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Healthcare‐associated pneumonia: Can we salvage anything from the wreckage?

Despite decades of promise that improvements in microbiological testing would take the guesswork out of treating patients with pneumonia, empiric therapy based on an assessment of the likely pathogens remains the standard of care. In the 2005 update on the treatment of nosocomial pneumonias, the American Thoracic Society and Infectious Diseases Society of America included Healthcare-associated pneumonia (HCAP) as a separate category on the premise that a set of risk factors identified patients at high risk of pathogens not covered by typical communityacquired pneumonia empiric therapy. Unfortunately the premise for HCAP, that patients with significant contact with the hospital environment have a high risk of non-standard pathogens like methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, has been found to apply to a limited number of sites predominantly in the United States. With publication of the guidelines for HCAP there has been increasing evidence of massive overuse of broad-spectrum antibiotics not normally indicated in community-acquired pneumonia with inevitable problems of increasing antibiotic-resistant pathogens and antibiotic-related complications such as Clostridium difficle infection. Rather than improving outcomes it has been difficult to demonstrate that empiric broader-spectrum antibiotic therapy for patients with HCAP risk factors improves outcomes. The marked differences in the validity of HCAP across different areas and the significant adverse impacts of the classification have led to calls for its abandonment as a separate category of pneumonia.. In this issue of Respirology, Metersky et al. analyse 61 000 patients admitted with pneumonia and having HCAP risk factors from the Veterans Affairs Database in the United States. The first major finding is the very low prevalence of either pathogen being coded as the cause of pneumonia—1.9% for Pseudomonas and 1.0% for MRSA. We do not know the overall proportion of patients with a confirmed aetiological diagnosis, but Metersky et al. clearly show a massive and alarming overuse of broad-spectrum antibiotic therapy that would have had not just significant financial costs, but all the other problems attendant on the overuse of these drugs. The primary focus of Metersky et al. was to try and tease out whether there were clear factors identifying either MRSA or Pseudomonas, but not both, to enable a more focused approach to empiric therapy in patients with HCAP risk factors. Although there were a significant number of common risk factors, intravenous drug abuse and diabetes predicted a much higher risk of MRSA, whereas chronic obstructive pulmonary disease and prior use of broad-spectrum beta-lactams, fluroquinolones and carbapenems predicted a higher risk of Pseudmononas. Unfortunately none of these pathogen-specific risk factors had a positive or negative predictive value sufficient to reliably determine empiric antibiotic therapy. So what should physicians do about HCAP? The key remains, as it always has done, in knowing the aetiology of pneumonia in your own catchment population. Rather than worrying about whether someone has HCAP or not, physicians treating patients with pneumonia need to know if there are patients at risk of having pathogens resistant to standard empiric therapies. Clinicians cannot rely on published data from other sites but must have an understanding of what pathogens are causing pneumonia in their own hospitals and clinics. This does not mean that every hospital has to undertake rigorous aetiological studies of pneumonia, but ensuring that there is periodic but comprehensive collection of sputum and blood cultures on a reasonable series of patients is essential. Equally annual summaries of pathogens identified and their antibiotic sensitivity is important. Finally clinicians do have to be aware if there are very specific risk factors in their area to be aware of (for example a high prevalence of MRSA in intravenous drug abusers or in the local dialysis population). Publications like Meterksy et al. should not be used in prescriptive fashion (e.g. cover for Pseudomonas if the patient has chronic obstructive pulmonary disease) but as a guide to what potential issues to look for in your local data.