PostScript
CAP and HCAP are different? An unresolved question We read with interest the recent article by Polverino et al.1 Data of this study show a very low incidence of multidrug-resistant pathogens (MDR) in patients with community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP); authors conclude that microbial aetiology of HCAP does not differ from CAP, and that patients with HCAP in Spain do not need nosocomial antibiotic coverage. Surprisingly, the reported data conflict with a recent prospective study by Giannella et al,2 conducted in 72 internal medicine wards in Spain, and enrolling 1002 patients; in this study Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus caused 17% and 12.3% of HCAP, respectively; moreover, HCAP was an independent risk factor for pneumonia due do difficult-to-treat micro-organisms. How can these differences be explained? The substantial differences observed in two large multicentric populations of a same country may be indicators of two important problems: (1) since most patients 676
Thorax July 2014 Vol 69 No 7
PostScript of the study of Polverino et al were hospitalised in pneumology wards this may introduce a selection bias in term of epidemiology, diagnostic procedures and outcomes; patients hospitalised in internal medicine wards may be more frequently affected by multiple comorbidities and more likely to be repeatedly exposed to the healthcare setting;3 (2) in both studies routine sampling included blood cultures, urine antigens and sputum cultures but patients were not prospectively assigned to invasive diagnostic procedures like bronchoscopy with bronchoalveolar lavage cultures; as matter of fact, an aetiology was obtained in a minority of cases (34.9% and 26%, respectively), and a large proportion of patients with HCAP and CAP remained without diagnosis. The importance of an aggressive diagnostic approach was demonstrated by Lacroix et al,4 who, using the early mini bronchoalveolar lavage in the diagnosis of HCAP, identified a microbial aetiology in 46.3% of cases, and when the patient did not receive antibiotic therapy before the procedure pathogens were identified in 72.6% of cases (16% of cases had a MDR aetiology). This experience suggests that an aggressive diagnostic approach may be more accurate to assess aetiology of CAP and HCAP. Since data about microbiology of CAP and HCAP are contradictory, probably we need future interventional studies to define the role of MDR pathogens in patients with community-onset pneumonia. Until then, an individualised risk assessment for MDR organisms appears reasonable in patients fulfilling HCAP definition,5 to determine which patients presenting with pneumonia may require broad-spectrum antibiotic coverage.
To cite Falcone M, Russo A, Venditti M. Thorax 2014;69:676–677. Received 2 December 2013 Accepted 9 January 2014 Published Online First 28 January 2014
▸ http://dx.doi.org/10.1136/thoraxjnl-2013-203828 ▸ http://dx.doi.org/10.1136/thoraxjnl-2014-205210 Thorax 2014;69:676–677. doi:10.1136/thoraxjnl-2013-204935
REFERENCES 1
2
3
4
5
Polverino E, Torres A, Menendez R, et al.; HCAP Study investigators. Microbial aetiology of healthcare associated pneumonia in Spain: a prospective, multicentre, case-control study. Thorax 2013;68:1007–14. Giannella M, Pinilla B, Capdevila JA, et al. Pneumonia treated in the internal medicine department: focus on healthcare-associated pneumonia. Clin Microbiol Infect 2012;18:786–94. Falcone M, Blasi F, Menichetti F, et al. Pneumonia in frail older patients: an up to date. Intern Emerg Med 2012;7:415–24. Lacroix G, Prunet B, Bordes J, et al. Evaluation of early mini-bronchoalveolar lavage in the diagnosis of health care-associated pneumonia: a prospective study. Crit Care 2013;17:R24. Maruyama T, Fujisawa T, Okuno M, et al. 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. Clin Infect Dis 2013;57:1373–83.
Marco Falcone, Alessandro Russo, Mario Venditti Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Rome, Italy Correspondence to Dr Marco Falcone, Department of Public Health and Infectious Diseases, Policlinico Umberto I, “Sapienza” University of Rome, Viale del Policlinico 155, Rome 00161, Italy; [email protected] Contributors MF and AR contributed to the conception of the work; MV revised it critically for important intellectual content. The final version was approved to be published. MF is responsible for the overall content. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
Thorax July 2014 Vol 69 No 7
677
PostScript
Author’s response to ‘CAP and HCAP are different? An unresolved question’ Dear Editor, We thank the authors for the interest in our recent publication and for their useful comments. Unfortunately we consider the comparison with the publication from Giannella et al1 poorly appropriate in many aspects. The main strength of our work is the multicentre prospective case–control study design (match by age, gender and period of hospitalisation). Although severity scores were not used for matching, we considered this design the most appropriate to describe healthcare-associated pneumonia (HCAP) features. In fact, the Giannella group performed an observational prospective study only on patients admitted to internal medicine departments: these elements (study design and patients) could justify a different population composition and, consequently, different microbiological and clinical findings. In fact, in comparison
Thorax July 2014 Vol 69 No 7
with our HCAP patients, this population (Giannella et al1) clearly showed older age (mean age; Giannella: 83 years vs Polverino: 78.8 years), poorer functional status (mean Barthel score; 30 vs 58) and more aspiration risk (50% vs 39%). We have also reanalysed the number of comorbidities across the sites of care (respiratory and internal medicine departments) of our study. We observed that cases (HCAP) did systematically show more comorbidities than controls (CAP) in all departments. Moreover, the mean number of comorbidities of HCAP admitted to respiratory departments (mean±SD, 2.5±1.9) was similar to that of HCAP patients admitted to internal medicine (2.7±1.6) departments. Similarly, the modified Charlson index for comorbidities was systematically higher for HCAP in comparison with CAP independently of the site of care. HCAP cases showed similar Charlson index in both respiratory (mean±SD, 2.5 ±1.6) and internal medicine (mean±SD, 2.5±1.8) departments. In comparison with our study, the HCAP population from the Giannella study presents poorer functional status, more risk factors for CAP severity and for MDR pathogens. For these reasons in our opinion, the work of Giannella et al does not fully represent the general population unlike our study that includes patients from all medical services potentially attending pneumonia patients. On the other hand, we agree with Falcone et al2 about the fact that BAL is the best diagnostic option for pneumonia; for this reason, we included BAL in our microbiological panel. Unfortunately a number of reasons did not consent us to perform a minimal number of BAL: (1) the bad clinical condition of our patients at admission ( particularly HCAP), (2) the usual unavailability of bronchoscopy at the emergency departments and (3) the frequent patients’ rejection of bronchoscopy. Unfortunately these difficulties reflect the real world of clinical practice. Nonetheless, our microbiological results are fully coherent with other studies from Spain3 4 and UK,5 while the assessment of MDR risk should possibly be based on specific clinical factors (ie, previous antibiotic therapy, etc.) in any population (including CAP6) rather than on the HCAP label that has shown poor predictive value for it.7 For all these reasons, we think that current guidelines for CAP are still valid for HCAP in Europe, but risk factors for MDR should still be considered individually.
677
PostScript Eva Polverino, Antoni Torres, on behalf of the HCAP study group 2
Respiratory Disease Department, Hospital Clínic i Provincial de Barcelona, IDIBAPS, CIBER de Enfermedades Respiratorias (Ciberes), Barcelona, Spain Correspondence to Respiratory Disease Department, Hospital Clínic i Provincial de Barcelona, IDIBAPS, CIBER de Enfermedades, Respiratorias (Ciberes), Villarroel 170, Barcelona 08036, Spain; [email protected] Contributors EP is the main author of the paper, while AT is the leader of the study group and guarantor of the entire study. The authors of this authors’ response write on behalf of the whole HCAP study group. Competing interests None. Patient consent Obtained.
3
To cite Polverino E, Torres A, on behalf of the HCAP study group. Thorax 2014;69:677–678. Received 31 January 2014 Revised 25 February 2014 Accepted 27 February 2014 Published Online First 25 March 2014
5
▸ http://dx.doi.org/10.1136/thoraxjnl-2013-204935
6
Thorax 2014;69:677–678. doi:10.1136/thoraxjnl-2014-205210 7
Ethics approval Hospitals’ Ethical committee.
REFERENCES
Provenance and peer review Not commissioned; internally peer reviewed.
1
678
4
Giannella M, Pinilla B, Capdevila JA, et al. Pneumonia treated in the internal medicine department: focus on
healthcare-associated pneumonia. Clin Microbiol Infect 2012;18:786–94. Falcone M, Russo A, Venditti M. CAP and HCAP are different? An unresolved question. Thorax 2014;69:678–9 Garcia-Vidal C, Viasus D, Roset A, et al. Low incidence of multidrug-resistant organisms in patients with healthcare-associated pneumonia requiring hospitalization. Clin Microbiol Infect 2011;17: 1659–65. Carratala J, Mykietiuk A, Fernandez-Sabe N, et al. Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med 2007;167:1393–9. Chalmers JD, Taylor JK, Singanayagam A, et al. Epidemiology, antibiotic therapy, and clinical outcomes in health care-associated pneumonia: a UK cohort study. Clin Infect Dis 2011;53:107–13. Aliberti S, Cilloniz C, Chalmers JD, et al. Multidrugresistant pathogens in hospitalized patients coming from the community with pneumonia. Barcelona: Oral communication from ERS Congress, 2013. Shorr AF, Zilberberg MD, Micek ST, et al. Prediction of infection due to antibiotic-resistant bacteria by select risk factors for health care-associated pneumonia. Arch Intern Med 2008;168:2205–10.
Thorax July 2014 Vol 69 No 7
Copyright of Thorax is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
CAP and HCAP are different? An unresolved question We read with interest the recent article by Polverino et al.1 Data of this study show a very low incidence of multidrug-resistant pathogens (MDR) in patients with community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP); authors conclude that microbial aetiology of HCAP does not differ from CAP, and that patients with HCAP in Spain do not need nosocomial antibiotic coverage. Surprisingly, the reported data conflict with a recent prospective study by Giannella et al,2 conducted in 72 internal medicine wards in Spain, and enrolling 1002 patients; in this study Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus caused 17% and 12.3% of HCAP, respectively; moreover, HCAP was an independent risk factor for pneumonia due do difficult-to-treat micro-organisms. How can these differences be explained? The substantial differences observed in two large multicentric populations of a same country may be indicators of two important problems: (1) since most patients 676
Thorax July 2014 Vol 69 No 7
PostScript of the study of Polverino et al were hospitalised in pneumology wards this may introduce a selection bias in term of epidemiology, diagnostic procedures and outcomes; patients hospitalised in internal medicine wards may be more frequently affected by multiple comorbidities and more likely to be repeatedly exposed to the healthcare setting;3 (2) in both studies routine sampling included blood cultures, urine antigens and sputum cultures but patients were not prospectively assigned to invasive diagnostic procedures like bronchoscopy with bronchoalveolar lavage cultures; as matter of fact, an aetiology was obtained in a minority of cases (34.9% and 26%, respectively), and a large proportion of patients with HCAP and CAP remained without diagnosis. The importance of an aggressive diagnostic approach was demonstrated by Lacroix et al,4 who, using the early mini bronchoalveolar lavage in the diagnosis of HCAP, identified a microbial aetiology in 46.3% of cases, and when the patient did not receive antibiotic therapy before the procedure pathogens were identified in 72.6% of cases (16% of cases had a MDR aetiology). This experience suggests that an aggressive diagnostic approach may be more accurate to assess aetiology of CAP and HCAP. Since data about microbiology of CAP and HCAP are contradictory, probably we need future interventional studies to define the role of MDR pathogens in patients with community-onset pneumonia. Until then, an individualised risk assessment for MDR organisms appears reasonable in patients fulfilling HCAP definition,5 to determine which patients presenting with pneumonia may require broad-spectrum antibiotic coverage.
To cite Falcone M, Russo A, Venditti M. Thorax 2014;69:676–677. Received 2 December 2013 Accepted 9 January 2014 Published Online First 28 January 2014
▸ http://dx.doi.org/10.1136/thoraxjnl-2013-203828 ▸ http://dx.doi.org/10.1136/thoraxjnl-2014-205210 Thorax 2014;69:676–677. doi:10.1136/thoraxjnl-2013-204935
REFERENCES 1
2
3
4
5
Polverino E, Torres A, Menendez R, et al.; HCAP Study investigators. Microbial aetiology of healthcare associated pneumonia in Spain: a prospective, multicentre, case-control study. Thorax 2013;68:1007–14. Giannella M, Pinilla B, Capdevila JA, et al. Pneumonia treated in the internal medicine department: focus on healthcare-associated pneumonia. Clin Microbiol Infect 2012;18:786–94. Falcone M, Blasi F, Menichetti F, et al. Pneumonia in frail older patients: an up to date. Intern Emerg Med 2012;7:415–24. Lacroix G, Prunet B, Bordes J, et al. Evaluation of early mini-bronchoalveolar lavage in the diagnosis of health care-associated pneumonia: a prospective study. Crit Care 2013;17:R24. Maruyama T, Fujisawa T, Okuno M, et al. 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. Clin Infect Dis 2013;57:1373–83.
Marco Falcone, Alessandro Russo, Mario Venditti Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Rome, Italy Correspondence to Dr Marco Falcone, Department of Public Health and Infectious Diseases, Policlinico Umberto I, “Sapienza” University of Rome, Viale del Policlinico 155, Rome 00161, Italy; [email protected] Contributors MF and AR contributed to the conception of the work; MV revised it critically for important intellectual content. The final version was approved to be published. MF is responsible for the overall content. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
Thorax July 2014 Vol 69 No 7
677
PostScript
Author’s response to ‘CAP and HCAP are different? An unresolved question’ Dear Editor, We thank the authors for the interest in our recent publication and for their useful comments. Unfortunately we consider the comparison with the publication from Giannella et al1 poorly appropriate in many aspects. The main strength of our work is the multicentre prospective case–control study design (match by age, gender and period of hospitalisation). Although severity scores were not used for matching, we considered this design the most appropriate to describe healthcare-associated pneumonia (HCAP) features. In fact, the Giannella group performed an observational prospective study only on patients admitted to internal medicine departments: these elements (study design and patients) could justify a different population composition and, consequently, different microbiological and clinical findings. In fact, in comparison
Thorax July 2014 Vol 69 No 7
with our HCAP patients, this population (Giannella et al1) clearly showed older age (mean age; Giannella: 83 years vs Polverino: 78.8 years), poorer functional status (mean Barthel score; 30 vs 58) and more aspiration risk (50% vs 39%). We have also reanalysed the number of comorbidities across the sites of care (respiratory and internal medicine departments) of our study. We observed that cases (HCAP) did systematically show more comorbidities than controls (CAP) in all departments. Moreover, the mean number of comorbidities of HCAP admitted to respiratory departments (mean±SD, 2.5±1.9) was similar to that of HCAP patients admitted to internal medicine (2.7±1.6) departments. Similarly, the modified Charlson index for comorbidities was systematically higher for HCAP in comparison with CAP independently of the site of care. HCAP cases showed similar Charlson index in both respiratory (mean±SD, 2.5 ±1.6) and internal medicine (mean±SD, 2.5±1.8) departments. In comparison with our study, the HCAP population from the Giannella study presents poorer functional status, more risk factors for CAP severity and for MDR pathogens. For these reasons in our opinion, the work of Giannella et al does not fully represent the general population unlike our study that includes patients from all medical services potentially attending pneumonia patients. On the other hand, we agree with Falcone et al2 about the fact that BAL is the best diagnostic option for pneumonia; for this reason, we included BAL in our microbiological panel. Unfortunately a number of reasons did not consent us to perform a minimal number of BAL: (1) the bad clinical condition of our patients at admission ( particularly HCAP), (2) the usual unavailability of bronchoscopy at the emergency departments and (3) the frequent patients’ rejection of bronchoscopy. Unfortunately these difficulties reflect the real world of clinical practice. Nonetheless, our microbiological results are fully coherent with other studies from Spain3 4 and UK,5 while the assessment of MDR risk should possibly be based on specific clinical factors (ie, previous antibiotic therapy, etc.) in any population (including CAP6) rather than on the HCAP label that has shown poor predictive value for it.7 For all these reasons, we think that current guidelines for CAP are still valid for HCAP in Europe, but risk factors for MDR should still be considered individually.
677
PostScript Eva Polverino, Antoni Torres, on behalf of the HCAP study group 2
Respiratory Disease Department, Hospital Clínic i Provincial de Barcelona, IDIBAPS, CIBER de Enfermedades Respiratorias (Ciberes), Barcelona, Spain Correspondence to Respiratory Disease Department, Hospital Clínic i Provincial de Barcelona, IDIBAPS, CIBER de Enfermedades, Respiratorias (Ciberes), Villarroel 170, Barcelona 08036, Spain; [email protected] Contributors EP is the main author of the paper, while AT is the leader of the study group and guarantor of the entire study. The authors of this authors’ response write on behalf of the whole HCAP study group. Competing interests None. Patient consent Obtained.
3
To cite Polverino E, Torres A, on behalf of the HCAP study group. Thorax 2014;69:677–678. Received 31 January 2014 Revised 25 February 2014 Accepted 27 February 2014 Published Online First 25 March 2014
5
▸ http://dx.doi.org/10.1136/thoraxjnl-2013-204935
6
Thorax 2014;69:677–678. doi:10.1136/thoraxjnl-2014-205210 7
Ethics approval Hospitals’ Ethical committee.
REFERENCES
Provenance and peer review Not commissioned; internally peer reviewed.
1
678
4
Giannella M, Pinilla B, Capdevila JA, et al. Pneumonia treated in the internal medicine department: focus on
healthcare-associated pneumonia. Clin Microbiol Infect 2012;18:786–94. Falcone M, Russo A, Venditti M. CAP and HCAP are different? An unresolved question. Thorax 2014;69:678–9 Garcia-Vidal C, Viasus D, Roset A, et al. Low incidence of multidrug-resistant organisms in patients with healthcare-associated pneumonia requiring hospitalization. Clin Microbiol Infect 2011;17: 1659–65. Carratala J, Mykietiuk A, Fernandez-Sabe N, et al. Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med 2007;167:1393–9. Chalmers JD, Taylor JK, Singanayagam A, et al. Epidemiology, antibiotic therapy, and clinical outcomes in health care-associated pneumonia: a UK cohort study. Clin Infect Dis 2011;53:107–13. Aliberti S, Cilloniz C, Chalmers JD, et al. Multidrugresistant pathogens in hospitalized patients coming from the community with pneumonia. Barcelona: Oral communication from ERS Congress, 2013. Shorr AF, Zilberberg MD, Micek ST, et al. Prediction of infection due to antibiotic-resistant bacteria by select risk factors for health care-associated pneumonia. Arch Intern Med 2008;168:2205–10.
Thorax July 2014 Vol 69 No 7
Copyright of Thorax is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
