The Controversial Label of Health Care-Associated Pneumonia

Just how helpful is it to label a pneumonia infection as health care-associated (HCAP)? Sure, from an infection prevention standpoint, surveillance of these events is often important, but from a medical treatment standpoint, is it really necessary?

The classification of health care-associated pneumonia was introduced by the American Thoracic Society/Infectious Disease Society of America in 2005. The new concept included criteria like recent hospitalization for 2 days or more, residence in a nursing home or extended care facility, and use of therapy.

Following this introduction, guidelines were established that recommended the use of empiric broad-spectrum antibiotic therapy for these patients, based on the perceived increased risk for drug-resistant pathogens and the fact that patients were often older adults.

Recently though, many have noted that this classification may not be as helpful as anticipated in reducing risks for drug resistance. Many clinicians opt not to use broad spectrum antibiotics in HCAP patients and some have noted that this guideline-concordant therapy regimen doesn’t actually improve the progress. Investigators are now discussing this controversial labeling of pneumonia and whether it impacts patient care.

In the latest volume of Clinical Microbiology and Infection, the investigators on a report sought to address this issue and provide an update using literature to assess patients who met criteria for health care-associate pneumonia from 2014 to 2018. They assessed either health care-associated pneumonia or community-associated pneumonia (CAP) in studies discussing clinical characteristics and found that HCAP patients tended to be older and have more comorbidities.

The investigators reviewed 970 abstracts and further evaluated 33 articles, leading to a deep-dive into 8 studies, which included 3 retrospective studies, from Korea, China, and Turkey. Mortality rates for HCAP patients ranged from 5-33%. Interestingly, the criteria to define HCAP varied pretty considerably between patient populations and the definitions and rates of multidrug-resistant pneumonia varied too. Predictors of multidrug-resistant pathogens included liver cirrhosis, diabetes mellitus, and more.

Efforts to treat these patients varied, as broad-spectrum guideline-concordant treatment didn’t seem to reduce mortality in the observational studies that the team assessed. For those using the HCAP criteria as a predictive tool, it was found to be subpar in identifying multidrug-resistance or pathogens that were not covered by treatment for CAP.

A newer score, Drug Resistance In Pneumonia (DRIP), was found to actually be better in the prediction of such resistant pathogens. The investigators indicate that in the studies reviewed, the HCAP definition was limited, ranging from a lack of proof for a causal association of increased multidrug-resistant rates and excess mortality, the absence of a benefit applying 2005 guideline-concordant recommendations, and variables populations behind the HCAP label as a result of a diverse HCAP criteria and the frequency of patients that meet the criteria.

There were several predictors of certain resistant organisms, which clinicians should take into consideration instead of broadly applying HCAP definitions.

Overall, the investigators found that the label of HCAP should not be used to determine whether patients are at risk for multidrug-resistant organisms. They noted that “the use of validated predictive scores along with implementation of de-escalation strategies and careful individual assessment of comorbidity and functional status seem superior strategies for the clinical management.”

This study underscores that the HCAP definition and concept fail to improve clinical practice and is a poor tool to predict infection with resistant organisms, which will likely result in over-treatment.