THE PRINCIPLES FOR CARE OF HCAP

TUTIK K
INTRODUCTION
 Pneumonia is a major cause of morbidity and
mortality worldwide.
 CDC: a leading cause of death from infectious
diseases.
 Hospitalization for elderly patients with CAP has
increased by 30% since 1988
 Experts started advocating for HCAP as a new
classification of pneumonia in the early twenty-
first century
 In 2005, ATS/IDSA: healthcare-associated
pneumonia (HCAP) as a new category of
pneumonia.
Seymann, 2008; Attridge, 2011; Falcone et al, 2011; Yap et al 2011, Magnuson, 2013
 HCAP vs CAP
 HCAP is distinct from CAP:
 patient characteristics, pathogen distribution
patterns,and outcomes

 Compared to CAP patients, HCAP patients present:

 more severe disease
 more likely to be infected with drug-resistant
pathogens
 suffer worse health outcomes.
 greater length of hospitalization.

Kollef et al, 2005; Jung, et al, 20011, Attridge, 2011; Guimaraes, 2011
Definitions of various types of pneumonia based on
historical data

Jung et al, 2011

DEFINITION
 HCAP was defined by the ATS guidelines as pneumonia
occurring in the setting of any of the following risk
factors:
 (1) Hospitalization for more than 2 days in an acute
care hospital in the last 90 days;
 (2) Residence in a skilled nursing facility;
 (3) Recent Intravenous antibiotic therapy,
chemotherapy, or wound care in the last 30 days
 (4) Attending a hospital or hemodialys is clinic;
 (5) Immunosuppression.
Magnuson, 2013,Yap, 2013
 Patients who increased risk for HCAP have also
risk factors for colonization with resistant organisms

Magnuson, 2013
Definition of HCAP according to the ATS-IDSA 2005

Kohno S et al, 2013

HCAP definitions, by study

Attridge, 2009
 Immunosuppressive disease and/ therapy

 Seropositivity for human immunodeficiency virus (HIV)

 Radiation or chemotherapy for underlying malignancy within 6 months
 Receipt of either solid organ transplant or bone marrow transplant
 Daily administration of corticosteroids (≥5mg/day of prednisone or
equivalent)
 Use of other immunosuppressive agent (e.g., cyclosporine)
 Acquired immune deficiency disorders

Attridge, 2009
Percentage of patients included in four criteria for HCAP

Falcone, 2011
ETIOLOGY
 HCAP etiology may be most similar to HAP and VAP

 CAP is typically attributed to more-susceptible bacteria

(Streptococcus pneumoniae, Haemophilus influenzae, Legionella species)

 HCAP are usually infected with potentially antibiotic resistant

bacteria :
 Methicillin-Resistant Staphylococcus Aureus, MRSA
 Pseudomonas aeruginosa,
 Acinetobacter species

ATS, 2005; Attridge, 2011; Seymann, 2013,

Variation between studies in percentage culture positive for selected
healthcare-associated pneumonia pathogens

Attridge, 2011
FODP mini- BAL was more efficient than blood cultures for identifying
pathogens in patients presenting with HCAP

Lacroix et al, 2011

Resistant Pathogens, By Risk Factor

(Shorr et al 2008 ; Atridge, 2009)

The number of HCAP risk factors increased in pathogens

Attridge, 2011
Comparison of Etiology and Outcomes, HCAP vs. CAP

Attridge, 2009
 Previous hospitalization needs to be considered with the
additional knowledge of :
 reason for previous admission,
 duration of hospitalization,
 receipt of antibiotic therapy,

 all of which may play a role in a patient’s risk for a drug-

resistant pathogen.

Attridge, 2009
Proportion “Recent Hospitalization “of the HCAP Cohort, By Study

Attridge, 2009
 THERAPY
• Establishing the diagnosis of pneumonia can be difficult,
especially those on mechanical ventilation in whom clinical,
radiologic, and microbiologic findings can be due to
numerous etiologies besides pneumonia.
• The difficulty in diagnosis may lead to overtreatment
with its attendant risks of superinfection and antibiotic
toxicity.
• Choice of specific agents should be based on local
microbiology, cost, drug availability, patients’allergies, and
pharmacy formulary restrictions

File, 2013; Magnuson, 2013

• Antimicrobial selection should be based upon risk factors
for multidrug-resistant (MDR)

• For patients with risk factors for MDR pathogens empiric

broad-spectrum, multidrug therapy is recommended.

• Once the results of pretherapy cultures are available, therapy

should be narrowed based upon the susceptibility pattern of
the pathogens identified.

File, 2013
 The recommendations of (ATS/IDSA) that HCAP should be
treated like HAP and therefore different from CAP

ATS, 2005; Guaimares, 2011

ATS, 2005
 When appropriate (either a pathogen is identified or there is
evidence of clinical improvement), monotherapy is preferred
because:
 it is less expensive and decreases antibiotic exposure to patients
with pneumonia,thus decreasing the potential risk for MDR
pathogens and/or adverse outcomes related to broad-spectrum
antibiotics.

Magnuson, 2013
ATS, 2005
What are the initial empiric antibiotic therapies for HCAP?

Magnuson, 2013
Is there benefit to combination versus
monoantibiotic therapy?

Combination therapy was thought to be necessary

in the treatment of suspected and/ or proven
gram-negative HCAP, specifically P aeruginosa.

Magnuson,2013
ATS, 2005
No known multidrug resistance risk factors
 Ceftriaxone (2 g intravenously daily).
 Ampicillin-sulbactam (3 g intravenously every six hours).
 Levofloxacin (750 mg intravenously daily) or moxifloxacin (400
mg intravenously daily).
 When the patient is able to take oral medications, either agent may be
administered orally at the same dose as that used for IV
administration.
 Ertapenem (1 g intravenously daily).

(File, 2013). Treatment of hospital-acquired, ventilator-associated,

and healthcare-associated pneumonia in adults . Update, 2013
For patients with known MDR risk factors, we recommend
empiric combination therapy including: ONE of the
following:

 Antipseudomonal cephalosporin such as cefepime (2 g

intravenously every eight hours) or ceftazidime (2 g
intravenously every 8 hours).
 Antipseudomonal carbapenem such as imipenem (500 mg
intravenously every six hours) or meropenem (1 g intravenously
every eight hours) or doripenem (500 mg intravenously every
eight hours; administered over one hour for HAP or HCAP,
administered over four hours for VAP) [53,54].
 Piperacillin-tazobactam (4.5 g intravenously every six hours).
PLUS consider adding one of the following
 Antipseudomonal fluoroquinolone, preferred regimen if
Legionella is likely, such as ciprofloxacin (400 mg intravenously
every eight hours) or levofloxacin (750 mg intravenously daily).
 Aminoglycoside such as gentamicin or tobramycin (7 mg/kg
intravenously once daily) or amikacin (20 mg/kg intravenously
once daily); once daily dosing is only appropriate for patients
with normal renal function.

File, 2013
 PLUS ONE of the following (if MRSA is suspected,
there are MRSA risk factors, or there is a high incidence of
MRSA locally):
 Linezolid (600 mg intravenously every 12 hours; may be
administered orally when the patient is able to take oral
medications)
 Vancomycin (15 to 20 mg/kg [based on actual body weight]
intravenously every 8 to 12 hours for patients with normal renal
function, with a target serum trough concentration of 15 to 20
mg/L.)

File, 2013
What is the optimal duration of antibiotic therapy?
 Clinical response to antimicrobial therapy usually
becomes apparent after the first 48 to 72 hours, and
therefore empiric therapy should not be changed during
this time unless evidence of clinical deterioration
requires escalation of therapy
 If patients receive an initially appropriate antibiotic
regimen, the preferred duration of therapy is as short as
7 days  the causative pathogen is not P aeruginosa,
had a good clinical response with no signs or symptoms
of active infection).
Jung, 2011; Magnuson, 2013
 Most patients with nosocomial pneumonia show good
clinical response within the first 5 to 6 days when
receiving appropriate antimicrobial therapy.

 Prolonged therapy can lead to colonization with resistant

pathogens and recurrent drug-resistant pneumonias.

 Patients with HCAP caused by P aeruginosa should be

treated with antibiotics for 2 weeks to prevent relapse.
Magnuson, 2013
 The risk score was calculated using the following weighted
points:
 Recent hospitalization of at least 48 hours during the preceding
90 days – 4 points
 Residence in a nursing home – 3 points
 Chronic hemodialysis – 2 points
 Critical illness – 1 point

File, 2013
 Clinical algorithm for treatment of HCAP. ICU

Health care- associated pneumonia is a heterogeneous disease, and all

patients do not need the same broad-spectrum antibiotic therapy as
complex nosocomial pneumonia
Data from Brito V, Niederman MS. Curr Opin Infect Dis2009; 22(3):316–25.)
Distribution of CAP vs HCAP

Attridge, 2011
Inappropriate treatment by pathogen distribution

Micek et al, 2007

Mortality rate by pneumonia category

Kollef, 2005
 Several causes of non responding patient are:
 MDR pathogens,
 Extrapulmonary sites of infection,
 Complications of pneumonia and/ or antibiotic therapy,
 Non infectious mimics of pneumonia.
Summary
 Pneumonia occurring before hospital admission in patients
with recent contact with the health system has been termed
‘healthcare-associated pneumonia’ (HCAP)
 HCAP is distinct from CAP in terms of its epidemiology,
etiology, and risk for infection with multidrug-resistant
(MDR) pathogens
 The concept of HCAP was created to identify the group of
patients that are infected with resistant pathogens.
 The microbiological features of HCAP are more similar to HAP
and VAP than to CAP.
 The management of HCAP is equivalent to the management of
late-onset HAP or VAP
Summary..

 The empiric antibiotic therapy is based on the patient’s risk

factors for MDR pathogens and need for broad-spectrum
antibiotics.
 Initiation of broad-spectrum empiric antibiotic therapy
should come with the expectation to deescalate antibiotics as
soon as possible.
 Appropriate monotherapy is probably as efficacious as
combination therapy for patients with HCAP who are not
severely ill and have no risk factors for MDR pathogens
 Prolonged therapy simply leads to colonization with
antibiotic resistant bacteria.
 Mortality among HCAP patients was significantly greater
than CAP patients.
Thank You