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Yuichiro Shindo, MD; Kazuyoshi Imaizumi, MD, PhD; Yoshinori Hasegawa, MD, PhD, FCCP
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Affiliations: Drs. Shindo, Imaizumi, and Hasegawa are affiliated with the Department of Respiratory Medicine, Nagoya University Graduate School of Medicine.

Correspondence to: Yuichiro Shindo, MD, Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan; e-mail: yshindo@med.nagoya-u.ac.jp


Financial/nonfinancial disclosures: The authors have reported to the ACCP that no significant 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 (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(6):1703. doi:10.1378/chest.09-1762
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To the Editor:

We thank Teramoto and colleagues for their thoughtful and insightful comments regarding our recent article in CHEST (March 2009).1 They stated that most hospitalized patients with pneumonia (including those with community-acquired pneumonia [CAP] and hospital-acquired pneumonia) were elderly and that the incidence of aspiration pneumonia was high in those patients. They also mentioned the importance of assessing silent aspiration and their interpretation of the treatment of health-care–associated pneumonia (HCAP).

Although they pointed out the age difference between patients with HCAP and CAP, we analyzed our data by adjusting the age distribution, and assessing the severity of illness in both patients with HCAP and CAP by the same clinical prediction rule.1 Taking into account these analytical backgrounds, the proportion of in-hospital mortality and the occurrence of potentially drug-resistant (PDR) pathogens were significantly higher among patients with moderate HCAP than among those that of CAP patients. Furthermore, the frequency of PDR pathogens was almost the same in patients with moderate and severe HCAP, whereas it was dependent on the severity of pneumonia in CAP patients; the occurrence of PDR pathogens was associated with the initial treatment failure and inappropriate antibiotic treatment. Therefore, as the first step to improve the outcomes of HCAP patients, our results suggest that HCAP, which has been categorized into CAP, should be identified as a distinct entity, as has been shown by more recent articles.2,3

Patients with aspiration pneumonia are included in all pneumonia categories (CAP, HCAP, hospital-acquired pneumonia, and ventilator-associated pneumonia). Although the assessment of silent aspiration may be a meaningful intervention, physicians are required to quickly identify patients with risks for infection with drug-resistant pathogens.2 For many physicians approaching the optimal decision on the initial antibiotic treatment after identifying HCAP patients, the next step should be to ask questions that consider the current priorities, as follows: (1) what are the acceptable risk factors for infection with PDR pathogens? (2) should we stratify those risk factors? and (3) should we consider the severity of illness in the selection of initial empirical antibiotic agents?1,46

For the management of HCAP patients, a preventive strategy is quite important, because their pneumonia may frequently recur. From this point of view, it is important to strictly assess the patient's swallowing function, as Teramoto and colleagues1 mentioned. Swallowing rehabilitation and oral care may improve the quality of the management for patients with HCAP.

Shindo Y, Sato S, Maruyama E, et al. Health-care-associated pneumonia among hospitalized patients in a Japanese community hospital. Chest. 2009;135:633-640. [PubMed] [CrossRef]
 
Kollef MH, Morrow LE, Baughman RP, et al. Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes–proceedings of the HCAP Summit. Clin Infect Dis. 2008;46suppl:S296-S334. [PubMed]
 
Micek ST, Kollef KE, Reichley RM, et al. Health care-associated pneumonia and community-acquired pneumonia: a single-center experience. Antimicrob Agents Chemother. 2007;51:3568-3573. [PubMed]
 
Brito V, Niederman MS. Healthcare-associated pneumonia is a heterogeneous disease, and all patients do not need the same broad-spectrum antibiotic therapy as complex nosocomial pneumonia. Curr Opin Infect Dis. 2009;22:316-325. [PubMed]
 
Anand N, Kollef MH. The alphabet soup of pneumonia: CAP, HAP, HCAP, NHAP, and VAP. Semin Respir Crit Care Med. 2009;30:3-9. [PubMed]
 
Shorr AF, Zilberberg MD, Micek ST, et al. Prediction of infection due to antibiotic-resistant bacteria by select risk factors for health care-associated pneumonia. Arch Intern Med. 2008;168:2205-2210. [PubMed]
 

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References

Shindo Y, Sato S, Maruyama E, et al. Health-care-associated pneumonia among hospitalized patients in a Japanese community hospital. Chest. 2009;135:633-640. [PubMed] [CrossRef]
 
Kollef MH, Morrow LE, Baughman RP, et al. Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes–proceedings of the HCAP Summit. Clin Infect Dis. 2008;46suppl:S296-S334. [PubMed]
 
Micek ST, Kollef KE, Reichley RM, et al. Health care-associated pneumonia and community-acquired pneumonia: a single-center experience. Antimicrob Agents Chemother. 2007;51:3568-3573. [PubMed]
 
Brito V, Niederman MS. Healthcare-associated pneumonia is a heterogeneous disease, and all patients do not need the same broad-spectrum antibiotic therapy as complex nosocomial pneumonia. Curr Opin Infect Dis. 2009;22:316-325. [PubMed]
 
Anand N, Kollef MH. The alphabet soup of pneumonia: CAP, HAP, HCAP, NHAP, and VAP. Semin Respir Crit Care Med. 2009;30:3-9. [PubMed]
 
Shorr AF, Zilberberg MD, Micek ST, et al. Prediction of infection due to antibiotic-resistant bacteria by select risk factors for health care-associated pneumonia. Arch Intern Med. 2008;168:2205-2210. [PubMed]
 
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