Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, Québec, Canada.
J Antimicrob Chemother. 2011 Jul;66(7):1617-24. doi: 10.1093/jac/dkr176. Epub 2011 May 17.
A new category of healthcare-associated pneumonia (HCAP) has been added in the most recent American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines, since multidrug-resistant (MDR) pathogens are more common in patients with HCAP than in those with community-acquired pneumonia (CAP). The optimal empirical management of patients with HCAP remains controversial and adherence to guidelines is inconsistent.
A retrospective cohort study of 3295 adults admitted for pneumonia in an academic centre of Canada, between 1997 and 2008.
MDR pathogens were more common among patients with HCAP than in those with CAP, but less so than in other studies. Compared with patients with CAP, those with HCAP had a higher all-cause 30 day mortality [68/563 (12%) versus 201/2732 (7%); P < 0.001] and more frequent need for mechanical ventilation [78/563 (14%) versus 276/2732 (10%); P = 0.01]. In patients with CAP, mortality was lower when treatment was concordant with guidelines [86/1557 (6%) versus 109/1097 (10%) if discordant; adjusted odds ratio 0.6 (0.4-0.8); P < 0.001]. In HCAP, mortality was similar whether or not empirical treatment was concordant with guidelines [6/35 (17%) versus 18/148 (12%) if discordant; P = 0.4]. However, 30 day mortality tended to be higher when the empirical treatment was microbiologically ineffective [4/22 (18%) versus 17/187 (9%) when effective; P = 0.3].
HCAP is associated with worse outcomes than CAP. MDR pathogens were implicated in only a small fraction of HCAP cases. In our study, unlike CAP, non-respect of current HCAP guidelines had no adverse effect on the ultimate outcome. Strategies for the empirical management of HCAP should be tailored to the local epidemiological context.
在最近的美国胸科学会/传染病学会（ATS/IDSA）指南中增加了一个新的医疗保健相关肺炎（HCAP）类别，因为与社区获得性肺炎（CAP）相比，HCAP 患者中多药耐药（MDR）病原体更为常见。HCAP 患者的最佳经验性治疗仍然存在争议，并且对指南的遵循并不一致。
这是一项对加拿大一家学术中心 1997 年至 2008 年间因肺炎入院的 3295 名成年人进行的回顾性队列研究。
与 CAP 患者相比，HCAP 患者中 MDR 病原体更为常见，但与其他研究相比则较少。与 CAP 患者相比，HCAP 患者的全因 30 天死亡率更高[68/563（12%）比 201/2732（7%）；P < 0.001]，更需要机械通气[78/563（14%）比 276/2732（10%）；P = 0.01]。在 CAP 患者中，治疗与指南一致时死亡率较低[如果不一致，则为 86/1557（6%）比 109/1097（10%）；调整后的优势比为 0.6（0.4-0.8）；P < 0.001]。在 HCAP 中，无论经验性治疗是否与指南一致，死亡率相似[如果不一致，则为 6/35（17%）比 18/148（12%）；P = 0.4]。但是，当经验性治疗在微生物学上无效时，30 天死亡率较高[4/22（18%）比 17/187（9%）；当有效时；P = 0.3]。
HCAP 与 CAP 相比，预后更差。仅在一小部分 HCAP 病例中涉及 MDR 病原体。在我们的研究中，与 CAP 不同，不遵守当前的 HCAP 指南对最终结果没有不利影响。HCAP 的经验性治疗策略应根据当地的流行病学情况进行调整。
