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Health Care–Associated Pneumonia

By Sanjay Sethi, MD, Professor and Chief, Pulmonary, Critical Care and Sleep Medicine, and Assistant Vice President for Health Sciences, University at Buffalo SUNY

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Health care–associated pneumonia (HCAP) occurs in non-hospitalized patients who reside in a nursing home or other long-term care facility, have undergone IV therapy (including chemotherapy) or wound care within the previous 30 days, have been hospitalized in an acute care hospital for ≥ 2 days within the previous 90 days, or have attended a hospital or hemodialysis center within the previous 30 days. In addition to the usual community-acquired pathogens, HCAP pathogens include gram-negative bacilli (including Pseudomonas aeruginosa) and Staphylococcus aureus (including methicillin-resistant S. aureus) and various antibiotic-resistant pathogens. Symptoms and signs are similar to those of pneumonia that occurs in other settings, except many elderly patients have less prominent changes in vital signs. Diagnosis is based on clinical presentation and chest x-ray. Treatment is with broad-spectrum antibiotics. Mortality is moderately high but may be due in part to coexisting disorders.

(See also Overview of Pneumonia.)

The definition of health care–associated pneumonia is designed to identify patients who are at higher risk of developing pneumonia due to antibiotic-resistant organisms and who, therefore, might require broader spectrum empiric antibiotic therapy (see Overview of Pneumonia). Nursing home–acquired pneumonia is the most common subset of HCAP. Risk factors are common among debilitated nursing home residents; they include

  • Poor functional status

  • Mood disorder

  • Altered mental status

  • Difficulty swallowing

  • Immunosuppression

  • Older age

  • Use of tube feedings

  • Influenza or other viral respiratory infections

  • Conditions that predispose to bacteremia (eg, indwelling bladder catheter, pressure ulcers)

  • Presence of a tracheostomy tube


In addition to the usual community-acquired pathogens, HCAP pathogens include gram-negative bacilli (including P. aeruginosa) and Staphylococcus aureus (including methicillin-resistant S. aureus) and various antibiotic-resistant pathogens.

The most common pathogens are

  • Streptococcus pneumoniae

  • Gram-negative bacilli

These organisms may be responsible for roughly equal numbers of infections; it is not clear whether gram-negative bacilli are sometimes bacteria that are colonizing the patient rather than causative pathogens. Haemophilus influenzae and Moraxella catarrhalis are next most common. Chlamydia, Mycoplasma, and Legionella spp are rarely identified.

Polymicrobial infection, as well as infection with antibiotic-resistant organisms, particularly methicillin-resistant S. aureus and Pseudomonas infection, is much more likely with prior antibiotic treatment (within the previous 90 days). Infection with a resistant organism markedly worsens mortality and morbidity. Other risk factors for polymicrobial infection and antibiotic-resistant organisms include

  • Current hospitalization of ≥ 5 days

  • High incidence of antibiotic resistance in the community, hospital, or specific hospital unit

  • Hospitalization for ≥ 2 days within the previous 90 days

  • Residence in a nursing home or extended care facility

  • Home infusion therapy (including antibiotics)

  • Dialysis treatments

  • Home wound care

  • Family member with infection due to an antibiotic-resistant pathogen

  • Immunosuppressive disease or therapy

However, new evidence indicates several of these factors may overestimate the risk of polymicrobial and antibiotic-resistant organisms and thus drive overuse of broad-spectrum antibiotics. Revised guidelines for HCAP are being written and will likely recommend limiting broad-spectrum antibiotics to patients with prior antibiotic treatment in the previous 90 days, while individualizing therapy for the other HCAP-associated factors.

Symptoms and Signs

Symptoms of health care–associated pneumonia often resemble those of community-acquired pneumonia but may be more subtle. Cough and altered mental status are common, as are nonspecific symptoms of anorexia, weakness, restlessness and agitation, falling, and incontinence. Subjective dyspnea occurs but is less common.

Signs include diminished or absent responsiveness, fever, tachycardia, tachypnea, sputum production, wheezes or crackles, and stertorous, wet breathing.


  • Clinical manifestations

  • Chest x-ray

  • Assessment of renal function and oxygenation

Diagnosis of health care–associated pneumonia is based on clinical manifestations (eg, fever, cough, sputum production) and a chest x-ray demonstrating an infiltrate. Blood tests may show leukocytosis. Because detection of physical changes may be delayed in a nursing home setting and because these patients are at greater risk of complications, evaluation for hypoxemia with pulse oximetry and for decreased intravascular volume with serum BUN and creatinine should be done.

X-rays are often difficult to obtain in nursing home patients, so it may be necessary to transfer them to a hospital at least for initial evaluation. In some cases (eg, if clinical diagnosis is clear, if illness is mild, or if aggressive care is not the goal), treatment may be started without x-ray confirmation. It is thought that nursing home patients may initially lack a radiographic infiltrate, presumably because of the dehydration that commonly accompanies febrile pneumonia in the elderly or a blunted immune response.


Mortality rate for patients with health care–associated pneumonia requiring admission for treatment is 13 to 41%.


  • Antibiotics

Few data are available to guide decisions about where treatment should take place. In general, patients should be hospitalized if they have 2 unstable vital signs and if the nursing home cannot administer acute care. Some nursing home patients, such as those undergoing end-of-life care or who have advance directives asking for limited medical measures, are not candidates for aggressive treatment or hospital transfer under any circumstances.

Antibiotics are the mainstay of treatment of health care–associated pneumonia. An antibiotic regimen should be chosen that is effective against S. pneumoniae, H. influenzae, and common gram-negative bacilli. A common regimen is an oral antipneumococcal quinolone (eg, levofloxacin 750 mg once/day or moxifloxacin 400 mg once/day). Ceftriaxone, ertapenem, and ampicillin/sulbactam (each as monotherapy) are alternatives. For patients who are to be hospitalized, one dose of an appropriate antibiotic should be given before transfer.

Key Points

  • Health care–associated pneumonia (HCAP) occurs in non-hospitalized patients who have had recent contact with the health care system, including nursing homes, dialysis centers, and infusion centers.

  • The causative pathogen profile of health care–associated pneumonia differs from that of community-acquired pneumonia and requires broader empiric antibiotic therapy that is active against antibiotic-resistant organisms.