european respiratory society annual congress 2013 11 th september 2013 catriona rother healthcare...

E u r o p e a n R e s p i r a t o r y S o c i e t yA n n u a l C o n g r e s s 2 0 1 3

1 1 t h S e p t e m b e r 2 0 1 3C a t r i o n a R o t h e r

Healthcare associated pneumonia does not accurately identify potentially resistant pathogens: a

systematic review and meta-analysis.

Healthcare associated pneumonia (HCAP)

• Pneumonia diagnosed in outpatients with regular healthcare contacts

Criteria for HCAP (ATS/IDSA 2005 guidelines). Any one of the following:

Resident of a nursing home or extended care facility.

Chronic dialysis within preceding 30 days.

Home infusion therapy (including antibiotics).

Home wound care.

Hospitalisation for 2 or more days in the preceding 90 days.

Family member with multi-drug resistant pathogen.

Research Aim

• To determine the reliability of HCAP to predict potentially resistant pathogens.

MRSAP. aeruginosa

Gram negative Enterobacteriaceae

Research Methods

Systematic review + meta-analysis Studies comparing the frequency of potentially resistant pathogens

in HCAP and CAP populations

24 studies: 22,456 patients

1) Comparison of microbiology in HCAP vs. CAP

Comparison of microbiology

Comparison of microbiology

Comparison of microbiology

Similar results when limited to prospective studies.

Comparison of microbiology

2) Quality of HCAP studies

2) Quality of HCAP studies

Poor overall

Analysis for sources of bias: Variable definition of HCAP Frequency of testing for microorganisms Publication bias

Publication bias

MRSA

P. aeruginosa

3) Ability of HCAP definition to predict potentially resistant organisms

Predictive accuracy of HCAP

Predictive accuracy of HCAP

Predictive accuracy of HCAP

Predictive accuracy of HCAP

Number needed to treat

Number needed to treat

4) Clinical outcomes in HCAP vs. CAP

Mortality in HCAP vs. CAP

Lower risk Higher risk

Mortality in HCAP vs. CAP

Adjusted for confounders

Lower risk with HCAP Higher risk with HCAP

No clear increased risk of mortality in HCAP.

Conclusions

HCAP concept is a poor discriminator of patients at risk of potentially resistant pathogens.

Excess mortality in HCAP not due to increased frequency of resistant microorganisms.

HCAP studies Poor quality studies Heterogenous study methods Publication bias

A c k n o w l e d g e m e n t s :D r J a m e s D C h a l m e r s

P r o fe s s o r D r S a nti a g o Ew i gD r Wa l e e d S a l i h

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