Incidence and Outcomes of Non–Ventilator-Associated Hospital-Acquired Pneumonia in 284 US Hospitals Using Electronic Surveillance Criteria

Abstract

ImportanceNon–ventilator-associated hospital-acquired pneumonia (NV-HAP) is a common and deadly hospital-acquired infection. However, inconsistent surveillance methods and unclear estimates of attributable mortality challenge prevention.ObjectiveTo estimate the incidence, variability, outcomes, and population attributable mortality of NV-HAP.Design, Setting, and ParticipantsThis cohort study retrospectively applied clinical surveillance criteria for NV-HAP to electronic health record data from 284 US hospitals. Adult patients admitted to the Veterans Health Administration hospital from 2015 to 2020 and HCA Healthcare hospitals from 2018 to 2020 were included. The medical records of 250 patients who met the surveillance criteria were reviewed for accuracy.ExposuresNV-HAP, defined as sustained deterioration in oxygenation for 2 or more days in a patient who was not ventilated concurrent with abnormal temperature or white blood cell count, performance of chest imaging, and 3 or more days of new antibiotics.Main Outcomes and MeasuresNV-HAP incidence, length-of-stay, and crude inpatient mortality. Attributable inpatient mortality by 60 days follow-up was estimated using inverse probability weighting, accounting for both baseline and time-varying confounding.ResultsAmong 6 022 185 hospitalizations (median [IQR] age, 66 [54-75] years; 1 829 475 [26.1%] female), there were 32 797 NV-HAP events (0.55 per 100 admissions [95% CI, 0.54-0.55] per 100 admissions and 0.96 per 1000 patient-days [95% CI, 0.95-0.97] per 1000 patient-days). Patients with NV-HAP had multiple comorbidities (median [IQR], 6 [4-7]), including congestive heart failure (9680 [29.5%]), neurologic conditions (8255 [25.2%]), chronic lung disease (6439 [19.6%]), and cancer (5,467 [16.7%]); 24 568 cases (74.9%) occurred outside intensive care units. Crude inpatient mortality was 22.4% (7361 of 32 797) for NV-HAP vs 1.9% (115 530 of 6 022 185) for all hospitalizations; 12 449 (8.0%) were discharged to hospice. Median [IQR] length-of-stay was 16 (11-26) days vs 4 (3-6) days. On medical record review, pneumonia was confirmed by reviewers or bedside clinicians in 202 of 250 patients (81%). It was estimated that NV-HAP accounted for 7.3% (95% CI, 7.1%-7.5%) of all hospital deaths (total hospital population inpatient death risk of 1.87% with NV-HAP events included vs 1.73% with NV-HAP events excluded; risk ratio, 0.927; 95% CI, 0.925-0.929).Conclusions and RelevanceIn this cohort study, NV-HAP, which was defined using electronic surveillance criteria, was present in approximately 1 in 200 hospitalizations, of whom 1 in 5 died in the hospital. NV-HAP may account for up to 7% of all hospital deaths. These findings underscore the need to systematically monitor NV-HAP, define best practices for prevention, and track their impact.

Stewardship Prompts to Improve Antibiotic Selection for Pneumonia

“…Pneumonia is a leading cause of hospitalization and unnecessary use of extended-spectrum antibiotics, with an estimated 750 000 hospitalized adults receiving extendedspectrum antibiotics annually in the US. [1][2][3][4]12,15,24,25 The CPOE bundle intervention resulted in a rapid, sustained, and safe reduction of empiric extended-spectrum antibiotic use for noncritically ill patients hospitalized with pneumonia. This trial focused on reducing use of extended-spectrum agents before microbiology results were available.…”

Association Between Daily Toothbrushing and Hospital-Acquired Pneumonia

“…While the risk per patient is higher for intubated patients receiving mechanical ventilation, most cases of nosocomial pneumonia occur in nonintubated patients by virtue of their greater numbers in the hospital population. Crude and adjusted mortality rates associated with nonventilator HAP (NV-HAP) are similar to those of ventilator-associated pneumonia (VAP) …”

“…Hospital-acquired pneumonia (HAP) is the most common and morbid nosocomial infection. It affects approximately 1% of hospitalized patients and is associated with increased mortality, longer length of stay, and higher costs . While the risk per patient is higher for intubated patients receiving mechanical ventilation, most cases of nosocomial pneumonia occur in nonintubated patients by virtue of their greater numbers in the hospital population.…”

Daily Toothbrushing to Prevent Hospital-Acquired Pneumonia—Brushing Away the Risk

“…Often overlooked and understudied, oral care is critical to health, quality of life, and prevention of infection such as hospital-acquired pneumonia (HAP). HAP is classified into ventilator-associated pneumonia (VAP) and nonventilator HAP (NV-HAP), with both leading to poor outcomes . HAP is largely due to aspiration of microflora from the oral microbiome, a complex and highly diverse ecosystem with an estimated 700 species of bacteria, fungi, viruses, and protozoa .…”