The Full Wiki

Healthcare-associated pneumonia: Wikis

Advertisements
  

Note: Many of our articles have direct quotes from sources you can cite, within the Wikipedia article! This article doesn't yet, but we're working on it! See more info or our list of citable articles.

Encyclopedia

From Wikipedia, the free encyclopedia

Pneumonia
Streptococcus pneumoniae-263.jpg
Infectious pneumonias
Pneumonias caused by infectious or noninfectious agents
Noninfectious pneumonia

In medicine, healthcare-associated pneumonia (HCAP) is a category of pneumonia in patients with recent close contact with the health care system.

HCAP is a condition in patients who are not hospitalised (similar to community-acquired pneumonia, CAP) but its causes, prognosis, prevention and treatment are more similar to hospital-acquired pneumonia (HAP).[1] The category was introduced because healthcare has increasingly shifted from hospital-based to home care, and more people are residing in nursing homes or extended care facilities.

Nursing home-acquired pneumonia is an important subgroup of HCAP. Residents of long term care facilities may become infected through their contacts with the healthcare system; as such, the microbes responsible for their pneumonias may be different from those traditionally seen in community-dwelling patients, requiring therapy with different antibiotics. Other groups include patients who admitted as a day case for regular hemodialysis or intravenous infusion (for example, chemotherapy). Especially in the very old and in demented patients, HCAP is likely to present with atypical symptoms.[2][3]

Compared to subjects with CAP, the pneumonia in HCAP is more likely to be caused by bacteria resistant to first line antibiotics, such as methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa. The optimal antibiotic strategy for the treatment of HCAP remains controversial. Influenza vaccines have been shown to reduce the risk of pneumonia in nursing home residents.[4] The pneumococcal polysaccharide vaccine is also recommended, although the evidence for its preventative role against pneumonia is more conflicting.[5][6][7][8]

HCAP was first suggested as a novel category of pneumonia in 2005 by the American Thoracic Society and Infectious Diseases Society of America.[9]

Contents

Definition

Healthcare-associated pneumonia can be defined as pneumonia in a patient with at least one of the following risk factors:

  • hospitalization in an acute care hospital for two or more days in the last 90 days;
  • residence in a nursing home or long-term care facility in the last 90 days
  • receiving outpatient intravenous therapy (like antibiotics or chemotherapy) within the past 30 days
  • receiving home wound care within the past 30 days
  • attending a hospital clinic or dialysis center in the last 30 days
  • having a family member with known multi-drug resistant pathogens

Although patients with HCAP may have more severe disease than those with classic CAP, disease severity does not determine if a patient has HCAP or not; the label HCAP is merely an indicator of risk factors for multi-drug resistant bacteria.

A recent study defined HCAP as admittance to a hospital or underwent surgery in the past 180 days, based on the observation that colonization with hospital-acquired bacteria can occur for extended periods.[10]

Epidemiology

Several studies found that healthcare-associated pneumonia is the second most common type of pneumonia, occurring less commonly than community-acquired pneumonia but more frequently than hospital-acquired pneumonia and ventilator-associated pneumonia. In a recent observational study, the rates for CAP, HCAP and HAP were 60%, 25% and 15% respectively.[10] Patients with HCAP are older and more commonly have simultaneous health problems (such as previous stroke, heart failure and diabetes).[11]

The number of residents in long term care facilities is expected to rise dramatically over the next 30 years. These older adults are known to develop pneumonia 10 times more than their community-dwelling peers, and hospital admittance rates are 30 times higher.[1][12]

Causes

The bacteria found in patients with HCAP are more similar to HAP than to CAP; compared to CAP, they have higher rates of Staphylococcus aureus (S. aureus) and Pseudomonas aeruginosa, and less Streptococcus pneumoniae and Haemophilus influenzae. It is well known that nursing home residents have high rates of colonization with MRSA. However, not all studies have found high rates of S. aureus and gram-negative bacteria.[12] One factor responsible for these differences is the reliance on sputum samples and the strictness of the criteria to discriminate between colonising or disease-causing bacteria.[13] Moreover, sputum samples might be less frequently obtained in the elderly.[1]

Aspiration (both of microscopic drops and macroscopic amounts of nose and throat secretions) is thought to be the most important cause of HCAP. Dental plaque might also be a reservoir for bacteria in HCAP.[14][15][16][17]

Prognosis

Healthcare-associated pneumonia seems to have fatality rates similar to hospital-acquired pneumonia, worse than community-acquired pneumonia but less severe than pneumonia in ventilated patients.[11] Besides clinical markers like tachypnea (fast breathing) or a high white cell count (leukocytosis), the prognosis seems to be influenced by the underlying associated diseases (comorbidities) and functional capacities (for example, the ADL score).[18][19][20] Many patients have a decreased health condition after the episode.[21]

Treatment

Patients with HCAP are more likely than those with community-acquired pneumonia to receive inappropriate antibiotics that do not target the bacteria causing their disease.

In 2002, an expert panel made recommendations about the evaluation and treatment of probable nursing home-acquired pneumonia.[22] They defined probably pneumonia, emphasized expedite antibiotic treatment (which is known to improve survival) and drafted criteria for the hospitalization of willing patients.

For initial treatment in the nursing home, a fluoroquinolone antibiotic suitable for respiratory infections (moxifloxacin, for example), or amoxicillin with clavulanic acid plus a macrolide has been suggested.[13] In a hospital setting, injected (parenteral) fluoroquinolones or a second- or third-generation cephalosporin plus a macrolide could be used.[13] Other factors that need to be taken into account are recent antibiotic therapy (because of possible resistance caused by recent exposure), known carrier state or risk factors for resistant organisms (for example, known carrier of MRSA or presence of bronchiectasis predisposing to Pseudomonas aeruginosa), or suspicion of possible Legionella pneumophila infection (legionnaires disease).[23]

In 2005, the American Thoracic Society and Infectious Diseases Society of America have published guidelines suggesting antibiotics specifically for HCAP.[9] The guidelines recommend combination therapy with an agent from each of the following groups to cover for both Pseudomonas aeruginosa and MRSA. This is based on studies using sputum samples and intensive care patients, in whom these bacteria were commonly found.

In one observational study, empirical antibiotic treatment that was not according to international treatment guidelines was an independent predictor of worse outcome among HCAP patients.[10]

Guidelines from Canada suggest that HCAP can be treated like community-acquired pneumonia with antibiotics targeting Streptococcus pneumoniae, based on studies using blood cultures in different settings which have not found high rates of MRSA or Pseudomonas.[24]

Besides prompt antibiotic treatment, supportive measure for organ failure (such as cardiac decompensation) are also important. Another consideration goes to hospital referral; although more severe pneumonia requires admission to an acute care facility, this also predisposes to hazards of hospitalization such as delirium, urinary incontinence, depression, falls, restraint use, functional decline, adverse drug effects and hospital infections.[25] Therefore, mild pneumonia might be better dealt with inside the long term care facility.[26][27][28] In patients with a limited life expectancy (for example, those with advanced dementia), end-of-life pneumonia also requires recognition and appropriate, palliative care.[29]

References

  1. ^ a b c Furman CD, Rayner AV, Tobin EP (October 2004). "Pneumonia in older residents of long-term care facilities". Am Fam Physician 70 (8): 1495–500. PMID 15526736. http://www.aafp.org/afp/20041015/1495.html.  
  2. ^ Loeb M (April 2004). "Pneumonia in the elderly". Curr. Opin. Infect. Dis. 17 (2): 127–30. doi:10.1097/00001432-200404000-00010. PMID 15021052. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0951-7375&volume=17&issue=2&spage=127.  
  3. ^ Johnson JC, Jayadevappa R, Baccash PD, Taylor L (October 2000). "Nonspecific presentation of pneumonia in hospitalized older people: age effect or dementia?". J Am Geriatr Soc 48 (10): 1316–20. PMID 11037021.  
  4. ^ Jefferson T, Rivetti D, Rivetti A, Rudin M, Di Pietrantonj C, Demicheli V (October 2005). "Efficacy and effectiveness of influenza vaccines in elderly people: a systematic review". Lancet 366 (9492): 1165–74. doi:10.1016/S0140-6736(05)67339-4. PMID 16198765. http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(05)67339-4.  
  5. ^ Vila-Córcoles A, Ochoa-Gondar O, Hospital I, et al. (October 2006). "Protective effects of the 23-valent pneumococcal polysaccharide vaccine in the elderly population: the EVAN-65 study". Clin. Infect. Dis. 43 (7): 860–8. doi:10.1086/507340. PMID 16941367. http://www.journals.uchicago.edu/cgi-bin/resolve?CID39878.  
  6. ^ Jackson LA, Neuzil KM, Yu O, et al. (May 2003). "Effectiveness of pneumococcal polysaccharide vaccine in older adults". N. Engl. J. Med. 348 (18): 1747–55. doi:10.1056/NEJMoa022678. PMID 12724480. http://content.nejm.org/cgi/pmidlookup?view=short&pmid=12724480&promo=ONFLNS19.  
  7. ^ Ortqvist A, Hedlund J, Burman LA, et al. (February 1998). "Randomised trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people. Swedish Pneumococcal Vaccination Study Group". Lancet 351 (9100): 399–403. doi:10.1016/S0140-6736(97)07358-3. PMID 9482293. http://linkinghub.elsevier.com/retrieve/pii/S0140673697073583.  
  8. ^ Koivula I, Stén M, Leinonen M, Mäkelä PH (October 1997). "Clinical efficacy of pneumococcal vaccine in the elderly: a randomized, single-blind population-based trial". Am. J. Med. 103 (4): 281–90. doi:10.1016/S0002-9343(97)00149-6. PMID 9382120. http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(97)00149-6.  
  9. ^ a b American Thoracic Society; Infectious Diseases Society of America. (2005). "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia". Am. J. Respir. Crit. Care Med. 171 (4): 388–416. doi:10.1164/rccm.200405-644ST. PMID 15699079.  
  10. ^ a b c Venditti M, Falcone M, Corrao S, Licata G, Serra P (January 2009). "Outcomes of patients hospitalized with community-acquired, health care-associated, and hospital-acquired pneumonia". Ann. Intern. Med. 150 (1): 19–26. PMID 19124816. http://www.annals.org/cgi/pmidlookup?view=long&pmid=19124816.  
  11. ^ a b Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS (2005). "Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia". Chest 128 (6): 3854–62. doi:10.1378/chest.128.6.3854. PMID 16354854.  
  12. ^ a b Muder RR (October 1998). "Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention". Am. J. Med. 105 (4): 319–30. doi:10.1016/S0002-9343(98)00262-9. PMID 9809694. http://linkinghub.elsevier.com/retrieve/pii/S0002934398002629.  
  13. ^ a b c Mylotte JM (2006). "Nursing home-acquired pneumonia: update on treatment options". Drugs Aging 23 (5): 377–90. doi:10.2165/00002512-200623050-00002. PMID 16823991.  
  14. ^ Terpenning M (June 2005). "Geriatric oral health and pneumonia risk". Clin. Infect. Dis. 40 (12): 1807–10. doi:10.1086/430603. PMID 15909270. http://www.journals.uchicago.edu/cgi-bin/resolve?CID35052.  
  15. ^ Sarin J, Balasubramaniam R, Corcoran AM, Laudenbach JM, Stoopler ET (February 2008). "Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions". J Am Med Dir Assoc 9 (2): 128–35. doi:10.1016/j.jamda.2007.10.003. PMID 18261707. http://linkinghub.elsevier.com/retrieve/pii/S1525-8610(07)00443-4.  
  16. ^ Scannapieco FA (October 2006). "Pneumonia in nonambulatory patients. The role of oral bacteria and oral hygiene" (). J Am Dent Assoc 137 Suppl: 21S–25S. PMID 17012732. http://jada.ada.org/cgi/pmidlookup?view=long&pmid=17012732.  
  17. ^ Azarpazhooh A, Leake JL (September 2006). "Systematic review of the association between respiratory diseases and oral health". J. Periodontol. 77 (9): 1465–82. doi:10.1902/jop.2006.060010. PMID 16945022.  
  18. ^ Mehr DR, Zweig SC, Kruse RL, et al. (October 1998). "Mortality from lower respiratory infection in nursing home residents. A pilot prospective community-based study". J Fam Pract 47 (4): 298–304. PMID 9789516.  
  19. ^ Mehr DR, Binder EF, Kruse RL, et al. (November 2001). "Predicting mortality in nursing home residents with lower respiratory tract infection: The Missouri LRI Study". JAMA 286 (19): 2427–36. doi:10.1001/jama.286.19.2427. PMID 11712938. http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11712938.  
  20. ^ Naughton BJ, Mylotte JM, Tayara A (October 2000). "Outcome of nursing home-acquired pneumonia: derivation and application of a practical model to predict 30 day mortality". J Am Geriatr Soc 48 (10): 1292–9. PMID 11037018.  
  21. ^ Fried TR, Gillick MR, Lipsitz LA (March 1997). "Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer". J Am Geriatr Soc 45 (3): 302–6. PMID 9063275.  
  22. ^ Hutt E, Kramer AM (August 2002). "Evidence-based guidelines for management of nursing home-acquired pneumonia". J Fam Pract 51 (8): 709–16. PMID 12184969. http://www.jfponline.com/Pages.asp?AID=1275.  
  23. ^ (Dutch) Depuydt P, Vogelaers D (2007). "Nosocomial pneumonia outside the hospital: health-care associated pneumonia and nursing home pneumonia". Tijdschrift voor Geneeskunde (Belgium) 63 (5): 174–181. doi:10.2143/TVG.63.05.2000033.  
  24. ^ Grossman RF, Rotschafer JC, Tan JS (July 2005). "Antimicrobial treatment of lower respiratory tract infections in the hospital setting". Am. J. Med. 118 Suppl 7A: 29S–38S. doi:10.1016/j.amjmed.2005.05.011. PMID 15993675. http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(05)00385-2.  
  25. ^ Fernandez HM, Callahan KE, Likourezos A, Leipzig RM (February 2008). "House staff member awareness of older inpatients' risks for hazards of hospitalization". Arch. Intern. Med. 168 (4): 390–6. doi:10.1001/archinternmed.2007.87. PMID 18299494. http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=18299494.  
  26. ^ Muder RR, Brennen C, Swenson DL, Wagener M (November 1996). "Pneumonia in a long-term care facility. A prospective study of outcome". Arch. Intern. Med. 156 (20): 2365–70. doi:10.1001/archinte.156.20.2365. PMID 8911243.  
  27. ^ Kruse RL, Mehr DR, Boles KE, et al. (September 2004). "Does hospitalization impact survival after lower respiratory infection in nursing home residents?". Med Care 42 (9): 860–70. doi:10.1097/01.mlr.0000135828.95415.b1. PMID 15319611.  
  28. ^ Dosa D (2005). "Should I hospitalize my resident with nursing home-acquired pneumonia?". J Am Med Dir Assoc 6 (5): 327–33. doi:10.1016/j.jamda.2005.06.005. PMID 16165074. http://linkinghub.elsevier.com/retrieve/pii/S1525-8610(05)00387-7.  
  29. ^ Janssens JP, Krause KH (February 2004). "Pneumonia in the very old". Lancet Infect Dis 4 (2): 112–24. doi:10.1016/S1473-3099(04)00931-4. PMID 14871636. http://linkinghub.elsevier.com/retrieve/pii/S1473309904009314.  

Further reading

Advertisements

Advertisements






Got something to say? Make a comment.
Your name
Your email address
Message