Healthcare-associated Pneumonia and Aspiration Pneumonia

Volume 6, Number 1; 27-37, February 2015 http://dx.doi.org/10.14336/AD.2014.0127 Review Article Healthcare-associated Pneumonia and Aspiration Pneum...
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Volume 6, Number 1; 27-37, February 2015 http://dx.doi.org/10.14336/AD.2014.0127

Review Article

Healthcare-associated Pneumonia and Aspiration Pneumonia Kosaku Komiya1, 2, Hiroshi Ishii3, Jun-ichi Kadota1 1

Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Yufu, Japan Clinical Research Center of Respiratory Medicine, Tenshindo Hetsugi Hospital, Oita, Japan 3 Department of Respiratory Medicine, Fukuoka University Hospital, Jonan-ku, Fukuoka, Japan 2

[Received November 26, 2013; Revised January 24, 2014; Accepted January 27, 2014]

ABSTRACT: Healthcare-associated pneumonia (HCAP) is a new concept of pneumonia proposed by the American Thoracic Society/Infectious Diseases Society of America in 2005. This category is located between community-acquired pneumonia and hospital-acquired pneumonia with respect to the characteristics of the causative pathogens and mortality, and primarily targets elderly patients in healthcare facilities. Aspiration among such patients is recognized to be a primary mechanism for the development of pneumonia, particularly since the HCAP guidelines were published. However, it is difficult to manage patients with aspiration pneumonia because the definition of the condition is unclear, and the treatment is associated with ethical aspects. This review focused on the definition, prevalence and role of aspiration pneumonia as a prognostic factor in published studies of HCAP and attempted to identify problems associated with the concept of aspiration pneumonia.

Key words: healthcare-associated pneumonia, aspiration pneumonia, elderly, diagnosis.

A new classification of pneumonia, healthcare-associated pneumonia (HCAP), was introduced by the American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) in 2005 [1]. The definition of HCAP includes hospitalization for two days or more within the preceding 90 days, residence in a nursing home or extended care facility, the use of home infusion therapy (including antibiotics), receipt of chronic dialysis within 30 days, home wound care and a history of infection with a multidrug-resistant pathogen in a family member. Patients with HCAP are characterized by an older age, increased risk factors for infection with drug-resistant pathogens and poorer prognosis compared to those with community-acquired pneumonia (CAP) [2]. Consequently, guidelines recommend the use of empiric broad-spectrum antibiotic therapy in these patients. However, most clinicians do not actually choose broadspectrum antibiotics in cases of HCAP [3]. In fact, the use

of guideline-concordant therapy does not improve the prognosis, and host factors, rather than the presence of drug-resistant pathogens, appear to influence the prognosis [4-7]. Previous studies have demonstrated aspiration pneumonia to be a host factor associated with mortality in patients with HCAP [8-11]. Aspiration pneumonia is defined as the misdirection of oropharyngeal or gastric contents into the larynx and lower respiratory tract [12, 13]. Although initial clinical reports focused on aspiration pneumonia resulting from accidental exogenous factors, such as the ingestion of oil [14-16], the number of studies regarding aspiration pneumonia due to the aspiration of oropharyngeal secretions in the elderly has increased as the population ages, especially in developed countries [13, 17-22]. However, the definition of aspiration pneumonia remains vague and unclear, which is likely to complicate clinical research regarding the prognosis of pneumonia. We

*Correspondence should be addressed to: Kosaku Komiya, M.D., Ph.D. Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Oita, Japan. E-mail: [email protected] ISSN: 2152-5250

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The Definition of Aspiration Pneumonia

therefore reviewed previously published papers focusing on aspiration pneumonia among patients with HCAP in order to clarify the variability in the definition of aspiration pneumonia, as well as the prevalence of the condition and its impact on the prognosis. In addition, we

discuss the meaning and purpose of a diagnosis of aspiration pneumonia according to guidelines for pneumonia.

Table 1. Definition of aspiration pneumonia among studies of healthcare-associated pneumonia Patients

Definition of aspiration pneumonia or risk factors for aspiration pneumonia

prospective

CAP/HCAP

Patients with risk factors such as compromised consciousness, altered gag reflex, dysphagia, severe periodontal disease, putrid sputum and radiographic evidence of involvement of a dependent pulmonary segment or necrotizing pneumonia.

prospective

CAP/HCAP

Same as CarratalàJ, et al. 2007.

prospective

CAP/HCAP

Same as Garcia-Vidal C, et al. 2011.

prospective

CAP/HCAP/HAP

Falcone M, et al. Italy 201210

prospective

HCAP

Fukuyama H, et Japan al. 201320

prospective

CAP/NHCAP

Shindo Y, et al. Japan 200949

retrospective

CAP/HCAP

Miyashita N, et Japan al. 201230

retrospective

CAP/NHCAP

Ishida T, et al. Japan 201227

retrospective

CAP/NHCAP

retrospective

NHCAP

retrospective

CAP/NHCAP

retrospective

CAP/HCAP

retrospective

CAP/NHCAP

Study

Country Design

Carratalà J, et Spain al. 200748 Garcia-Vidal C, Spain et al. 201123 Simonetti A, et Spain al. 201222 Giannella M, et Spain al. 201221

Miyashita N, et Japan al. 201326 Oshitani Y, et Japan al. 201325 Komiya K, et al. Japan 20138 Nakagawa N, et Japan al. 201324

Altered consciousness, altered gag reflex, dysphagia, severe periodontal disease or putrid sputum. Patients with risk factors such as compromised consciousness, altered gag reflex, dysphagia, severe periodontal disease, putrid sputum or necrotizing pneumonia in absence of positive respiratory specimen cultures. Patients with apparent aspiration, a condition in which aspiration is strongly expected or the existence of an abnormal swallowing function or dysphagia. Suspected patients were assessed using water swallowing tests or VE for the purpose of evaluating the swallowing function. Probable aspiration was defined as any witnessed aspiration before hospital admission or aspiration confirmed by fluid-drinking test on hospital admission. Pneumonia in a patient with a predisposition to aspiration because of dysphagia or a swallowing disorder. The swallowing function was assessed using the water-swallowing test, repetitive salivaswallowing test, simple swallowing provocation test and VF. When the swallowing function was not assessed using these examinations, the presence of overt symptoms of dysphagia or a medical history of aspiration was determined to a swallowing disorder in the patient. Trained nurses checked the following factors three times: a past history of aspiration, the occurrence of a choking sensation with a wet cough during meals and the presence of massive fur on the tongue. If at least one factor was identified, the patient was judged to have a risk of aspiration and the swallowing function was assessed using the water swallowing test, repetitive saliva swallowing test, VE and VF. Same as Miyashita N, et al. 2012. Involvement of aspiration was defined as dysphagia or aspiration confirmed or strongly suspected. Patients with both risk factors for aspiration and evidence of gravitydependent opacity on chest CT. Aspiration was recorded when witnessed by a patient’s family member or care staff member before the onset of pneumonia and confirmed by a water swallowing test or swallowing test using a laryngoscope.

Abbreviations: CAP = community-acquired pneumonia; HCAP = healthcare-associated pneumonia; NHCAP=nursing and healthcare-associated pneumonia; VE = videoendocsopy; VF = videofluorography

Aging and Disease • Volume 6, Number 1, February 2015

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The Definition of Aspiration Pneumonia

Table 2. Prevalence and role of aspiration pneumonia as a prognostic factor among studies defining aspiration pneumonia in patients with CAP and (N)HCAP Study

Ratio in CAP/(N)HCAP

Ratio in CAP

Ratio in (N)HCAP

Crude mortality or adjusted OR or HR

CarratalàJ, et al. 200748

44/727 (6.1%)

18/601 (18%)

26/126 (20.6%)

n.a.

Garcia-Vidal C, et al. 201123

162/2153 (7.5%)

91/1668 (5.5%)

71/485 (14.6%)

n.a.

Simonetti A, et al. 201222

123/1593 (7.7%)

68/1274 (5.3%)

55/319 (17.2%)

no significance?

Giannella M, et al. 201221

262/898 (29.2%)

108/591 (18.3%)

154/307 (50.2%)

OR 0.87 (0.48-1.57) p=0.66 for in-hospital mortality

Falcone M, et al. 201210

n.a.

n.a.

55/217 (25.3%)

OR 4.94 (1.71-14.27) as inhospital mortality with significance

Fukuyama H, et al. 201320

129/306 (42.2%)

7/114 (6.1%)

122/192 (63.5%)

14.8% vs 4.3% 30 daymortality

Shindo Y, et al. 200949

124/371 (33.4%)

42/230 (18.3%)

82/141 (58.2%)

n.a.

Miyashita N, et al. 201230

492/1385 (35.5%)

122/786 (15.5%)

370/599 (61.8%)

no significance?

Ishida T, et al. 201227

376/893 (42.1%)

96/451 (21.3%)

280/442 (63.3%)

n.a.

Miyashita N, et al. 201326

n.a.

n.a.

370/599 (61%)

n.a.

Oshitani Y, et al. 201325

382/718 (53.2%)

24/241 (10%)

358/477 (75.1%)

no significance in NHCAP

Komiya K, et al. 20138

116/637 (18.2%)

n.a.

n.a.

HR 5.690 (2.306–14.040)