title: 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.
abstract: BACKGROUND
  Optimal empiric therapy for hospitalized patients with healthcare-associated pneumonia (HCAP) is uncertain.
  
  
  METHODS
  We prospectively applied a therapeutic algorithm, based on the presence of risk factors for multidrug-resistant (MDR) pathogens in a multicenter cohort study of 445 pneumonia patients, including both community-acquired pneumonia (CAP; n = 124) and HCAP (n = 321).
  
  
  RESULTS
  MDR pathogens were more common (15.3% vs 0.8%, P < .001) in HCAP patients than in CAP patients, including Staphylococcus aureus (11.5% vs 0.8%, P < .001); methicillin-resistant S. aureus (6.9% vs 0%, P = .003); Enterobacteriaceae (7.8% vs 2.4%, P = .037); and Pseudomonas aeruginosa (6.9% vs 0.8%, P = .01). Using the proposed algorithm, HCAP patients with ≥2 MDR risk factors, one of which was severity of illness (n = 170), vs HCAP patients with 0-1 risk factor (n = 151) had a significantly higher frequency of MDR pathogens (27.1% vs 2%, P < .001). In total, 93.1% of HCAP patients were treated according to the therapy algorithm, with only 53% receiving broad-spectrum empiric therapy, yet 92.9% received appropriate therapy for the identified pathogen. Thirty-day mortality was significantly higher for HCAP than for CAP (13.7% vs 5.6%, P = .017), but among HCAP patients with 0-1 MDR risk factor, mortality was lower than with ≥2 MDR risk factors (8.6% vs 18.2%, P = .012). In multivariate analysis, initial treatment failure, but not inappropriate empiric antibiotic therapy, was a mortality risk factor (odds ratio, 72.0).
  
  
  CONCLUSIONS
  Basing empiric HCAP therapy on its severity and the presence of risk factors for MDR pathogens is a potentially useful approach that achieves good outcomes without excessive use of broad-spectrum antibiotic therapy.
  
  
  BACKGROUND
  Japan Medical Association Center for Clinical Trials, JMA-IIA00054.
authors.affiliation: Department of Respiratory Medicine, National Hospital Organization, Mie National Hospital, Tsu.
authors.forename: Takaya
authors.initials: T
authors.lastname: Maruyama
authors.forename: Takao
authors.initials: T
authors.lastname: Fujisawa
authors.forename: Masataka
authors.initials: M
authors.lastname: Okuno
authors.forename: Hirokazu
authors.initials: H
authors.lastname: Toyoshima
authors.forename: Kiyoyuki
authors.initials: K
authors.lastname: Tsutsui
authors.forename: Hikaru
authors.initials: H
authors.lastname: Maeda
authors.forename: Hisamichi
authors.initials: H
authors.lastname: Yuda
authors.forename: Masamichi
authors.initials: M
authors.lastname: Yoshida
authors.forename: Hiroyasu
authors.initials: H
authors.lastname: Kobayashi
authors.forename: Osamu
authors.initials: O
authors.lastname: Taguchi
authors.forename: Esteban C
authors.initials: EC
authors.lastname: Gabazza
authors.forename: Yoshiyuki
authors.initials: Y
authors.lastname: Takei
authors.forename: Naoyuki
authors.initials: N
authors.lastname: Miyashita
authors.forename: Toshiaki
authors.initials: T
authors.lastname: Ihara
authors.forename: Veronica
authors.initials: V
authors.lastname: Brito
authors.forename: Michael S
authors.initials: MS
authors.lastname: Niederman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001419:Bacteria / Q000302:isolation & purification; D016009:Chi-Square Distribution; D017714:Community-Acquired Infections / Q000188:drug therapy / Q000382:microbiology; D003428:Cross Infection / Q000188:drug therapy / Q000382:microbiology*; D024901:Drug Resistance, Multiple, Bacterial; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000188:drug therapy / Q000382:microbiology*; D011446:Prospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents
keywords: appropriate therapy; empiric antibiotic therapy; healthcare-associated pneumonia; multidrug resistance; risk factors