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Original Research: HEALTH-CARE-ASSOCIATED PNEUMONIA |

Why Mortality Is Increased in Health-Care-Associated Pneumonia: Lessons From Pneumococcal Bacteremic Pneumonia

Jordi Rello, MD, PhD; Manel Luján, MD; Miguel Gallego, MD; Jordi Vallés, MD, PhD; Yolanda Belmonte, MD; Dionisia Fontanals, PhD; Emili Diaz, MD, PhD; Thiago Lisboa, MD, PhD; for the PROCORNEU Study Group*
Author and Funding Information

From the Critical Care Department (Drs Rello, Diaz, and Lisboa), Joan XXIII University Hospital, IISPV, Rovira i Virgili University; the Pneumology Service (Drs Luján, Gallego, and Belmonte), Critical Care Service (Dr Vallés), and UDIAT Centre diagnòstic (Dr Fontanals), Corporació Parc Tauli, Institut Universitari Parc Taulí, Departament de Medicina, Universitat Autònoma de Barcelona, Sabadell, Spain.

Correspondence to: Jordi Rello, MD, PhD, Critical Care Department, Joan XXIII University Hospital, Carrer Mallafre Guasch, 4, Tarragona 43007, Spain; e-mail: jrello.hj23.ics@gencat.cat

A complete list of participants is located in the appendix.


Funding/Support: This study was supported in part by CIBER enfermedades respiratorias (CIBERes) 06/06/36, AGAUR 2009/SGR/1226, FISS 08/0452, and FISS 04/1500. The Proyecto Corporativo de Neumonía (PROCORNEU) Study Group is supported by CIBERes, Instituto de Salud Carlos III.

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


© 2010 American College of Chest Physicians


Chest. 2010;137(5):1138-1144. doi:10.1378/chest.09-2175
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Background:  A cohort of patients with bacteremic Streptococcus pneumoniae pneumonia was reviewed to assess why mortality is higher in health-care-associated pneumonia (HCAP) than in community-acquired pneumonia (CAP).

Methods:  A prospective cohort of all adult patients with bacteremic pneumococcal pneumonia attended at the ED was used.

Results:  One hundred eighty-four cases were classified as CAP and 44 (19%) as HCAP. Fifty-two (23%) were admitted to the ICU. Three (1.5%) isolates were resistant to β-lactams, and only two patients received inappropriate therapy. The CAP cohort was significantly younger (median age 68 years, interquartile range [IQR] 42-78 vs 77 years, IQR 67-82, P < .001). The HCAP cohort presented a higher Charlson index (2.81 ± 1.9 vs 1.23 ± 1.42, P < .001) and had higher severity of illness at admission (altered mental status, respiratory rate > 30/min, Pao2/Fio2 < 250, and multilobar involvement). HCAP patients had a lower rate of ICU admission (11.3% vs 25.5%, P < .05), and a trend toward lower mechanical ventilation (9% vs 19%, P = .17) and vasopressor use (9% vs 18.4%, P = .17) were documented. More patients in the HCAP cohort presented with a pneumonia severity index score > 90 (class IV-V, 95% vs 65%, P < .001), and 30-day mortality was significantly higher (29.5% vs 7.6%, P < .001). A multivariable regression logistic analysis adjusting for underlying conditions and variables related to severity of illness confirmed that HCAP is an independent variable associated with increased mortality (odds ratio = 5.56; 95% CI, 1.86-16.5).

Conclusions:  Pneumococcal HCAP presents excess mortality, which is independent of bacterial susceptibility. Differences in outcomes were probably due to differences in age, comorbidities, and criteria for ICU admission rather than to therapeutic decisions.

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