The 2005 IDSA guidelines for healthcare-associated pneumonia are a little bit broad. If you, a family member, or a pet has e-mailed or read about someone in the hospital, the recommendations are for a full-court press with coverage for multi-drug resistant pathogens.
However, this is clearly inappropriate. The HCAP population is profoundly heterogenous, where patients receiving home wound care are grouped with patients with recent hospitalization and receipt of IV antibiotics. It is clear, then, patients will suffer adverse effects and costs from overly-broad spectrum antibiotic coverage.
This group in Japan developed a decision instrument to guide antibiotic therapy, and prospectively evaluated it in 124 CAP and 321 HCAP patients over a two-year period. Their HCAP stratification is very reasonable: mild disease with 1 additional risk factor for MDR or severe disease with zero risk factors for MDR were treated as CAP. Everyone else received full HCAP coverage, with MRSA and anti-pseudomonal coverage.
A presumptive causative organism was diagnosed in about 50% of CAP and 60% of HCAP. Of the 93 patients an organism isolated in the “low-risk” HCAP category, none had MRSA, and 3 had pseudomonas. In the higher-risk HCAP groups, the low-severity group had 18 of 63 with an MDR pathogen, and the high-severity group had 28 of 56.
It is difficult to conclusively describe the safety of the treating-HCAP-as-CAP strategy, given the lack of a control group and the differences between baseline disease severity. However, on first glance, it seems unlikely this conservative strategy impacts initial treatment failure and mortality rates in a clinical significant fashion. This is an approach I’ve advocated for in the past, and plan to continue based on this addition to the body of evidence for individualized antibiotic selection for HCAP.
“A New Strategy for Healthcare-Associated Pneumonia: A 2-Year Prospective Multicenter Cohort Study Using Risk Factors for Multidrug- Resistant Pathogens to Select Initial Empiric Therapy”
http://www.ncbi.nlm.nih.gov/pubmed/23999080