HCAP

Q: Health care-associated pneumonia (HCAP) is a critical concept for any clinician to be aware of, as it helps start antibiotics before cultures are available, saves lives, and decreases overall use of inappropriate antibiotics.

A) True

B) False

Answer: B

The category/idea/concept of health care-associated pneumonia (HCAP) has been removed from the 2016 and 2019 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines, as well as the combined 2017 European and Latin American Hospital-acquired pneumonia (HAP) (nosocomial) guidelines.

Previously, HCAP was defined as pneumonia acquired in health care facilities such as Long-Term Acute Care (LTAC), nursing homes, rehab centers, hemodialysis centers, or outpatient clinics, or within 90 days of a hospitalization. The whole purpose was to treat with antibiotics at the early stage of infection, particularly multidrug-resistant (MDR) infections. 

Later studies and evidence have shown that this was not a very prudent approach, as it led to increased, more inappropriate use of broad-spectrum antibiotics. The use of 'big guns' antibiotics was very high in comparison to the risk for MDR pathogens. This negates the concept of 'antibiotics stewardship'.

A new approach returns to the previous practice of treating HCAP as community-acquired pneumonia (CAP), and decides whether to consider MDR pathogens on a case-by-case basis based on prior exposures, risk factors, severity of illness, prior antimicrobial use, comorbidities, and functional status.

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References:

1. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61.

2. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019; 200:e45.

3. Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J 2017; 50.

4. Kollef MH. Health care-associated pneumonia: perception versus reality. Clin Infect Dis 2009; 49:1875.

5. Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis 2014; 58:330.