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Revising the HCAP Criteria: Is There Still a Role for ESRD/Hemodialysis? FREE TO VIEW

Matthew Schreiber, MD; Andrew Shorr, MPH; Chee Chan, MPH
Chest. 2011;140(4_MeetingAbstracts):279A. doi:10.1378/chest.1114457
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PURPOSE: The healthcare associated pneumonia (HCAP) concept is intended to identify patients at risk for infection with drug resistant organisms (DRO) (i.e. Methicillin-resistant Staphylococcus aureus (MRSA), P. aeruginosa (PA)). The need for chronic hemodialysis (HD) is one criterion of HCAP. However, little data confirm that the microbiology of pneumonia in HD patients is different from persons with community-acquired pneumonia. We assessed how deleting HD as an aspect of HCAP alters the performance of HCAP criteria in correctly identifying patients with DROs.

METHODS: We retrospectively identified (2005-2007) subjects admitted for pneumonia that required mechanical ventilation (MV) on presentation and had laboratory confirmation of bacterial infection. The microbiology of these infections represented the primary endpoint. Pneumonia was diagnosed based on standard clinical criteria. Microbiologic diagnoses were made from invasive lower airway cultures, blood cultures, and urinary antigens. We compared the distribution of pathogens between those with HCAP due to non-HD criteria to persons meeting HCAP only because of their need for HD.

RESULTS: The sample included 190 subjects. DROs were frequently identified: MRSA (n=35, 18.4%), PA (n=25, 13.1%), and Extended Spectrum Beta Lactamase organisms (n=2, 1.1%). Hemodialysis was frequent (n=29, 15.3%). The incidence of DRO’s was high in persons needing chronic HD (n=13, 44.8%). However, most patients requiring HD (n=16, 55.2%) met at least one other criteria for HCAP. Among those where HD was the lone criteria for HCAP DROs occurred infrequently (n=1, 8.3%), and this was at no different a rate than in persons defined as community-acquired pneumonia.

CONCLUSIONS: HD is frequently identified as an HCAP risk in patients with severe pneumonia requiring MV. The need for HD is often accompanied with additional risks for HCAP. The presence of DRO’s was rare in patients with HD as their only risk for HCAP.

CLINICAL IMPLICATIONS: HD alone may not reflect a significant risk for DRO’s. Patients presenting with severe pneumonia and HD as a lone risk factor may not require initially broad spectrum antibiotic treatment. Acknowledging this distinction may aid in antibiotic stewardship.

DISCLOSURE: Andrew Shorr: Consultant fee, speaker bureau, advisory committee, etc.: Trius, Consultant fee, speaker bureau, advisory committee, etc.: Forrest , Consultant fee, speaker bureau, advisory committee, etc.: Bayer , Consultant fee, speaker bureau, advisory committee, etc.: Theravance , Consultant fee, speaker bureau, advisory committee, etc.: Astellas , Consultant fee, speaker bureau, advisory committee, etc.: Pfizer

The following authors have nothing to disclose: Matthew Schreiber, Chee Chan

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