PURPOSE: To apply the latest ATS/IDSA guidelines of community acquired pneumonia(CAP) and nosocomial pneumonia(NP) in African American(AA)-predominant population and study the various characteristics and outcome of each different subgroups.
METHODS: Retrospective chart review of patients with culture-positive pneumonia over two years period (2005 & 2006). They were reviewed for demographics, chart diagnosis,diagnosis per guidelines, clinical & radiographic data, microbiologic characteristics, length of stay, ventilator days and final outcome.
RESULTS: 312 patients, 94% AA & 53% males. 31% CAP, 39% healthcare associated pneumonia(HCAP), 15% hospital acquired pneumonia(HAP) & 15% ventilator associated pneumonia(VAP) per guidelines criteria. Chart diagnosis was wrong in 66% of patients using the guidelines diagnosis as the standard. 63% VAP, 57% CAP, 44% HAP & 1.6% HCAP were diagnosed correctly. Overall mortality for study group was 21.22%; & individually it was 11%, 43%, 23% and 23% for CAP, HAP, HCAP and VAP respectively. Mean length of stay(LOS) for CAP was (11.02 days) as compared to HAP(24.67), HCAP(15.72) and VAP(37.82). Mean ventilator days were (1.74)CAP, (8.21)HAP, (6.35)HCAP & (30.50)VAP. CAP-patients tend to be younger (mean age=57.09) as compared to HAP(72.15), HCAP(65.85) and VAP(68.58). 13.4% CAP patients, 13.04% HAP, 21.95% HCAP and 28.26% VAP patients had culture positive for pseudomonas. 28.87% of patients with CAP, 78.26% HAP, 62.60% HCAP and 82.61% VAP patients had MDR-bacteria. 18.56% CAP patients, 45.65% HAP, 36.59% HCAP and 39.13% VAP had MRSA-positive cultures. ESBL-bacteria was found in 3.09% CAP, 10.87% HAP, 13.01% HCAP and 19.57% VAP. 55% of study group received appropriate initial antibiotics, 75% CAP, 50% HAP, 47% HCAP & 41% VAP received appropriate initial antibiotics. The difference in mortality rates were not statistically significant between those who received appropriate initial antibiotics and those who did not in both the general study group and the different subgroups (Chi square-test; P=0.7, Fisher's-Exact-test; P=0.7, 0.8, 0.5 & 0.7). Also there was no statistically significant difference between long course of appropriate antibiotics use (>8 days) vs short course of appropriate antibiotics use (8 days or less); in terms of mortality (57% vs. 43%; P-value=0.65). Using multi-logistic regression analysis; PSI-score and immune status were two significant background factors predicting the mortality in our study group.
CONCLUSION: In our AA-predominant population;HCAP behaves like HAP&VAP not as CAP based on the differences in demographics, LOS & number of ventilator days,microbiologic distribution and mortality. There was high incidence of MDR-bacteria in our study population; with high incidence of pseudomonas & MRSA in CAP patients. HAP, VAP & HCAP had higher incidence of inappropriate antimicrobial therapy which may explain the reason for our high MDR-bacteria incidence rates. Short appropriate antimicrobial therapy courses are not associated with increased mortality. Immune-deficiency and high PSI-score are predictors of poor outcome.
CLINICAL IMPLICATIONS: The new ATS/IDSA guidelines of CAP and NP are applicable to our AA-predominant patient population.
DISCLOSURE: Qassim Durrani, No Financial Disclosure Information; No Product/Research Disclosure Information