OBJECTIVES: 

Compare the clinical practice and outcomes in severe community-acquired pneumonia (sCAP) patients to those in non-sCAP patients using guideline-defined criteria for sCAP.

DESIGN: 

Retrospective observational cohort study.

SETTING: 

One hundred seventy-seven U.S. hospitals within the Premier Healthcare Database.

PATIENTS: 

Hospitalized adult (≥ 18 yr old) patients with pneumonia.

MEASUREMENTS AND MAIN RESULTS: 

Adult patients (≥ 18 yr old) with a principal diagnosis of pneumonia or a secondary diagnosis of pneumonia paired with a principal diagnosis of sepsis or respiratory failure were included. Patients with at least one guideline-defined major criterion for severe pneumonia were compared with patients with nonsevere disease. Among 154,799 patients with pneumonia, 21,805 (14.1%) met criteria for sCAP. They had higher organ failure scores (1.9 vs 0.63; p < 0.001) and inpatient mortality (22.0 vs 5.0%; p < 0.001), longer lengths of stay (8 vs 5 d; p < 0.001), and higher costs ($20,046 vs $7,543; p < 0.001) than those with nonsevere disease. Patients with sCAP had twice the rate of positive blood cultures (10.0% vs 4.5%; p < 0.001) and respiratory cultures (34.2 vs 21.1%; p < 0.001) and more often had isolates resistant to first-line community-acquired pneumonia antibiotics (10% of severe vs 3.1% of nonsevere; p < 0.001). Regardless of disease severity, Streptococcus pneumoniae was the most common pathogen recovered from blood cultures and Staphylococcus aureus and Pseudomonas species were the most common pathogens recovered from the respiratory tract. Although few patients with sCAP had cultures positive for a resistant organism, 65% received vancomycin and 42.8% received piperacillin-tazobactam.

CONCLUSIONS: 

sCAP patients had worse outcomes and twice the rate of culture positivity. S. aureus and S. pneumoniae were the most common organisms in respiratory and blood specimens, respectively. Although only recommended for sCAP patients, nearly all pneumonia patients received blood cultures, a quarter of nonsevere patients received sputum cultures, and treatment with broad-spectrum agents was widespread, indicating fertile ground for antimicrobial and diagnostic stewardship programs.

中文翻译：

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美国大样本中严重社区获得性肺炎患者的病因、治疗和结果*

目标： 

使用指南定义的 sCAP 标准，比较严重社区获得性肺炎 (sCAP) 患者与非 sCAP 患者的临床实践和结果。

设计： 

回顾性观察队列研究。

环境： 

Premier Healthcare 数据库中有一百七十七家美国医院。

患者： 

住院成人（≥ 18 岁）肺炎患者。

测量和主要结果： 

主要诊断为肺炎或次要诊断为肺炎并主要诊断为败血症或呼吸衰竭的成年患者（≥ 18 岁）被纳入研究。将至少具有一项指南定义的严重肺炎主要标准的患者与非严重疾病患者进行比较。在 154,799 名肺炎患者中，21,805 名（14.1%）符合 sCAP 标准。他们的器官衰竭评分较高（1.9 vs 0.63；p < 0.001），住院死亡率较高（22.0 vs 5.0%；p < 0.001），住院时间较长（8 天 vs 5 天；p < 0.001），费用较高（20,046 美元 vs与患有非严重疾病的患者相比，花费7,543 美元；p < 0.001）。sCAP 患者的血培养阳性率（10.0% vs 4.5%；p < 0.001）和呼吸道培养阳性率（34.2 vs 21.1%；p < 0.001）是其两倍，而且更常见的是分离株对一线社区获得性肺炎抗生素耐药（严重者为 10%，非严重者为 3.1%；p < 0.001）。无论疾病严重程度如何，肺炎链球菌是从血培养中回收的最常见病原体，金黄色葡萄球菌和假单胞菌是从呼吸道中回收的最常见病原体。尽管很少有 sCAP 患者的耐药菌培养呈阳性，但 65% 的患者接受了万古霉素治疗，42.8% 的患者接受了哌拉西林-他唑巴坦治疗。

结论： 

sCAP 患者的预后较差，培养阳性率是其两倍。金黄色葡萄球菌和肺炎链球菌分别是呼吸道和血液标本中最常见的微生物。尽管只推荐用于 sCAP 患者，但几乎所有肺炎患者都接受了血培养，四分之一的非重症患者接受了痰培养，并且广泛使用广谱药物治疗，这表明抗菌和诊断管理计划有肥沃的土壤。