Abstract
The Japanese guidelines for nursing- and healthcare-associated pneumonia (NHCAP) categorize patients by risk of resistant bacteria and defined antimicrobials to be used, similar to the healthcare-associated pneumonia (HCAP) guidelines of the United States. The data were collected in large-scale hospitals, possibly a cause of inconsistency with everyday practice in medium-sized community hospitals. To test the feasibility of this guideline based on a retrospective study performed in a medium-sized community hospital in Japan, the medical records of pneumonia patients were retrospectively studied [718 patients: NHCAP, 477, 66.4 %; community-acquired pneumonia (CAP), 241, 33.4 %). Factors related to patients’ background, clinical and laboratory findings, treatment, and outcome were compared between NHCAP and CAP. The A-DROP system, scored by age, dehydration, respiratory failure, disorientation, and low blood pressure, evaluated the severity of pneumonia. In contrast to CAP patients, NHCAP patients included more elderly patients requiring nursing care and revealed higher rates of poor nutrition, dementia, aspiration, severe cases, detection of drug-resistant bacteria, and mortality. For NHCAP, the success rate did not differ between those receiving and not receiving proper initial treatment (76.9 vs. 78.5 %) nor did mortality rate within 30 days differ (13.1 vs. 13.8 %). Risk factors for mortality within 30 days for NHCAP were diabetes [adjusted odds ratio (AOR) 2.394, p = 0.009], albumin <2.5 g/dl (AOR 2.766, p = 0.002), A-DROP very severe (AOR 1.930, p = 0.021), and imaging showing extensive pneumonia (AOR 2.541, p = 0.002). The severity of pneumonia rather than risk of resistant bacteria should be considered, in addition to ethical concerns, in initial treatment strategy in NHCAP to avoid excessive use of broad-spectrum antimicrobials.
Similar content being viewed by others
References
American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388–416.
Kollef MH, Morrow LE, Baughman RP, Craven DE, McGowan JE Jr, Micek ST, et al. Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes: proceedings of the HCAP Summit. Clin Infect Dis. 2008;46:S296–334.
Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest. 2005;128:3854–62.
Micek ST, Kollef KE, Reichley RM, Roubinian N, Kollef MH. Health care-associated pneumonia and community-acquired pneumonia: a single-center experience. Antimicrob Agents Chemother. 2007;51:3568–73.
Lim WS, Macfarlane JT. A prospective comparison of nursing home acquired pneumonia with community acquired pneumonia. Eur Respir J. 2001;18:362–8.
Lim WS, Baudouin SV, George RC, Hill AT, Jamieson C, Le Jeune I, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax 2009; 64(suppl iii):1–55.
Carratalà J, Mykietiuk A, Fernández-Sabé N, Suárez C, Dorca J, Verdaguer R, et al. Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med. 2007;167:1393–9.
Shindo Y, Sato S, Maruyama E, Ohashi T, Ogawa M, Hashimoto N, et al. Health-care-associated pneumonia among hospitalized patients in a Japanese community hospital. Chest. 2009;135:633–40.
Maruyama T, Niederman MS, Kobayashi T, Kobayashi H, Takagi T, D’Alessandro-Gabazza CN, et al. A prospective comparison of nursing home-acquired pneumonia with hospital-acquired pneumonia in non-intubated elderly. Respir Med. 2008;102:1287–95.
Tamiya N, Noguchi H, Nishi A, Reich MR, Ikegami N, Hashimoto H, et al. Population ageing and well-being: lessons from Japan’s long-term care insurance policy. Lancet. 2011;378:1183–92.
Hashimoto H, Ikegami N, Shibuya K, Izumida N, Noguchi H, Yasunaga H, et al. Cost containment and quality of care in Japan: is there a trade-off? Lancet. 2011;378:1174–82.
Guidelines for the Management of Nursing and Healthcare-associated Pneumonia (NHCAP). Committee for Creation of Guidelines for Nursing and Healthcare-associated Pneumonia. Tokyo: Japanese Respiratory Society; 2011 (in Japanese).
Guidelines for the Management of Adult Community-acquired Pneumonia. Committee for Creation of Guidelines for Respiratory Infectious Diseases. Tokyo: Japanese Respiratory Society; 2007 (in Japanese).
Watanabe A, Goto H, Kohno S, Matsushima T, Abe S, Aoki N, et al. Nationwide survey on the 2005 guidelines for the management of community-acquired adult pneumonia: validation of severity assessment. Respir Invest. 2012;50(1):14–22.
Marrie TJ. Bacteraemic pneumococcal pneumonia: a continuously evolving disease. J Infect. 1992;24:247–55.
Marrie TJ, Durant H, Kwan C. Nursing home-acquired pneumonia. A case–control study. J Am Geriatr Soc. 1986;34:697–702.
Miyashita N, Kawai Y, Akaike H, Ouchi K, Hayashi T, Kurihara T, et al. Clinical features and the role of atypical pathogens in nursing and healthcare-associated pneumonia (NHCAP): differences between a teaching university hospital and a community hospital. Intern Med. 2012;51:585–94.
Drinka PJ, Gauerke C, Voeks S, Miller J, Schultz S, Krause P, et al. Pneumonia in a nursing home. J Gen Intern Med. 1994;9:650–2.
Zilberberg MD, Shorr AF, Micek ST, Mody SH, Kollef MH. Antimicrobial therapy escalation and hospital mortality among patients with health-care-associated pneumonia: a single-center experience. Chest. 2008;134:963–8.
Park HK, Song JU, Um SW, Koh WJ, Suh GY, Chung MP, et al. Clinical characteristics of health care-associated pneumonia in a Korean teaching hospital. Respir Med. 2010;104:1729–35.
Venditti M, Falcone M, Corrao S, Licata G, Serra P. Outcomes of patients hospitalized with community-acquired, health care-associated, and hospital-acquired pneumonia. Ann Intern Med. 2009;150:19–26.
Brito V, Niederman MS. Healthcare-associated pneumonia is a heterogeneous disease, and all patients do not need the same broad-spectrum antibiotic therapy as complex nosocomial pneumonia. Curr Opin Infect Dis. 2009;22:316–25.
Ewig S, Welte T, Chastre J, Torres A. Rethinking the concepts of community-acquired and health-care-associated pneumonia. Lancet Infect Dis. 2010;10:279–87.
Yende S, van der Poll T, Lee M, Huang DT, Newman AB. The influence of pre-existing diabetes mellitus on the host immune response and outcome of pneumonia: analysis of two multicentre cohort studies. Thorax. 2010;65:870–7.
Maruyama T, Taguchi O, Niederman MS, Morser J, Kobayashi H, Kobayashi T, et al. Efficacy of 23-valent pneumococcal vaccine in preventing pneumonia and improving survival in nursing home residents: double blind, randomised and placebo controlled trial. BMJ. 2010;34:c1004.
Hedlund J, Hansson LO, Ortqvist A. Short- and long-term prognosis for middle-aged and elderly patients hospitalized with community-acquired pneumonia: impact of nutritional and inflammatory factors. Scand J Infect Dis. 1995;27:32–7.
Dennis MS, Lewis SC, Warlow C, FOOD Trial Collaboration. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet. 2005;365:764–72.
Acknowledgments
We thank Dr. Toshihisa Aoyama, Geriatric Medicine, Sekishinkai Sayama Hospital; National Hospital Organization Tokyo Hospital Department of Clinical Research for funding.
Conflict of interest
None.
Ethical approval
National Hospital Organization Tokyo Hospital Department of Clinical Research.
Author information
Authors and Affiliations
Corresponding author
About this article
Cite this article
Oshitani, Y., Nagai, H., Matsui, H. et al. Reevaluation of the Japanese guideline for healthcare-associated pneumonia in a medium-sized community hospital in Japan. J Infect Chemother 19, 579–587 (2013). https://doi.org/10.1007/s10156-012-0517-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10156-012-0517-1