Reevaluation of the Japanese guideline for healthcare-associated pneumonia in a medium-sized community hospital in Japan

Abstract

The Japanese guidelines for nursing- and healthcare-associated pneumonia (NHCAP) categorize patients by risk of resistant bacteria and defined antimicrobials to be used, similar to the healthcare-associated pneumonia (HCAP) guidelines of the United States. The data were collected in large-scale hospitals, possibly a cause of inconsistency with everyday practice in medium-sized community hospitals. To test the feasibility of this guideline based on a retrospective study performed in a medium-sized community hospital in Japan, the medical records of pneumonia patients were retrospectively studied [718 patients: NHCAP, 477, 66.4%; community-acquired pneumonia (CAP), 241, 33.4%). Factors related to patients' background, clinical and laboratory findings, treatment, and outcome were compared between NHCAP and CAP. The A-DROP system, scored by age, dehydration, respiratory failure, disorientation, and low blood pressure, evaluated the severity of pneumonia. In contrast to CAP patients, NHCAP patients included more elderly patients requiring nursing care and revealed higher rates of poor nutrition, dementia, aspiration, severe cases, detection of drug-resistant bacteria, and mortality. For NHCAP, the success rate did not differ between those receiving and not receiving proper initial treatment (76.9 vs. 78.5%) nor did mortality rate within 30days differ (13.1 vs. 13.8%). Risk factors for mortality within 30days for NHCAP were diabetes [adjusted odds ratio (AOR) 2.394, p=0.009], albumin <2.5g/dl (AOR 2.766, p=0.002), A-DROP very severe (AOR 1.930, p=0.021), and imaging showing extensive pneumonia (AOR 2.541, p=0.002). The severity of pneumonia rather than risk of resistant bacteria should be considered, in addition to ethical concerns, in initial treatment strategy in NHCAP to avoid excessive use of broad-spectrum antimicrobials.