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From Health-care Associated to Health-care Confused: Which Pneumonia Does My Patient Have and How Should I Treat It? FREE TO VIEW

Heleen Aardema, MD; Jack J. Ligtenberg, MD, PhD; Jan G. Zijlstra, MD, PhD
Author and Funding Information

From the Department of Critical Care, University Medical Center Groningen.

Correspondence to: Heleen Aardema, MD, University Medical Center Groningen, Department of Critical Care (ICV), PO Box 30.001, Groningen, The Netherlands, NL-9700 RP; e-mail: h.aardema@icv.umcg.nl


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


© 2011 American College of Chest Physicians


Chest. 2011;139(1):227. doi:10.1378/chest.10-1605
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To the Editor:

In their interesting study in CHEST (June 2010), Schreiber et al1 evaluate the value of the concept of using health-care-associated pneumonia (HCAP) to recognize those patients who will be infected with resistant pathogens when presenting with nonnosocomial pneumonia leading to respiratory failure. In their study,1 HCAP was considered present when at least one of these criteria was met: recent hospitalization, admission from a long-term care facility, chronic hemodialysis or wound care, immunosuppression, or recent treatment with broad-spectrum antimicrobials. Notably, HCAP alone appeared to be a poor screening test for identifying resistance (sensitivity and specificity 78.3% and 56.2%, respectively), whereas immunosuppression, long-term admission, and prior antibiotic use were independently associated with resistance while the prevalence of hemodialysis and recent hospitalization was not significantly different in those with and without resistant organisms.

These differences in subgroups underscore the perception that the concept of using HCAP to recognize those likely to have resistant organisms may be attractive; the definition of the concept itself might not be so. Therefore, as already suggested by the authors,1 to redefine the definition of HCAP might be worthwhile. Indeed, because inappropriate antibiotics are associated with worse outcome,2 it is crucial to be able to identify those prone to have a multiresistant pathogen causing pneumonia.

For instance, patients with exacerbated COPD admitted to the ICU appear to have a higher rate of infection with multidrug-resistant organisms, with a high rate of inappropriate antibiotic therapy and subsequent worse outcome.3 In the present study,1 patients with COPD tended to be overrepresented in the group of patients with resistant organisms (26.7% vs 17.7%, respectively, P = .178). Likewise, patients with cystic fibrosis often present with infections with resistant Pseudomonas aeruginosa, Burkholderia spp, and Stenotrophomonas maltophilia.4 Patients in these groups, however, would not necessarily meet the criteria for HCAP and thus might not be identified as being predisposed to resistance when presenting with pneumonia in the outpatient setting.

In patients susceptible to HCAP, it seems then logical to perform surveillance on a regular basis, which can be done on an outpatient basis because, by definition, patients who will be presenting with HCAP will have appointments in health-care settings from time to time. Because colonization is quite strongly linked to the causative organism in pneumonia,5 surveillance data can help in guiding initial therapy when pneumonia occurs, as was shown by Papadomichelakis et al5 in the critical care setting. After all, knowing the real (microbiologic) enemy is half the battle.

Schreiber MP, Chan CM, Shorr AF. Resistant pathogens in nonnosocomial pneumonia and respiratory failure: is it time to refine the definition of health-care-associated pneumonia? Chest. 2010;1376:1283-1288. [CrossRef] [PubMed]
 
Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999;1152:462-474. [CrossRef] [PubMed]
 
Nseir S, Di Pompeo C, Cavestri B, et al. Multiple-drug-resistant bacteria in patients with severe acute exacerbation of chronic obstructive pulmonary disease: prevalence, risk factors, and outcome. Crit Care Med. 2006;3412:2959-2966. [PubMed]
 
Elborn JS. Difficult bacteria, antibiotic resistance and transmissibility in cystic fibrosis. Thorax. 2004;5911:914-915. [CrossRef] [PubMed]
 
Papadomichelakis E, Kontopidou F, Antoniadou A, et al. Screening for resistant gram-negative microorganisms to guide empiric therapy of subsequent infection. Intensive Care Med. 2008;3412:2169-2175. [CrossRef] [PubMed]
 

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References

Schreiber MP, Chan CM, Shorr AF. Resistant pathogens in nonnosocomial pneumonia and respiratory failure: is it time to refine the definition of health-care-associated pneumonia? Chest. 2010;1376:1283-1288. [CrossRef] [PubMed]
 
Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999;1152:462-474. [CrossRef] [PubMed]
 
Nseir S, Di Pompeo C, Cavestri B, et al. Multiple-drug-resistant bacteria in patients with severe acute exacerbation of chronic obstructive pulmonary disease: prevalence, risk factors, and outcome. Crit Care Med. 2006;3412:2959-2966. [PubMed]
 
Elborn JS. Difficult bacteria, antibiotic resistance and transmissibility in cystic fibrosis. Thorax. 2004;5911:914-915. [CrossRef] [PubMed]
 
Papadomichelakis E, Kontopidou F, Antoniadou A, et al. Screening for resistant gram-negative microorganisms to guide empiric therapy of subsequent infection. Intensive Care Med. 2008;3412:2169-2175. [CrossRef] [PubMed]
 
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