Does health care associated pneumonia really exist?

Factors That Affect Oral Care Outcomes for Institutionalized Elderly

The aim of this study was to evaluate the effect of an oral care intervention program on the incidence of pneumonia and fever as a surrogate endpoint. In addition, we tried to determine the oral care risk factors for the incidence of fever. We provided an oral care program for the elderly at one private nursing home in July 2013. The maximum capacity of the nursing home was 60 residents. The body temperatures of all residents were measured twice a day and were summarized as the incidence of fever over a one-month period, which was used as the dependent variable. The residents' life conditions, number of teeth, and prescribed diet were used as independent variables. The factors that affected the incidence of fever were the number of remaining teeth, a prescribed diet of sliced food, the meal care level, and the oral Candida levels. These risk factors affected the incidence of fever independently or interactively with oral care. Some risk factors for the incidence of fever were enhanced by the oral care program. It is important to evaluate and control these factors before the implementation of an oral care program.

Burden and risk factors for Pseudomonas aeruginosa community-acquired pneumonia: a multinational point prevalence study of hospitalised patients

Pseudomonas aeruginosa is a challenging bacterium to treat due to its intrinsic resistance to the antibiotics used most frequently in patients with community-acquired pneumonia (CAP). Data about the global burden and risk factors associated with P. aeruginosa-CAP are limited. We assessed the multinational burden and specific risk factors associated with P. aeruginosa-CAP.We enrolled 3193 patients in 54 countries with confirmed diagnosis of CAP who underwent microbiological testing at admission. Prevalence was calculated according to the identification of P. aeruginosa Logistic regression analysis was used to identify risk factors for antibiotic-susceptible and antibiotic-resistant P. aeruginosa-CAP.The prevalence of P. aeruginosa and antibiotic-resistant P. aeruginosa-CAP was 4.2% and 2.0%, respectively. The rate of P. aeruginosa CAP in patients with prior infection/colonisation due to P. aeruginosa and at least one of the three independently associated chronic lung diseases (i.e. tracheostomy, bronchiectasis and/or very severe chronic obstructive pulmonary disease) was 67%. In contrast, the rate of P. aeruginosa-CAP was 2% in patients without prior P. aeruginosa infection/colonisation and none of the selected chronic lung diseases.The multinational prevalence of P. aeruginosa-CAP is low. The risk factors identified in this study may guide healthcare professionals in deciding empirical antibiotic coverage for CAP patients.

Inappropriate Use of Antimicrobials for Lower Respiratory Tract Infections in Elderly Patients: Patient- and Community-Related Implications and Possible Interventions

The elderly are more susceptible to infections, which is reflected in the incidence and mortality of lower respiratory tract infections (LRTIs) increasing with age. Several aspects of antimicrobial use for LRTIs in elderly patients should be considered to determine appropriateness. We discuss possible differences in microbial etiology between elderly and younger adults, definitions of inappropriate antimicrobial use for LRTIs currently found in the literature, along with their results, and the possible negative impact of antimicrobial therapy at both an individual and community level. Finally, we propose that both antimicrobial stewardship interventions and novel rapid diagnostic techniques may optimize antimicrobial use in elderly patients with LRTIs.

Should the patients colonized with extended-spectrum beta-lactamase-producing Gram-negative bacilli (E-GNB) coming to hospital from the community with pneumonia get anti-E-GNB active empirical treatment?

Extended-spectrum beta-lactamases are responsible for resistance of Gram-negative bacilli to several beta-lactam antibiotics, including those prescribed for treatment pneumonia. To evaluate the importance of colonization with E-GNB for the choice of empirical treatment we performed a retrospective case-control study including 156 patients, hospitalized for treatment of pneumonia from 2009 through 2013. Empirical treatment success and in-hospital survival were significantly lower in patients colonized with E-GNB compared to non-colonized (p = 0.002, p = 0.035). When comparing subgroups of colonized patients, treatment success was significantly lower in patients who were colonized with E-GNB resistant to empirical antibiotic (p = 0.010), but not in those colonized by E-GNB susceptible to empirically given antibiotic (p = 0.104). Difference in in-hospital mortality was insignificant in both subgroups (p = 0.056, p = 0.331). The results of study suggest that an anti-E-GNB active antibiotic should be used for empirical treatment of pneumonia in E-GNB colonized patients.

Classification of healthcare-associated infection: a systematic review 10 years after the first proposal

BACKGROUND

Ten years after the first proposal, a consensus definition of healthcare-associated infection (HCAI) has not been reached, preventing the development of specific treatment recommendations. A systematic review of all definitions of HCAI used in clinical studies is made.

METHODS

The search strategy focused on an HCAI definition. MEDLINE, SCOPUS and ISI Web of Knowledge were searched for articles published from earliest achievable data until November 2012. Abstracts from scientific meetings were searched for relevant abstracts along with a manual search of references from reports, earlier reviews and retrieved studies.

RESULTS

The search retrieved 49,405 references: 15,311 were duplicates and 33,828 were excluded based on title and abstract. Of the remaining 266, 43 met the inclusion criteria. The definition more frequently used was the initial proposed in 2002--in infection present at hospital admission or within 48 hours of admission in patients that fulfilled any of the following criteria: received intravenous therapy at home, wound care or specialized nursing care in the previous 30 days; attended a hospital or hemodialysis clinic or received intravenous chemotherapy in the previous 30 days; were hospitalized in an acute care hospital for ≥2 days in the previous 90 days, resided in a nursing home or long-term care facility. Additional criteria founded in other studies were: immunosuppression, active or metastatic cancer, previous radiation therapy, transfer from another care facility, elderly or physically disabled persons who need healthcare, previous submission to invasive procedures, surgery performed in the last 180 days, family member with a multi-drug resistant microorganism and recent treatment with antibiotics.

CONCLUSIONS

Based on the evidence gathered we conclude that the definition initially proposed is widely accepted. In a future revision, recent invasive procedures, hospitalization in the last year or previous antibiotic treatment should be considered for inclusion in the definition. The role of immunosuppression in the definition of HCAI still requires ongoing discussion.

Importance of functional assessment in the management of community-acquired and healthcare-associated pneumonia

OBJECTIVE

In Japan, the number of elderly people who have difficulties performing the activities of daily living (ADLs) is increasing. The objective of this study was to assess the relationship between ADL and the clinical characteristics of pneumonia.

METHODS

We conducted a retrospective study of 219 adult patients hospitalized due to pneumonia [151 patients with community-acquired pneumonia (CAP) and 68 patients with healthcare-associated pneumonia (HCAP)]. CAP, HCAP, and all the patients were stratified into two groups using a modified version of the Katz index of five ADLs as follows: independent in all ADLs or dependent in one to three ADLs (CAP-A, HCAP-A, and All-A groups) and dependent in four or five ADLs (CAP-B, HCAP-B, and All-B groups). Disease severity, microbiological findings, and mortality were compared between the groups.

RESULTS

As the ability to perform ADLs declined, A-DROP scores (the CAP severity measurement index) increased significantly in CAP (CAP-A: 1.1±1.1, CAP-B: 2.6±1.1), HCAP (HCAP-A: 2.0±1.0, HCAP-B: 2.8±1.0), and all patients (All-A: 1.3±1.1, All-B: 2.8±1.0). Thirty-day mortality was higher in the CAP-B (23.1%) and All-B (19.2%) groups than in the CAP-A (0.7%) and All-A (1.8%) groups, respectively. A multivariate Cox proportional hazards analysis showed an ADL score ≥ four to be a significant predictor of 30-day mortality in CAP patients [hazard ratio (HR), 19.057; 95% confidence interval (CI), 1.930-188.130] and in all patients (HR, 8.180; 95% CI, 1.998-33.494).

CONCLUSION

A functional assessment using a modified version of the Katz index is useful for the management of CAP and HCAP patients.

A comparison of microbiology and demographics among patients with healthcare-associated, hospital-acquired, and ventilator-associated pneumonia: a retrospective analysis of 1184 patients from a large, international study

Background

Acceptance of healthcare-associated pneumonia (HCAP) as an entity and the associated risk of infection by potentially multidrug-resistant (MDR) organisms such as methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas and Acinetobacter have been debated. We therefore compared patients with HCAP, hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) enrolled in a trial comparing linezolid with vancomycin for treatment of pneumonia.

Methods

The analysis included all patients who received study drug. HCAP was defined as pneumonia occurring < 48 hours into hospitalization and acquired in a long-term care, subacute, or intermediate health care facility; following recent hospitalization; or after chronic dialysis.

Results

Data from 1184 patients (HCAP = 199, HAP = 379, VAP = 606) were analyzed. Compared with HAP and VAP patients, those with HCAP were older, had slightly higher severity scores, and were more likely to have comorbidities. Pseudomonas aeruginosa was the most common gram-negative organism isolated in all pneumonia classes [HCAP, 22/199 (11.1%); HAP, 28/379 (7.4%); VAP, 57/606 (9.4%); p = 0.311]. Acinetobacter spp. were also found with similar frequencies across pneumonia groups. To address potential enrollment bias toward patients with MRSA pneumonia, we grouped patients by presence or absence of MRSA and found little difference in frequencies of Pseudomonas and Acinetobacter.

Conclusions

In this population of pneumonia patients, the frequencies of MDR gram-negative pathogens were similar among patients with HCAP, HAP, or VAP. Our data support inclusion of HCAP within nosocomial pneumonia guidelines and the recommendation that empiric antibiotic regimens for HCAP should be similar to those for HAP and VAP.