Etiology, Epidemiology, and Clinical Outcomes of Health Care Associated Pneumonia

描述(由研究人员提供)：美国胸科学会(ATS)和美国传染病学会(IDSA)定期发布肺炎的诊断和治疗指南。2005年，ATS/IDSA发布了指南，定义了肺炎的一个新亚类，名为卫生保健相关肺炎(HCAP)。HCAP涉及在肺炎之前经常与医疗保健系统互动的患者，肺炎被认为增加了由多重耐药(MDR)细菌引起的感染的风险。指南建议对HCAP采取积极的诊断和抗生素治疗方案。针对HCAP的研究有限，指南建议受到质疑。建议的目的包括：1)比较接受标准社区获得性肺炎(CAP)治疗的HCAP患者和接受指南类似治疗(GTS)等替代治疗的HCAP患者的临床结果]；2)与非MDR细菌相比，识别耐甲氧西林金黄色葡萄球菌(MRSA)和铜绿假单胞菌等耐多药细菌的风险因素，并开发准确识别感染MDR患者的模型。这将是一项对退伍军人事务医学中心HCAP住院患者进行的多中心回顾性队列研究。倾向得分匹配将用于调整与非随机治疗分配相关的潜在混杂和选择偏差。一般估计方程将被用来描述30天存活率和治疗之间的关系：标准CAP；抗MRSA和抗假单胞菌或GST、抗MRSA、抗假单胞菌或其他治疗方法。在目标2中，将确定所有受试者的MDR状态。将根据指南中报告的非特定于HCAP的风险标准以及来自队列的特定于HCAP的数据，使用Logistic回归来开发MDR风险的描述性模型。对特定的耐多药病原体：MRSA和铜绿假单胞菌将重复这一过程。MDR状态的最佳模型将用MRSA和铜绿假单胞菌数据进行改装，并与病原体特有的衍生模型进行比较。这项拟议的研究将确定遵循HCAP指南推荐的治疗是否可以提高存活率。进一步开发耐多药病原体的特定预测规则将完善未来经验性的HCAP抗生素选择。最后，确定哪些患者可能从经验性MDR指导的抗生素治疗中受益最大，这可能有助于限制抗生素耐药性。R&R：其他项目材料7.与公共健康相关的患者与医疗保健系统资源的接触增加了由抗生素耐药性细菌引起的感染的风险。这项研究的目的是确定抗生素耐药细菌引起卫生保健相关肺炎的频率，什么类型的卫生保健暴露与发生由耐药细菌引起的肺炎有关，以及什么抗生素治疗组合对卫生保健相关肺炎最有效。这项研究将通过帮助卫生保健提供者在治疗卫生保健相关肺炎时选择正确的抗生素，以及不使用超过必要的抗生素来改善公共健康。

DESCRIPTION (provided by investigator): The American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) have periodically published guidelines on the diagnosis and management of pneumonia. In 2005, the ATS/IDSA published guidelines which define a new subset of pneumonia entitled Health Care Associated Pneumonia (HCAP). HCAP pertains to patients that have frequently interacted with the Health Care system prior to pneumonia, which is thought to increase risk for infections caused by multiple drug-resistant (MDR) bacteria. The guidelines recommend aggressive diagnosis and antibiotic treatment regimens for HCAP. Research specific to HCAP is limited and the guideline recommendations have been questioned. Proposal Aims include: 1) to compare clinical outcome of patients with HCAP that receive standard community acquired pneumonia (CAP) therapy to those that receive alternative therapy such as guideline similar therapy (GTS)]; 2) identify risk factors for MDR bacteria including Methicillin-Resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, compared to non-MDR bacteria and develop models that accurately identify patients infected with MDR. This will be a multi- center retrospective cohort study of Veterans Affairs Medical Center inpatients with HCAP. Propensity score matching will be used to adjust for potential confounding and selection bias associated with non-random treatment allocation. Generalized estimating equations will be used to characterize associations between 30-day survival and treatments: standard CAP; anti-MRSA and anti-Pseudomonas or GST, anti-MRSA, anti-Pseudomonas, or other therapies. In Aim 2 MDR status will be determined for all subjects. Logistic regression will be used to develop descriptive models of MDR risk based on non-HCAP specific risk criteria reported in the guidelines as well as HCAP specific data from the cohort. The process will be repeated for specific MDR pathogens: MRSA and Pseudomonas aeruginosa. The best model of MDR status will be refitted with MRSA and Pseudomonas aeruginosa data and compared to pathogen- specific derived models. The proposed study will determine whether adherence to HCAP guideline recommended treatments improve survival. Further developing specific prediction rules for MDR pathogens will refine future empirical HCAP antibiotic selection. Finally, determining which patients may benefit most from empirical MDR directed antibiotic therapy may help to limit antibiotic resistance. R&R: Other Project Materials 7. PUBLIC HEALTH RELEVANCE Patients with exposure to the Health Care system resources are at increased risk for infections caused by antibiotic resistant bacteria. The purpose of this study is to determine how frequently antibiotic resistant bacteria cause Health Care Associated pneumonia, what type of Health Care exposures are related to developing a pneumonia due to resistant bacteria, and what antibiotic treatment combinations work the best for Health Care Associated pneumonia. This study will improve public health by helping health care providers choose the right antibiotics when treating Health Care Associated pneumonia and not using more antibiotics than necessary.