Clinical Infectious Diseases 1080 • CID 2019:68 (1 April) • Maruyama et al A Terapeutic Strategy for All Pneumonia Patients: A 3-Year Prospective Multicenter Cohort Study Using Risk Factors for Multidrug-resistant Pathogens to Select Initial Empiric Terapy Takaya Maruyama, 1 Takao Fujisawa, 2 Tadashi Ishida, 3 Akihiro Ito, 3 Yoshitaka Oyamada, 4 Kazuyuki Fujimoto, 4 Masamichi Yoshida, 5 Hikaru Maeda, 5 Naoyuki Miyashita, 6 Hideaki Nagai, 7 Yoshifumi Imamura, 8 Nobuaki Shime, 9 Shoji Suzuki, 10 Masaru Amishima, 11 Futoshi Higa, 12 Hiroyasu Kobayashi, 13 Shigeru Suga, 2 Kiyoyuki Tsutsui, 1 Shigeru Kohno, 8 Veronica Brito, 14 and Michael S. Niederman 15 Departments of 1 Respiratory Medicine and 2 Pediatrics, National Hospital Organization, Mie National Hospital, Tsu, 3 Department of Respiratory Medicine, Ohara Healthcare Foundation, Kurashiki Central Hospital, Okayama, 4 Department of Respiratory Medicine, National Hospital Organization, Tokyo Medical Center, Meguro-ku, 5 Department of Respiratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, 6 Department of Medicine, Kawasaki Medical School, Kurashiki, Okayama, 7 Center for Pulmonary Diseases, National Hospital Organization, Tokyo National Hospital, Kiyose-shi, 8 Second Department of Internal Medicine, Nagasaki University School of Medicine, 9 Department of Emergency and Critical Care Medicine, Institute of Biomedical and Health Sciences, Hiroshima University Advanced Emergency and Critical Care Center, Hiroshima University Hospital, Minami-ku, 10 Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, 11 Department of Respiratory Medicine, National Hospital Organization, Hokkaido Medical Center, Nishi-ku, Sapporo-shi, 12 Department of Respiratory Medicine, National Hospital Organization, Okinawa National Hospital, Ginowan-shi, and 13 Department of Respiratory Medicine, Suzuka General Hospital, Yasuzuka-cho, Mie, Japan; 14 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor Scott and White Health, Dallas, Texas; and 15 Division of Pulmonary and Critical Care Medicine, New York Presbyterian–Weill Cornell Medical Center Background. Empiric therapy of pneumonia is currently based on the site of acquisition (community or hospital), but could be chosen, based on risk factors for multidrug-resistant (MDR) pathogens, independent of site of acquisition. Methods. We prospectively applied a therapeutic algorithm based on MDR risks, in a multicenter cohort study of 1089 patients with 656 community-acquired pneumonia (CAP), 238 healthcare-associated pneumonia (HCAP), 140 hospital-acquired pneumo- nia (HAP), or 55 ventilator-associated pneumonia (VAP). Results. Approximately 83% of patients were treated according to the algorithm, with 4.3% receiving inappropriate therapy. Te frequency of MDR pathogens varied, respectively, with VAP (50.9%), HAP (27.9%), HCAP (10.9%), and CAP (5.2%). Tose with ≥2 MDR risks had MDR pathogens more ofen than those with 0–1 MDR risk (25.8% vs 5.3%, P < .001). Te 30-day mortality rates were as follows: VAP (18.2%), HAP (13.6%), HCAP (6.7%), and CAP (4.7%), and were lower in patients with 0–1 MDR risks than in those with ≥2 MDR risks (4.5% vs 12.5%, P < .001). In multivariate logistic regression analysis, 5 risk factors (advanced age, hemato- crit <30%, malnutrition, dehydration, and chronic liver disease), as well as hypotension and inappropriate therapy were signifcantly correlated with 30-day mortality, whereas the classifcation of pneumonia type (VAP, HAP, HCAP, CAP) was not. Conclusions. Individual MDR risk factors can be used in a unifed algorithm to guide and simplify empiric therapy for all pneu- monia patients, and were more important than the classifcation of site of pneumonia acquisition in determining 30-day mortality. Clinical Trials Registration. JMA-IIA00146. Keywords. pneumonia; antibiotic therapy; guidelines; community-acquired pneumonia; nosocomial pneumonia. Pneumonia can be classified into community-acquired pneu- monia (CAP), healthcare-associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), and ventilator-associ- ated pneumonia (VAP), each with its own individual therapy algorithm. Pneumonia guidelines initially recommended that HCAP be treated like HAP or VAP, but recent studies in Europe and Japan have reported that HCAP patients had a lower fre- quency of multidrug-resistant (MDR) pathogens than HAP patients and were often similar to CAP, and also that the con- cept of HCAP did not always accurately identify patients with drug-resistant pathogens [1–7]. The 2016 American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines removed the concept of HCAP from the classifi- cation of nosocomial pneumonia and instead considered it a form of CAP [8]. However, in the United States there is still a higher frequency of drug-resistant pathogens and mortal- ity in HCAP than in CAP patients [9, 10], especially in those with multiple MDR risk factors [11–15]. In contrast, there are reports that the etiology of HAP in nonintubated patients was similar to that of CAP in some studies [16], and to VAP in others [17]. MAJOR ARTICLE © The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com. DOI: 10.1093/cid/ciy631 Received 10 May 2018; accepted 31 July 2018; published online August 1, 2018. Correspondence: M. S. Niederman, New York Presbyterian Hospital, Weill Cornell Medical Center, 425 E 61st St, New York, NY 10065 (msn9004@med.cornell.edu). Clinical Infectious Diseases ® 2019;68(7):1080–8 Downloaded from https://academic.oup.com/cid/article-abstract/68/7/1080/5063558 by guest on 01 June 2020