2. European Respiratory Society Annual Congress 2013 11 th September 2013 Catriona Rother Healthcare associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis.

3. Healthcare associated pneumonia (HCAP) Pneumonia diagnosed in outpatients with regular healthcare contacts Criteria for HCAP (ATS/IDSA 2005 guidelines). Any one of the following: Resident of a nursing home or extended care facility. Chronic dialysis within preceding 30 days. Home infusion therapy (including antibiotics). Home wound care. Hospitalisation for 2 or more days in the preceding 90 days. Family member with multi-drug resistant pathogen.

4. Research Aim To determine the reliability of HCAP to predict potentially resistant pathogens. MRSA P. aeruginosa Gram negative Enterobacteriaceae

5. Research Methods Systematic review + meta-analysis  Studies comparing the frequency of potentially resistant pathogens in HCAP and CAP populations 24 studies: 22,456 patients

6. 1) Comparison of microbiology in HCAP vs. CAP

7. Comparison of microbiology

9. Similar results when limited to prospective studies.

10. Comparison of microbiology

11. 2) Quality of HCAP studies

12. Poor overall Analysis for sources of bias:  Variable definition of HCAP  Frequency of testing for microorganisms  Publication bias

13. Publication bias MRSA P. aeruginosa

14. 3) Ability of HCAP definition to predict potentially resistant organisms

15. Predictive accuracy of HCAP

19. Number needed to treat

21. 4) Clinical outcomes in HCAP vs. CAP

22. Mortality in HCAP vs. CAP Lower risk Higher risk

23. Mortality in HCAP vs. CAP Adjusted for confounders Lower risk with HCAPHigher risk with HCAP No clear increased risk of mortality in HCAP.

24. Conclusions HCAP concept is a poor discriminator of patients at risk of potentially resistant pathogens. Excess mortality in HCAP not due to increased frequency of resistant microorganisms. HCAP studies  Poor quality studies  Heterogenous study methods  Publication bias

25. Acknowledgements: Dr James D Chalmers Professor Dr Santiago Ewig Dr Waleed Salih Thanks for listening…