Critical Care Department, Joan XXIII University Hospital, Carrer Mallafre Guasch, 4, Tarragona 43007, Spain.
Chest. 2010 May;137(5):1138-44. doi: 10.1378/chest.09-2175. Epub 2009 Dec 1.
A cohort of patients with bacteremic Streptococcus pneumoniae pneumonia was reviewed to assess why mortality is higher in health-care-associated pneumonia (HCAP) than in community-acquired pneumonia (CAP).
A prospective cohort of all adult patients with bacteremic pneumococcal pneumonia attended at the ED was used.
One hundred eighty-four cases were classified as CAP and 44 (19%) as HCAP. Fifty-two (23%) were admitted to the ICU. Three (1.5%) isolates were resistant to beta-lactams, and only two patients received inappropriate therapy. The CAP cohort was significantly younger (median age 68 years, interquartile range [IQR] 42-78 vs 77 years, IQR 67-82, P < .001). The HCAP cohort presented a higher Charlson index (2.81 +/- 1.9 vs 1.23 +/- 1.42, P < .001) and had higher severity of illness at admission (altered mental status, respiratory rate > 30/min, Pao(2)/Fio(2) < 250, and multilobar involvement). HCAP patients had a lower rate of ICU admission (11.3% vs 25.5%, P < .05), and a trend toward lower mechanical ventilation (9% vs 19%, P = .17) and vasopressor use (9% vs 18.4%, P = .17) were documented. More patients in the HCAP cohort presented with a pneumonia severity index score > 90 (class IV-V, 95% vs 65%, P < .001), and 30-day mortality was significantly higher (29.5% vs 7.6%, P < .001). A multivariable regression logistic analysis adjusting for underlying conditions and variables related to severity of illness confirmed that HCAP is an independent variable associated with increased mortality (odds ratio = 5.56; 95% CI, 1.86-16.5).
Pneumococcal HCAP presents excess mortality, which is independent of bacterial susceptibility. Differences in outcomes were probably due to differences in age, comorbidities, and criteria for ICU admission rather than to therapeutic decisions.
对一组患有菌血症肺炎链球菌肺炎的患者进行了回顾性分析，以评估为何医院获得性肺炎（HCAP）的死亡率高于社区获得性肺炎（CAP）。
使用前瞻性队列研究，纳入所有在急诊科就诊的成人菌血症性肺炎链球菌肺炎患者。
184 例患者被归类为 CAP，44 例（19%）为 HCAP。52 例（23%）患者入住 ICU。3 例（1.5%）分离株对β-内酰胺类药物耐药，仅 2 例患者接受了不适当的治疗。CAP 组患者明显更年轻（中位数年龄 68 岁，四分位距[IQR] 42-78 岁 vs 77 岁，IQR 67-82 岁，P<.001）。HCAP 组的 Charlson 指数更高（2.81±1.9 分 vs 1.23±1.42 分，P<.001），入院时病情严重程度更高（意识状态改变、呼吸频率>30/min、PaO2/FIO2<250、多肺叶受累）。HCAP 患者 ICU 入住率较低（11.3% vs 25.5%，P<.05），机械通气（9% vs 19%，P=.17）和血管加压药使用（9% vs 18.4%，P=.17）的趋势也较低。HCAP 组中更患者表现出肺炎严重指数评分>90（IV-V 级，95% vs 65%，P<.001），30 天死亡率显著升高（29.5% vs 7.6%，P<.001）。多变量回归逻辑分析调整潜在疾病和与疾病严重程度相关的变量后证实，HCAP 是与死亡率增加相关的独立变量（比值比=5.56；95%CI，1.86-16.5）。
肺炎链球菌 HCAP 死亡率增加，且与细菌易感性无关。结果的差异可能是由于年龄、合并症和 ICU 入院标准的差异，而不是治疗决策的差异所致。
