Case 1 RUL Apical Segment PA

Health-care associated pneumonia (HCAP) is the term used to describe patients presenting with pneumonia who may be at higher risk of multi-drug resistant (MDR) pathogens than other patients presenting from the community due to recent contact with the health care system. What are the criteria for HCAP?

Criteria for HCAP [1]

  • Hospitalization for 2 days or more in the preceding 90 days
  • Residence in a nursing home or extended care facility
  • Home infusion therapy (including antibiotics and chemo)
  • Chronic dialysis within 30 days
  • Home wound care

The Seemingly Well-Appearing HCAP Patient

When a patient hits your ED with symptoms consistent with pneumonia and meets criteria for HCAP, you most likely reach for vancomycin plus a broad-spectrum, anti-pseudomonal beta-lactam such as piperacillin/tazobactam. Perhaps you even add on a second gram-negative agent such as a fluoroquinolone or aminoglycoside if you are closely following the old 2005 ATS pneumonia guidelines [1]. In an era where antimicrobial stewardship is becoming increasingly essential to prevent further development of drug resistance, do we need to be hitting all of these seemingly well HCAP patients with ‘gorillacillin?’ A new study in Clinical Infectious Diseases says maybe not [2].

Study Methods

In this Japanese multicenter, prospective study, the authors attempted to identify low-risk patients with HCAP who might fare just as well with a less aggressive antibiotic regimen such as that for community-acquired pneumonia (CAP). The study took into account criteria for HCAP in conjunction with risk factors for harboring MDR pathogens.

Risk Factors for Multi-drug Resistant Pathogens

  • Antimicrobial therapy in preceding 90 days
  • Current (recent) hospitalization of 5 days or more
  • Poor functional status
  • Immunosuppressive disease and/or therapy

Study Question

Can patients with HCAP with non-severe illness (i.e., not requiring intubation or ICU admission) and <2 risk factors for MDR be deemed as “low risk” and thus can be treated with CAP therapy (respiratory fluoroquinolone or beta-lactam plus macrolide) instead of HCAP guideline-concordant therapy (anti-pseudomonal beta-lactam plus fluoroquinolone or aminoglycoside plus vancomycin or linezolid)?

Results

Following this modified treatment approach where HCAP patients are divided into high-risk (HCAP regimen) versus low-risk (CAP regimen), only 50% received broad-spectrum coverage, yet 93% of regimens were appropriate for the identified pathogen! Of note, atypical organisms were also identified in 10% of the patients with HCAP, which is an interesting finding since empiric HCAP treatment (without the inclusion of a fluoroquinolone) does not cover atypical organisms.

Even more recent data…

A separate group evaluated a retrospective cohort comparing HCAP patients treated with CAP regimens versus HCAP regimens. They found NO increase in clinical cure rates in patients that received HCAP guideline-concordant regimens [3].

Take home points

  • Until the updated guidelines for the management of hospital-acquired and HCAP are released (IDSA’s projected publication is summer 2015), consider using CAP treatment for non-severely ill HCAP patients with < 2 risk factors for MDR pathogens. 
  • Although CAP treatment regimens provide a narrower spectrum therapy, they do add atypical organism coverage that most HCAP treatment regimens do not.
  • If you are giving HCAP treatment regimens, consider also providing atypical coverage (with a respiratory fluoroquinolone or macrolide).

References

  1. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416. PubMed
  2. Maruyama T, Fujisawa T, Okuno M, et al. A new strategy for healthcare-associated pneumonia: A 2-year prospective multicenter cohort study using risk factors for multidrug resistant pathogens to select initial empiric therapy.  Clin Infect Dis 2013;57:1373-83. Pubmed
  3. Chen J, Slater L, Kurdgelashvili G, Husain K, Gentry C. Treatment with guideline-concordant regimens versus community-acquired pneumonia guideline-concordant regimens for patients admitted to acute care wards from home.  Ann Pharmacother 2013;47:9-19. Pubmed

Emily Heil, PharmD, BCPS, AAHIVP

Emily Heil, PharmD, BCPS, AAHIVP

Clinical Assistant Professor, Pharmacy Practice
Clinical Pharmacy Specialist, Infectious Diseases
University of Maryland
Emily Heil, PharmD, BCPS, AAHIVP

@emilylheil

Assistant Professor @UMSOP and Infectious Diseases Pharmacist practicing @UMMC in Baltimore. @UNCPharmacy roots. Big fan of @SIDPharm. On a mission to #saveabx