects.  Am J Respir Crit Care Med. 1997;  156 1908-1914
    PubMedSearch in Google Scholar
  • 49 Marrie T J, Blanchard W. A comparison of nursing home-acquired pneumonia patients with patients with community-acquired pneumonia and nursing home patients without pneumonia.  J Am Geriatr Soc. 1997;  45 50-55
    PubMedSearch in Google Scholar
  • 50 Roghmann M C, Warner J, Mackowiak P A. The relationship between age and fever magnitude.  Am J Med Sci. 2001;  322 68-70
    CrossrefPubMedSearch in Google Scholar
  • 51 Feldman C. Pneumonia in the elderly.  Clin Chest Med. 1999;  20 563-573
    CrossrefPubMedSearch in Google Scholar
  • 52 Marik P E, Kaplan D. Aspiration pneumonia and dysphagia in the elderly.  Chest. 2003;  124 328-336
    CrossrefPubMedSearch in Google Scholar
  • 53 Groher M E. Managing dysphagia in a chronic care setting: an introduction.  Dysphagia. 1990;  5 59-60
    CrossrefPubMedSearch in Google Scholar
  • 54 Kayser-Jones J, Pengilly K. Dysphagia among nursing home residents.  Geriatr Nurs. 1999;  20 77-82
    CrossrefPubMedSearch in Google Scholar
  • 55 Kikuchi R, Watabe N, Konno T, Mishina N, Sekizawa K, Sasaki H. High incidence of silent aspiration in elderly patients with community-acquired pneumonia.  Am J Respir Crit Care Med. 1994;  150 251-253
    CrossrefPubMedSearch in Google Scholar
  • 56 Quagliarello V, Ginter S, Han L, Van N P, Allore H, Tinetti M. Modifiable risk factors for nursing home-acquired pneumonia.  Clin Infect Dis. 2005;  40 1-6
    CrossrefPubMedSearch in Google Scholar
  • 57 El-Solh A A, Pietrantoni C, Bhat A et al.. Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders.  Chest. 2004;  126 1575-1582
    CrossrefPubMedSearch in Google Scholar
  • 58 Watando A, Ebihara S, Ebihara T et al.. Daily oral care and cough reflex sensitivity in elderly nursing home patients.  Chest. 2004;  126 1066-1070
    CrossrefPubMedSearch in Google Scholar
  • 59 Yoneyama T, Yoshida M, Ohrui T et al.. Oral care reduces pneumonia in older patients in nursing homes.  J Am Geriatr Soc. 2002;  50 430-433
    CrossrefPubMedSearch in Google Scholar
  • 60 Waterer G W, Kessler L A, Wunderink R G. Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia.  Chest. 2006;  130 11-15
    CrossrefPubMedSearch in Google Scholar
  • 61 Metersky M L, Sweeney T A, Getzow M B, Siddiqui F, Nsa W, Bratzler D W. Antibiotic timing and diagnostic uncertainty in Medicare patients with pneumonia: is it reasonable to expect all patients to receive antibiotics within 4 hours?.  Chest. 2006;  130 16-21
    CrossrefPubMedSearch in Google Scholar
  • 62 Meehan T P, Fine M J, Krumholz H M et al.. Quality of care, process, and outcomes in elderly patients with pneumonia.  JAMA. 1997;  278 2080-2084
    CrossrefPubMedSearch in Google Scholar
  • 63 Houck P M, Bratzler D W, Nsa W, Ma A, Bartlett J G. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia.  Arch Intern Med. 2004;  164 637-644
    CrossrefPubMedSearch in Google Scholar
  • 64 Abrahamian F M, Deblieux P M, Emerman C L et al.. Health care-associated pneumonia: identification and initial management in the ED.  Am J Emerg Med. 2008;  26 1-11
    PubMedSearch in Google Scholar
  • 65 Kollef M H, Morrow L E, Baughman R P et al.. Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes: proceedings of the HCAP Summit.  Clin Infect Dis. 2008;  46(Suppl 4) S296-S334
    CrossrefPubMedSearch in Google Scholar
  • 66 Micek S T, Kollef K E, Reichley R M, Roubinian N, Kollef M H. Health care-associated pneumonia and community-acquired pneumonia: a single-center experience.  Antimicrob Agents Chemother. 2007;  51 3568-3573
    CrossrefPubMedSearch in Google Scholar
  • 67 El-Solh A A, Aquilina A T, Dhillon R S, Ramadan F, Nowak P, Davies J. Impact of invasive strategy on management of antimicrobial treatment failure in institutionalized older people with severe pneumonia.  Am J Respir Crit Care Med. 2002;  166 1038-1043
    CrossrefPubMedSearch in Google Scholar
  • 68 Tambyah P A, Habib A G, Ng T M, Goh H, Kumarasinghe G. Community-acquired methicillin-resistant Staphylococcus aureus infection in Singapore is usually “healthcare associated”.  Infect Control Hosp Epidemiol. 2003;  24 436-438
    CrossrefPubMedSearch in Google Scholar
  • 69 Naimi T S, LeDell K H, Como-Sabetti K et al.. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection.  JAMA. 2003;  290 2976-2984
    CrossrefPubMedSearch in Google Scholar
  • 70 Pop-Vicas A E, D'Agata E M. The rising influx of multidrug-resistant gram-negative bacilli into a tertiary care hospital.  Clin Infect Dis. 2005;  40 1792-1798
    CrossrefPubMedSearch in Google Scholar
  • 71 Mody L, Maheshwari S, Galecki A, Kauffman C A, Bradley S F. Indwelling device use and antibiotic resistance in nursing homes: identifying a high-risk group.  J Am Geriatr Soc. 2007;  55 1921-1926
    PubMedSearch in Google Scholar
  • 72 Mylotte J M. Nursing home-acquired pneumonia: update on treatment options.  Drugs Aging. 2006;  23 377-390
    CrossrefPubMedSearch in Google Scholar
  • 73 Seenivasan M H, Yu V L, Muder R R. Legionnaires' disease in long-term care facilities: overview and proposed solutions.  J Am Geriatr Soc. 2005;  53 875-880
    CrossrefPubMedSearch in Google Scholar
  • 74 Troy C J, Peeling R W, Ellis A G et al.. Chlamydia pneumoniae as a new source of infectious outbreaks in nursing homes.  JAMA. 1997;  277 1214-1218
    CrossrefPubMedSearch in Google Scholar

Antoni TorresM.D. Ph.D. 

Division of Pulmonary Medicine, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona–Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)–University of Barcelona (UB)–Ciber de Enfermedades Respiratorias (CIBERES), c. Villarroel

170, 08036 Barcelona, Spain

Email: atorres@ub.edu