How Certain Do We Make a Diagnosis of Pneumonia, How Well Do We Differentiate Community‐Acquired Pneumonia (CAP) from Health Care–Associated Pneumonia (HCAP), and Does This Lead to Errors in Selecting Antibiotics?

Background:

Pneumonia is a common entity associated with significant morbidity and mortality. Guidelines for the management of both CAP and HCAP have been recently published, with evidence that compliance is associated with better outcomes. These guidelines demand an accurate diagnosis, but there are few studies documenting that this occurs. We sought to determine how frequently an accurate diagnosis based on clinical characteristics and x‐ray and laboratory findings occurred in patients admitted and discharged with the diagnosis of pneumonia. We also tried to determine if the patients had criteria for CAP or HCAP and whether the antibiotic choice was supported by the guidelines.

Methods:

We performed a retrospective study of patients admitted and discharged with the diagnosis of pneumonia, since February 2008. We excluded patients who were pregnant, younger than 18 years old, immunocompromised or had end‐stage renal disease. We reviewed the records and determined if the diagnosis was supported by clinical characteristics and an infiltrate, and based on guidelines, if there were risk factors for multidrug‐resistant (MDR) pathogens defining HCAP.

Results:

The 67 patients in our study had an average age of 63 years; 51% were woman, 70% were Hispanic, and 74% had 2 or more comorbidities. We found that 48 (71%) were diagnosed with any clinical criterion for pneumonia and had an infiltrate on chest x‐ray, Eighteen (27%) had some clinical criteria but no Infiltrate. Of the patients with presumed pneumonia. 34 (51%) would be classified as HCAP and 33 (49%) as CAP. Of the 67 cases in 24 (32%) the antibiotics selected were concordant with the guidelines. Inappropriate antibiotic use was higher, 94%, in the patients classified as HCAP than in those classified with CAP, 33%.

Conclusions:

In this small pragmatic study, we found that a significant number of patients were diagnosed with pneumonia without a definitive infiltrate and that this was as common in patients with CAP as in those with HCAP. A surprisingly large number of patients could be classified as HCAP. We found that patients that we would classify as HCAP were infrequently given antibiotics based on the guidelines. Our findings suggest that pneumonia may at times represent a default diagnosis and that this may be particularly true in complex patient with underappreciated characteristics that would classify them as HCAP, leading to inappropriate antibiotics selection. This study suggest that it is necessary to focus on the accuracy of the diagnosis and appropriate classification of either CAP or HCAP if we are going to improve the outcomes in patients with “pneumonia.”

Author Disclosure:

J. Campo, none; J. Hanley, none.