Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis

Clin Infect Dis. 2014 Feb;58(3):330-9. doi: 10.1093/cid/cit734. Epub 2013 Nov 22.


Background: The 2005 American Thoracic Society/Infectious Diseases Society of America guidelines introduced a concept of healthcare-associated pneumonia (HCAP) to define patients at higher risk of antibiotic-resistant pathogens, thus requiring broad spectrum therapy. There has been no systematic evaluation of the ability of this definition to identify antibiotic-resistant pathogens.

Methods: We conducted a systematic review and meta-analysis of studies comparing the frequency of resistant pathogens (defined as methicillin-resistant Staphylococcus aureus, Enterobacteriaceae, and Pseudomonas aeruginosa) in populations with HCAP compared with populations with community-acquired pneumonia (CAP). Predictive accuracy was evaluated using the area under the receiver operator characteristic curve (AUC). The frequencies of pathogens in each group were pooled using a random effects model.

Results: Twenty-four studies were included (n = 22 456). Overall study quality was poor. HCAP was associated with an increased risk of methicillin-resistant S. aureus (odds ratio [OR], 4.72; 95% confidence interval [CI], 3.69-6.04) enterobactericeae (OR, 2.11; 95% CI, 1.69-2.63), and P. aeruginosa (OR, 2.75; 95% CI, 2.04-3.72; all P < .0001), but these analyses were confounded by publication bias. The discriminatory ability of HCAP for resistant pathogens was low (AUC, 0.70; 95% CI, 0.69-0.71) and was lower in high-quality (AUC, 0.66; 95% CI, 0.62-0.70) and prospective studies (AUC, 0.64; 95% CI 0.62-0.66). After adjustment for age and comorbidities, mortality was not increased in HCAP (OR, 1.20; 95% CI, 0.85-1.70; P = .30).

Conclusions: The HCAP concept is based on predominantly low-quality evidence and does not accurately identify resistant pathogens. Mortality in HCAP does not appear to be due to a higher frequency of resistant pathogens.

Keywords: guidelines; healthcare-associated infection; meta-analysis; mortality; pneumonia.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Bacteria / drug effects*
  • Bacteria / isolation & purification*
  • Drug Resistance, Bacterial*
  • Enterobacteriaceae / drug effects*
  • Enterobacteriaceae / isolation & purification
  • Humans
  • Methicillin-Resistant Staphylococcus aureus / drug effects*
  • Methicillin-Resistant Staphylococcus aureus / isolation & purification
  • Pneumonia, Ventilator-Associated / microbiology*
  • Pseudomonas aeruginosa / drug effects*
  • Pseudomonas aeruginosa / isolation & purification