Chest
Volume 137, Issue 5, May 2010, Pages 1138-1144
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ORIGINAL RESEARCH
HEALTH-CARE-ASSOCIATED PNEUMONIA
Why Mortality Is Increased in Health-Care-Associated Pneumonia: Lessons From Pneumococcal Bacteremic Pneumonia

https://doi.org/10.1378/chest.09-2175Get rights and content

Background

A cohort of patients with bacteremic Streptococcus pneumoniae pneumonia was reviewed to assess why mortality is higher in health-care-associated pneumonia (HCAP) than in community-acquired pneumonia (CAP).

Methods

A prospective cohort of all adult patients with bacteremic pneumococcal pneumonia attended at the ED was used.

Results

One hundred eighty-four cases were classified as CAP and 44 (19%) as HCAP. Fifty-two (23%) were admitted to the ICU. Three (1.5%) isolates were resistant to β-lactams, and only two patients received inappropriate therapy. The CAP cohort was significantly younger (median age 68 years, interquartile range [IQR] 42–78 vs 77 years, IQR 67–82, P < .001). The HCAP cohort presented a higher Charlson index (2.81 ± 1.9 vs 1.23 ± 1.42, P < .001) and had higher severity of illness at admission (altered mental status, respiratory rate > 30/min, Pao2/Fio2 < 250, and multilobar involvement). HCAP patients had a lower rate of ICU admission (11.3% vs 25.5%, P < .05), and a trend toward lower mechanical ventilation (9% vs 19%, P = .17) and vasopressor use (9% vs 18.4%, P = .17) were documented. More patients in the HCAP cohort presented with a pneumonia severity index score > 90 (class IV-V, 95% vs 65%, P < .001), and 30-day mortality was significantly higher (29.5% vs 7.6%, P < .001). A multivariable regression logistic analysis adjusting for underlying conditions and variables related to severity of illness confirmed that HCAP is an independent variable associated with increased mortality (odds ratio = 5.56; 95% CI, 1.86–16.5).

Conclusions

Pneumococcal HCAP presents excess mortality, which is independent of bacterial susceptibility. Differences in outcomes were probably due to differences in age, comorbidities, and criteria for ICU admission rather than to therapeutic decisions.

Section snippets

Study Population

Patients admitted between January 1999 and June 2007 to an 800-bed teaching hospital (500 beds for acute care patients and 300 for long-term hospitalization) were prospectively identified by one of the authors (M. L.). All patients aged ≥ 18 years who received a diagnosis of pneumonia (fever, productive cough, chest pain, shortness of breath, and crackles on auscultation in addition to a chest radiograph interpreted as pneumonia), and whose blood cultures obtained within the first 48 h of

Results

During the study period, all consecutive patients with bacteremic pneumococcal pneumonia were identified at the ED. Twenty were excluded because of HIV infection. Forty-four (19%) had HCAP and 184 had CAP. Hospitalization in the previous 90 days (25 patients, 56.8%) was the most common condition in the HCAP cohort, with 16 (38.5%) patients admitted from long-term care facilities. Only eight were receiving cancer chemotherapy, and one patient was receiving hemodialysis. Six patients met more

Discussion

This article compares CAP with HCAP specifically in monomicrobial bacteremic pneumococcal pneumonia, and evaluates the implications of HCAP in the ICU. Our findings endorse the concept that patients with pneumococcal HCAP present significant differences in terms of demographics, severity of illness, and complications. These differences are not only of academic interest, since HCAP was associated with higher mortality. Interestingly, inappropriate therapy was uncommon when isolates were

Acknowledgments

Author contributions: Dr Rello: contributed to study design, analysis of data, writing the first draft, and creating the final version of the manuscript.

Dr Luján: contributed to study design, enrolling patients, recording variables, conducting follow-up, collecting samples, analyzing data, writing the first draft, and creating the final version of the manuscript.

Dr Gallego: contributed to study design, analysis of data, writing the first draft, and creating the final version of the manuscript.

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Funding/Support: This study was supported in part by CIBER enfermedades respiratorias (CIBERes) 06/06/36, AGAUR 2009/SGR/1226, FISS 08/0452, and FISS 04/1500. The Proyecto Corporativo de Neumonía (PROCORNEU) Study Group is supported by CIBERes, Instituto de Salud Carlos III.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).

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A complete list of participants is located in the appendix.

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