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Health care-associated pneumonia is mostly dead. Long live the acronym PES?

Community-acquired pneumonia is most often caused by pneumococcus, Haemophilus influenzae, methicillinsensitive Staphylococcus aureus, Mycoplasma pneumoniae, Klebsiella species, and other bacteria sensitive to empirically prescribed antibiotics such as ceftriaxone and azithromycin. However, a few patients are infected with pathogens resistant to these antibiotics (1). Presuming that effective empiric antibiotic therapy would improve clinical outcomes, the 2005 American Thoracic Society/Infectious Disease Society of America nosocomial pneumonia guidelines recommended extended-spectrum antibiotic therapy for patients suspected of harboring a resistant organism (2). These patients were defined in the guideline using a limited set of risk factors as having health care–associated pneumonia (HCAP) (3). Since 2005, multiple investigators have further studied factors associated with resistant pathogens. Recent reviews highlight variable and mostly poor performance of the HCAP criteria in accurately identifying patients with resistant organisms (1, 4–6). Administering broadspectrum antibiotic therapy to patients at higher risk for resistant pathogens has not been shown to improve outcomes (4, 5). Consequently, use of the HCAP criteria to select patients for empiric, extendedspectrum antibiotics is mostly dead. In this issue of AnnalsATS, Prina and colleagues (pp. 153–160) identify clinical characteristics associated with drug-resistant pathogens among immunocompetent patients with pneumonia in a large, prospective, observational Spanish database (7). They propose a new acronym, PES, to signify the three prevalent groups of resistant organisms: Pseudomonas aeruginosa, Enterobacteriaceae producing extendedspectrum beta-lactamase, and methicillinresistant Staphylococcus aureus (MRSA). Previous authors have used the abbreviations MDR for multidrug-resistant pathogens or DRP for drug-resistant pathogens for resistant bacteria found in patients with pneumonia (1, 8). The 15year database in this study comprises 4,549 patients; a microbiological diagnosis was made in 1,597 cases. A PES organism was recovered in 94/4549 (2.1%) of all patients, representing 6% of the culture-positive subgroup. The authors identified seven independent PES predictors at the time of diagnosis: age>65 years, male sex, previous antibiotic use, chronic respiratory disease, chronic kidney disease, altered mental status, and temperature greater than 37.88C on arrival. Male sex, altered mental status, and fever have not been previously reported, nor would they seem conceptually associated with resistant pathogens. A probabilistic prediction score was derived based on weighted results from logistic regression, and a threshold of five points in individual patients was optimum for differentiating risk of pneumonia caused by PES pathogens. Using the denominator of 1,597, the area under the receiver operating curve (AUC-ROC) was 0.75 and the accuracy of classification was 71%. Although using this scoring threshold would have increased empiric administration of antibiotics with in vitro activity to 70% (66/94) of patients with resistant pathogens, 381 of the 1,597 patients (24%) would receive unnecessarily broad-spectrum antibiotics. Empirically prescribed antibiotics effective against PES organisms were not associated with improved survival. The test performance characteristics of PES are similar in predictive value to other previously published scores: sensitivity, specificity, and AUC-ROC in the 0.7 range (1, 4). Similar to other published scores, PES favors overtreatment. Considering that resistant organisms are more easily recovered and less likely causes of culture-negative pneumonia, additional overtreatment would result if the scoring model were applied to all patients presenting to the hospital with pneumonia (9, 10). A limitation of the study by Prina and colleagues is that 68% of identified pathogens were recovered only from expectorated sputum. Expectorated sputum passes through the oropharynx, where organisms capable of causing pneumonia are present as colonizers, not pathogens. Even when sputum collection and microbiology laboratory procedures are optimized as in this prospective study, bacteria recovered only in sputum are classified as “presumptive” rather than confirmed lung pathogens. Therefore, some of the 64 patients with PES on sputum culture alone would not have had a lower respiratory tract infection with a resistant pathogen. Selecting a small subset of patients with pneumonia with resistant pathogens at the time of presentation and treating them effectively is difficult. Although Prina and