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)?


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).


  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


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