Brito Veronica, Niederman Michael S
Department of Pulmonary, Critical Care and Sleep Medicine, Winthrop-University Hospital, New York, USA.
Curr Opin Infect Dis. 2009 Jun;22(3):316-25. doi: 10.1097/QCO.0b013e328329fa4e.
Healthcare-associated pneumonia (HCAP) develops in patients who have recently had contact with nosocomial and drug-resistant pathogens, because of a history of hospitalization in the past 90 days, need for hemodialysis or home wound care, or residence in a nursing home. HCAP was included in the 2005 American Thoracic Society/Infectious Diseases Society of America guidelines for nosocomial pneumonia, with the recommendation that all such patients receive empiric therapy with a multidrug regimen directed against drug-resistant organisms. The purpose of this review was to examine articles published since the guidelines were developed to see whether this therapy recommendation is correct.
All articles published since July 2004 were identified using PubMed and the key words HCAP, nursing home-acquired pneumonia, and antibiotic therapy. The search was limited to adults, with a focus on clinical trials, reviews, meta-analyses, or practice guidelines.
We identified eight unique studies of HCAP, which were either prospective or retrospective series, with bacteriologic data on both Gram-negative and Gram-positive organisms. We also examined three prospective, randomized therapy trials of nursing home-acquired pneumonia that included limited bacteriologic data. We found that patients with HCAP were a heterogeneous group, with some at risk for multidrug-resistant organisms, and others not, and this accounted for the observation that many patients were successfully treated with monotherapy regimens or with regimens used for patients with community-acquired pneumonia. Patients at risk for multidrug-resistant pathogens were those with severe illness or those with other risk factors including: hospitalization in the past 90 days, antibiotic therapy in the past 6 months, poor functional status as defined by activities of daily living score, and immune suppression.
On the basis of the risk factors identified in recent studies, we developed an algorithm for empiric therapy of HCAP, which suggests that not all such patients require a broad-spectrum multidrug regimen in order to achieve appropriate and effective therapy. This algorithm needs validation in future studies.
医疗保健相关性肺炎（HCAP）发生于近期接触过医院内及耐药病原体的患者，这些患者因在过去90天内有住院史、需要血液透析或家庭伤口护理，或居住在疗养院。HCAP被纳入2005年美国胸科学会/美国传染病学会医院获得性肺炎指南，建议所有此类患者接受针对耐药菌的多药联合经验性治疗。本综述的目的是研究自该指南制定以来发表的文章，以确定这一治疗建议是否正确。
使用PubMed和关键词HCAP、疗养院获得性肺炎及抗生素治疗，检索2004年7月以来发表的所有文章。检索限于成人，重点是临床试验、综述、荟萃分析或实践指南。
我们确定了8项关于HCAP的独特研究，均为前瞻性或回顾性系列研究，包含革兰阴性菌和革兰阳性菌的细菌学数据。我们还研究了3项关于疗养院获得性肺炎的前瞻性、随机治疗试验，这些试验包含有限的细菌学数据。我们发现HCAP患者是一个异质性群体，一些患者有感染多重耐药菌的风险，而另一些则没有，这就解释了为什么许多患者使用单药治疗方案或用于社区获得性肺炎患者的治疗方案就能成功治愈。有感染多重耐药病原体风险的患者是那些患有严重疾病或有其他风险因素的患者，包括：过去90天内住院、过去6个月内接受抗生素治疗、根据日常生活活动评分定义的功能状态差以及免疫抑制。
基于近期研究中确定的风险因素，我们制定了HCAP经验性治疗算法，该算法表明并非所有此类患者都需要广谱多药联合方案才能实现恰当且有效的治疗。这一算法需要在未来研究中进行验证。
