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Increasingly, patients are receiving treatment at facilities other than hospitals, including long-term–health care
facilities, assisted-living environments, rehabilitation facilities, and dialysis centers. As with hospital environ-
ments, nonhospital settings present their own unique risks of pneumonia. Traditionally, pneumonia in these
facilities has been categorized as community-acquired pneumonia (CAP). However, the new designation for
pneumonias acquired in these settings is health care–associated pneumonia (HCAP), which covers pneumonias
acquired in health care environments outside of the traditional hospital setting and excludes hospital-acquired
pneumonia (HAP), ventilator-associated pneumonia (VAP), and CAP. Although HCAP is currently treated
with the same protocols as CAP, recent evidence indicates that HCAP differs from CAP with respect to pathogens
and prognosis and, in fact, more closely resembles HAP and VAP. The HCAP Summit convened national
infectious disease opinion leaders for the purpose of analyzing current literature, clinical trial data, diagnostic
considerations, therapeutic options, and treatment guidelines related to HCAP. After an in-depth analysis of
these areas, the infectious disease investigators participating in the summit were surveyed with regard to 10
clinical practice statements. The results were then compared with results of the same survey as completed by
744 Infectious Diseases Society of America members. The similarities and differences between those survey
results are the basis of this publication.
Pneumonia is one of the most common infections re- ular contact with the health care system [1, 2]. Cur-
quiring hospitalization. Changes in the location and rently accepted classifications of pneumonia include
manner in which health care is currently administered community-acquired pneumonia (CAP), hospital-ac-
have resulted in the need to reassess the classification quired pneumonia (HAP), ventilator-associated pneu-
scheme employed for pneumonia. This is most evident monia (VAP), and nursing home–associated pneumo-
when dealing with the increasing numbers of ambu- nia (NHAP). The designation of health care–associated
latory and nonhospitalized individuals who are in reg- pneumonia (HCAP) was recently introduced to include
an already-ill population of nursing-home residents,
patients in long-term care, patients undergoing same-
Reprints or correspondence: Dr. Marin H. Kollef, Div. of Pulmonary and Critical day procedures, patients receiving home- or hospital-
Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave.,
Campus Box 8052, St. Louis, MO 63110 (mkollef@imwustl.edu). based intravenous therapy, and patients undergoing di-
Clinical Infectious Diseases 2008; 46:S296–334 alysis [3]. The patient population at risk for HCAP is
2008 by the Infectious Diseases Society of America. All rights reserved.
large and diverse, probably making up the largest single
1058-4838/2008/4608S4-0002$15.00
DOI: 10.1086/526355 category of patients with pneumonia [2, 4, 5]. In gen-
as it applied to nonhospitalized patients with HCAP. The ra- patient facility or ED or is admitted directly to the hospital.
tionale for including those with community-acquired HCAP However, there is a question regarding whether the guidelines
was that some data were available for this group, especially for for such patients should also apply to patients who remain in
those with NHAP. Therefore, the committee felt that there was a nonhospital environment, such as a nursing home or long-
sufficient evidence to make recommendations for some of the term-care facility, or who remain in another setting but who
issues. However, several areas with insufficient information meet the other ATS-IDSA criteria for having HCAP [3].
were identified.
Methods
STATEMENT 1: THE PATIENT IN/FROM A
A search of the OVID “1996-present” database to identify stud-
HEALTH CARE–ASSOCIATED, NONHOSPITAL
ies related to descriptions of HCAP was completed on 1 No-
ENVIRONMENT WHO DEVELOPS A CLINICAL
vember 2006. The search of the combined term “health care
PRESENTATION OF PNEUMONIA HAS HCAP
associated or healthcare-associated” produced a total of 144
Rationale and Definition of Statement articles. Next, the text word search for the term “HCAP” yielded
In defining HCAP as a distinct clinical entity, the most recent 66 articles, and the text word search for “healthcare-associated
ATS-IDSA nosocomial pneumonia guidelines defined a subset pneumonia” resulted in 7 articles. At this point, the 2 text word
of patients at risk for harboring resistant organisms despite searches were combined with the first combined-term search,
their residence in the community [3]. Criteria included hos- and the results were limited to the English language. This pro-
pitalization in an acute-care facility for ⭓2 days within 90 days duced 82 articles. The same search strategy was then used in
before the infection; residence in a nursing home or long-term- the OVID database “in process,” and an additional 10 articles
care facility; recent receipt of intravenous antibiotic therapy, were identified. By scanning the titles of these 92 articles, 14
chemotherapy, or wound care, within 30 days before the in- relevant articles were noted, and a review of the references for
fection; or attending a hospital or hemodialysis clinic [3]. Al- these 14 articles added 4 articles to the total. Thus, 18 articles
though the ATS-IDSA guidelines were intended to apply only were considered to be relevant to this statement.
to hospitalized patients with HCAP, it is apparent that these
concepts are being extrapolated to nonhospitalized patients Evidence
with HCAP as well [12]. By definition, the ATS-IDSA guidelines Definitions of HCAP. Several definitions of HCAP are stated
apply to patients coming to an acute-care facility from a non- or implied in the medical literature. One prevalent use of the
hospital environment, whether the patient is seen in an out- term, considered to be irrelevant to this discussion, is the use
Level of Support
When voting on the support for this statement in the group
at large, 55% of the summit participants accepted the statement
with some reservations, 27% accepted the statement with major
reservations, and 9% rejected the statement completely. In com-
parison, of the 383 IDSA members who participated in the
Grading of Evidence Figure 4. Voting comparison for statement 3 (“The recommended eval-
On the basis of a review of the studies cited previously, the 5 uation of HCAP with treatment failures is the same as that for HAP”).
“Summit members” refers to the 11-member summit panel; “IDSA mem-
members of this workshop agreed that the evidence available bers” refers to the members of the Infectious Diseases Society of America
to support this statement was category V for the statement in who responded to a Web-based survey. HAP, hospital-acquired pneumonia;
general, category IV for the statement as it applies to hospi- HCAP, health care–associated pneumonia.
NOTE. CAP, community-acquired pneumonia; CPIS, clinical pulmonary infection score; CXR, chest x-ray; HCAP, health care–associated pneumonia; ICU, intensive care unit; NR, not reported; VAP, ventilator-
associated pneumonia.
Treatment failure
Patients, or recurrence
Study no. Population rate, % Definition Causes and comments
Genne et al. 2006 [57] 224 CAP 24 One or more: fever for 13 days (or Cause of treatment failure: host factors, 34 (63%); unusual pathogens, 10
16 days if bacteremic), clinical (19%); superinfection, 4 (7%); incorrect drug dosing, 3 (6%); not pneumonia,
deterioration necessitating antibi- 3 (6%)
otic change, or death after 48 h
of antibiotic therapy
Arancibia et al. 2000 [58] 444 CAP 11 Fever, clinical deterioration, CXR film Nonresponding, 61%; progressive, 39%; only HAP related to mortality, persis-
tent infections due to resistance
El-Solh et al. 2001 [27] 104 CAP and NHAP NR None used The only intermediate outcome correlated with mortality was 24-h urine output
Rosón et al. 2004 [42] 1383 CAP 6 Early fever, hemodynamics, respira- Progressive pneumonia, 67%; empyema, 22%; failure associated with
tory, CXR film increased mortality
Genne et al. 2003 [59] 3048 CAP 11 Fever, clinical deterioration, antibi- Causes of failure: unknown, 82%; resistant, 8%; superinfection, 2%
otic change, resistant pathogen
NOTE. CAP, community-acquired pneumonia; CXR, chest x-ray; HAP, hospital-acquired pneumonia; NHAP, nursing home–associated pneumonia; NR, not reported.
Future Directions
HCAP is new, none of the studies cited specifically evaluated
Future directions discussed by the summit members focused
patients with HCAP exclusively. Additionally, the lack of a stan-
on the limitations of the previously discussed studies. Appro-
dardized definition of treatment failure makes conclusive state-
priately designed epidemiologic studies are clearly needed to
ments regarding treatment failure problematic. Furthermore,
better delineate the causes of treatment failure in CAP, HAP,
the existing literature did not report stratified analyses for the
and HCAP. Careful consideration and construction of clinically
HCAP and HAP populations; therefore, any conclusions should
useful definitions of treatment failure should be done before
be viewed as preliminary.
these studies are performed, so that clinically useful recom-
Given these limitations, this systematic assessment of treat-
mendations can be made. Once standardized definitions can
ment failure definitions and their relationship to mortality in
be validated, trends in treatment failure can be followed lon-
HAP and HCAP raises interesting questions and preliminary
gitudinally to assess changes in treatment failure rates and
observations. First, because of differences in study design, in-
causes over time.
clusion criteria, populations studied, and definitions used, there
is significant heterogeneity in terms of treatment failure rates
STATEMENT 5: SEVERE CAP IS NOT HCAP
both within and between groups. Although it appears that treat-
ment failure rates are higher among patients with HAP than Rationale and Definition of Statement
among patients with HCAP, because of the lack of a stratified Over the past decade, there has been an increase in infections
analysis, this is not necessarily the case. HCAP may fall some- due to MDR pathogens in individuals referred to acute-care
where between HAP and CAP in terms of treatment failure hospitals who have been previously hospitalized, have received
rates. However, a properly stratified analysis needs to be per- broad-spectrum antibiotics, or reside in nursing homes or other
formed before more-specific conclusions can be drawn, and long-term-care facilities [2, 3, 13, 16, 23, 60]. These individuals
clinically useful definitions need to be standardized. may need different empirical antibiotics for pneumonia, to
One consistent finding was that superinfection appeared to avoid delays in receiving appropriate antibiotic therapy. Such
be more of a problem in patients with HAP than in the CAP/ delays have been shown to result in poorer outcomes from
HCAP population reviewed. Unusual or resistant pathogens serious infections [2, 3, 61–63].
were more of a problem in the latter group. This is probably HCAP, as defined in the 2005 ATS-IDSA guidelines, includes
a result of differences in infection control and exposure, an- pneumonia in patients referred to hospitals for evaluation and
tibiotic use, and host factors. However, this finding should be treatment who were more likely to be colonized or infected
viewed with caution when HAP and HCAP are compared, ow- with MDR pathogens [3]. Risk factors for different MDR path-
ing to the lack of properly stratified data analysis. ogens are variable and complex; these factors may include pre-
Finally, this review demonstrates the importance of con- vious hospitalization, prior antibiotic therapy, chemotherapy,
structing sound and clinically useful definitions before ap- hemodialysis, wound therapy, and residence in nursing homes
proaching complex problems. Whether the same or different and long-term-care facilities, either alone or in combination.
definitions of treatment failure are used for HAP and HCAP Fewer data are available on these patients managed in non–
does not matter if the definitions are not valid and clinically acute-care settings where presentations, clinical data, and ther-
useful. At a minimum, a “good” definition of treatment failure apy are more limited [64, 65].
should do the following: Principles for the treatment of patients with HCAP referred
NOTE. Data are from [3]. ESBL+, extended-spectrum b-lactamase producing; MRSA, methicillin-resistant Staphylococcus aureus.
a
If Acinetobacter species or an ESBL+ isolate is suspected, a carbapenem is recommended, pending susceptibility results.
b
If MRSA is suspected or there is a high incidence locally.
c
If L. pneumophila is suspected, the combination antibiotic regimen should include a macrolide (e.g., azithromycin), or a fluoroquinolone (e.g., ciprofloxacin
or levofloxacin) should be used rather than the aminoglycoside.
antibiotic regimen in the long-term-care setting, the patient to support this statement was category III for the statement in
would then be eligible for referral to an acute-care hospital or general, category III for the statement as it applies to hospi-
clinic for evaluation (figure 7). talized patients with HCAP, and category V for the statement
Community-acquired MRSA was first seen in the 1990s in as it applies to nonhospitalized patients with HCAP (table 2).
children and more recently has occurred in adults [76]. This
strain is distinct from the hospital MRSA associated with HAP, Level of Support
VAP, and HCAP, because it has a mec IV gene and the Panton- When voting on the support for this statement, 91% of the
Valentine leukocidin gene, which may account, in part, for its
summit members and 83% of the IDSA members who re-
increased virulence and predisposition to abscess formation and
sponded to the survey accepted it completely; it was accepted
severe pneumonia. Outbreaks have occurred in nursing homes
with some reservations by 9% of the summit members and
and long-term-care facilities and have now been identified in
13% of the IDSA members. One percent of IDSA members
hospitals. In comparison with hospital-acquired MRSA, com-
accepted the statement with major reservations, 2% rejected
munity-acquired MRSA is more sensitive to antibiotics such as
the statement with reservations, and 1% rejected it completely
ciprofloxacin and clindamycin.
(figure 8).
HCAP questions of concern. Several questions need atten-
tion. Can and should severe HCAP be managed in nursing
homes or long-term-care facilities? Do the HCAP time lines Discussion
for prior antibiotic use and prior hospitalization apply to man- The management of pneumonia is dynamic, and the evolution
agement, or do they need to be altered? Are the HCAP defi- of MDR pathogens in community and health care settings will
nitions accurate? Should the severity of disease alter initial an- require frequent refining and careful monitoring. The statement
tibiotic management for patients with HCAP? How does the that severe CAP is not HCAP is based on multiple factors,
rapid evolution of community-acquired MRSA in nursing including the lack of a consensus on the definitions of severe
homes, long-term-care facilities, and hospitals alter the HCAP CAP, the clinical heterogeneity of patients, the pathogens, and
recommendations? the lack of validation of scoring systems. Other factors include
the lack of assessment for MDR pathogens, patient residence
Grading of Evidence in nursing homes, prior antibiotic therapy, outcomes related
On the basis of a review of the studies cited above, the 5 to appropriate antibiotic therapy, and confounding by other
members of this workshop agreed that the evidence available conditions, such as sepsis syndrome.
The definitions and data presented support the concept that long-term outcomes. There is a great deal to learn, and work
severe CAP is not HCAP. Although the approaches to diagnosis is needed to improve our databases and the current guidelines
and the management principles are similar, the definition of for both prevention and therapy for specific at-risk patient
HCAP is focused on the risk factors for infection with MDR populations. Ideally, observational, multicenter cohort studies
pathogens that may alter initial therapy for pneumonia; the using clear definitions and optimal data collection and analysis
definition of severe CAP is based on severity of disease that are needed. Also, patients should be followed longitudinally to
may be caused by a wide variety of non-MDR pathogens. Sev- assess changes in colonization with MDR pathogens over time.
eral scoring systems have been used to identify patients who
may need more clinical attention or intensive care and have a STATEMENT 6: INITIAL EMPIRICAL THERAPY
greater risk of mortality. Some patients with severe pneumonia FOR HCAP IS THE SAME AS THAT FOR HAP
who present to a clinic or hospital ED may have originally
received diagnoses of CAP but, with new definitions, are cat- Rationale and Definition of Statement
egorized as having HCAP because of their risk for infection Many issues in addition to antibiotic choice enter into the
with MDR pathogens. HCAP may share similar management decision making regarding initial empirical therapy for HCAP.
principles with CAP, including antibiotic de-escalation and du- The current definition of HCAP includes a heterogeneous
ration of therapy. However, the spectrum of HCAP outside of group of patients, with variability in features such as site of
the ATS-IDSA guidelines and the rapid evolution of commu- care (hospital or nonhospital), route of therapy (oral or intra-
nity-acquired MRSA in the community may have had an im- venous), and risk factors for infection with MDR pathogens.
pact on the spread of MDR isolates in the community outside Some patients are also at risk for infection with other organ-
of the current concepts of HCAP. isms, such as Legionella and viruses, which can be seen in CAP
more than in HAP. These organisms can be epidemic in certain
Future Directions nursing homes. Because of these varying patient characteristics,
Future directions discussed by the summit members reflected the initial empirical therapy needs to account for differences
many needs, including better-designed epidemiologic studies, in treatment approaches to HCAP and HAP, allowing for the
more-rigorous definition of terms, improved epidemiologic and possibility that some subpopulations should be managed like
microbiological criteria, and better-standardized diagnostic and patients with HAP, some like patients with CAP, and some with
laboratory criteria. Better data for HCAP are also needed in a hybrid approach. HCAP includes many patient populations,
the acute-care setting versus various long-term-care settings in some of which have been extensively studied, such as those
terms of epidemiology, diagnosis, management, and short- and with NHAP; other populations, such as those undergoing he-
modialysis and those recently hospitalized, are less well combined with the term “antibiotic therapy” (201,780 articles)
described. by use of the “AND” function, a total of 19 articles remained.
When the ATS-IDSA guidelines suggested that HCAP be The term “nursing home pneumonia” (452 articles) combined
treated like HAP, with a focus on MDR pathogens, it was im- with “antibiotic therapy” yielded 47 articles. These searches
plied that the patients evaluated were those in the hospital who were limited to adults, clinical trials, reviews, meta-analyses, or
were treated with intravenous antibiotics. However, as discussed practice guidelines.
in this review, HCAP also includes patients who are not ill To broaden the search, the term “hemodialysis” (35,454 ar-
enough to require hospital admission, those who are not at risk ticles) was combined with the term “pneumonia” to yield 107
for infection with MDR pathogens but are at risk for infection articles. Finally, the term “prior hospitalization” (5084 articles)
with CAP-associated pathogens, those who are treated orally, was combined with the term “pneumonia” to yield 205 articles.
and those who prefer to be treated at home or in a nursing Fourteen articles were deemed relevant to the statement. This
home, regardless of illness severity. database of articles was reviewed and cross-referenced to eval-
uate original studies of therapy for patient populations included
Methods within the definition of HCAP.
Studies of therapy were evaluated by searching PubMed. When
the term “healthcare associated pneumonia” (399 articles) was Evidence
Differences in the approach to therapy between HCAP and
HAP. There are a number of differences between HCAP and
HAP, making it likely that the initial empirical therapy for both
illnesses will not always be the same. By definition, HAP occurs
in the hospital and is treated in the hospital. However, HCAP
can arise outside of the hospital or in patients from health care
environments after they are admitted to the hospital, and it
can be treated both out of and in the hospital. If patients are
managed out of the hospital, therapy can be oral, as in the case
of the quinolones, which have been highly effective as therapy
for patients with NHAP managed both in the nursing home
Figure 8. Voting comparison for statement 5 (“Severe CAP is not
and in the hospital [19, 77, 78].
HCAP”). “Summit members” refers to the 11-member summit panel; “IDSA
members” refers to the members of the Infectious Diseases Society of HCAP arising in patients in nursing homes has been effec-
America who responded to a Web-based survey. CAP, community-acquired tively treated with oral quinolone therapy, and, in many in-
pneumonia; HCAP, health care–associated pneumonia. stances, this approach has averted hospital admission. In one
Discussion
The evidence presented highlights the complexity of HCAP and
its empirical therapy. For a number of reasons, HCAP should
not always be treated the same as HAP. If similar therapy were
routinely administered, it could needlessly overtreat some pa-
tients with an unnecessarily broad spectrum of antibiotics.
Level of Support
When voting on the support for this statement in the group
at large, 9% of the summit participants voted to accept it com-
pletely, 9% accepted the statement with some reservations, 64%
accepted the statement with major reservations, and 18% re-
Grading of Evidence
On the basis of this literature review, 6 members of the HCAP
Therapeutic Intervention workshop voted that the nature of Figure 12. Voting comparison for statement 8 (“Patients should receive
the evidence for the statement ranged from category II to V initial empirical therapy that covers MRSA at the time of HCAP diag-
nosis”). “Summit members” refers to the 11-member summit panel; “IDSA
for all patients, from category II to IV for patients admitted to
members” refers to the members of the Infectious Diseases Society of
the hospital, and from category II to V for patients never ad- America who responded to a Web-based survey. HCAP, health care–
mitted to the hospital. Therefore, the workshop voted that there associated pneumonia; MRSA, methicillin-resistant Staphylococcus
was poor evidence to support the statement for all patients and aureus.
Aspiration event
Aspiration pneumonitis
Pneumonia with no infiltrate
Therapy ⭐24 h (n p 47) 124 h (n p 21) (n p 42) (n p 60) P
Antibiotic prescribed in nursing home 16 (34) 6 (29) 6 (14) 14 (23) .19
Antibiotic prescribed in ED 36 (77) 18 (86) 28 (67) 35 (67) .04
Antibiotic prescribed after admission 42 (89) 20 (95) 41 (97) 45 (75) .004
No antibiotic prescribed, 1 dose of antibiotic, or 6 (13) 2 (10) 1 (2) 17 (28) .003
!24 h of antibiotic therapy
Duration of antibiotic therapy, mean days SD 5.2 2.0 (n p 36) 6.4 2.5 (n p 15) 5.5 3.1 (n p 34) 4.7 3.0 (n p 40) .19
(sample size)
Antibiotic prescribed at time of discharge 25 (66) 11 (69) 28 (82) 18 (45) .01
NOTE. Data are no. (%) unless otherwise indicated. ED, emergency department. Adapted from [106], with permission from Blackwell Publishing.