Clinical Interventions in Aging

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Prognostic value of severity indicators of nursinghome-acquired pneumonia versus communityacquired pneumonia in elderly patients
This article was published in the following Dove Press journal:
Clinical Interventions in Aging
11 February 2014
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Motoi Ugajin
Kenichi Yamaki
Natsuko Hirasawa
Takanori Kobayashi
Takeo Yagi
Department of Respiratory Medicine,
Ichinomiya-Nishi Hospital, Ichinomiya
City, Japan

Background: The credibility of prognostic indicators in nursing-home-acquired pneumonia

(NHAP) is not clear. We previously reported a simple prognostic indicator in communityacquired pneumonia (CAP): blood urea nitrogen to serum albumin (B/A) ratio. This retrospective study investigated the prognostic value of severity indicators in NHAP versus CAP in
elderly patients.
Methods: Patients aged $65 years and hospitalized because of NHAP or CAP within the previous 3 years were enrolled. Demographics, coexisting illnesses, laboratory and microbiological
findings, and severity scores (confusion, urea, respiratory rate, blood pressure, and age $65
[CURB-65] scale; age, dehydration, respiratory failure, orientation disturbance, and pressure
[A-DROP] scale; and pneumonia severity index [PSI]) were retrieved from medical records.
The primary outcome was mortality within 28 days of admission.
Results: In total, 138 NHAP and 307 CAP patients were enrolled. Mortality was higher in
NHAP (18.1%) than in CAP (4.6%) (P,0.001). Patients with NHAP were older and had lower
functional status and a higher rate of do-not-resuscitate orders, heart failure, and cerebrovascular diseases. The NHAP patients more frequently had typical bacterial pathogens. Using the
receiver-operating characteristics curve for predicting mortality, the area under the curve in
NHAP was 0.70 for the A-DROP scale, 0.69 for the CURB-65 scale, 0.67 for the PSI class, and
0.65 for the B/A ratio. The area under the curve in CAP was 0.73 for the A-DROP scale, 0.76
for the CURB-65 scale, 0.81 for the PSI class, and 0.83 for the B/A ratio.
Conclusion: Patient mortality was greater in NHAP than in CAP. Patient characteristics,
coexisting illnesses, and detected pathogens differed greatly between NHAP and CAP. The
existing severity indicators had less prognostic value for NHAP than for CAP.
Keywords: albumin, blood urea nitrogen, community-acquired pneumonia, mortality, nursinghome-acquired pneumonia, severity score

Introduction

Correspondence: Motoi Ugajin

Department of Respiratory Medicine,
Ichinomiya-Nishi Hospital, 1 Hira,
Kaimei, Ichinomiya City 494-0001, Japan
Tel +81 586 48 0077
Fax +81 586 48 0038
Email [email protected]

With the expansion of the aging population, the number of nursing home residents is
increasing globally. In Japan, the number of nursing home residents increased from
300,000 residents in 1995 to 600,000 residents in 2006. Among nursing home residents,
the most common cause of hospital admission is pneumonia.1,2 Therefore, nursinghome-acquired pneumonia (NHAP) is an important topic in public health.
NHAP is included under the concept of health-care-associated pneumonia (HCAP)
that has been proposed by the American Thoracic Society (ATS)/Infectious Diseases
Society of America (IDSA).3 However, it is controversial whether NHAP should
be managed as HCAP because several former reports showed that the influence of

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Ugajin etal

drug-resistant pathogens was not different between NHAP

and community-acquired pneumonia (CAP).4,5
Throughout the world, several severity indicators have
been introduced for CAP. The ATS/IDSA recommends the
pneumonia severity index (PSI);6 the British Thoracic Society recommends the confusion, urea, respiratory rate, blood
pressure, and age $65 (CURB-65) scale;7 and the Japanese
Respiratory Society recommends the age, dehydration,
respiratory failure, orientation disturbance, and pressure
(A-DROP) scale.8 Moreover, we previously reported that
the ratio of blood urea nitrogen to serum albumin (B/A) is a
simple severity indicator for CAP.9,10 However, the credibility
of these severity indicators in NHAP has not been confirmed.
In this retrospective study of an elderly population, we investigated the prognostic values of these severity indicators for
NHAP versus CAP.

Materials and methods

Study population
Consecutive patients hospitalized for pneumonia from August
2010 through July 2013 in Ichinomiya-Nishi Hospital (a
400-bed teaching hospital; Ichinomiya City, Aichi, Japan)
were enrolled in this study. Pneumonia was diagnosed in
patients who presented with a new radiographic infiltrate,
exhibited at least two compatible clinical symptoms (body
temperature .38C, productive cough, chest pain, shortness of breath, and crackles on auscultation), had not been
exposed to intravenous antibiotics during the 14 days before
enrollment, and had not been hospitalized in the last 90 days.
The patients admitted from a nursing home were defined as
having NHAP, and patients admitted from the community
were defined as having CAP.
Patients were excluded if they were younger than 65 years,
chronically immunosuppressed (chemotherapy, therapy
with systemic corticosteroids or other immunosuppressive
agents, or infection with human immunodeficiency virus),
had advanced liver disease, or had received hemodialysis or
had a serum creatinine level $1.5 mg/dL because of chronic
kidney disease.
This study protocol was approved by the ethics committee
of our hospital, called the Research Ethics Review Committee
of Ichinomiya-Nishi Hospital (Study Number 25016).

Study design
The following variables were retrieved from the patients
medical charts: demographic characteristics (age and sex);
performance status; coexisting illnesses; clinical data at
the time of admission (body temperature, respiratory rate,

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percutaneous oxygen saturation, blood pressure, cardiac

frequency, and mental status); laboratory and radiographic
findings on admission; the scores of PSI, CURB-65, and
A-DROP scales on admission; typical bacterial pathogens;
intravenous initial antibiotic regimens; do-not-resuscitate
order; and the clinical outcome.
Patient performance status before admission was evaluated in accordance with the European Cooperative Oncology
Group score.11 The grades are defined as follows: Grade 0,
fully active and able to perform all pre-disease performance
without restriction; Grade 1, restricted in performing physically strenuous activity but ambulatory and able to perform
light or sedentary work; Grade 2, ambulatory and capable of
all self-care but unable to perform any work activity, up and
approximately more than 50% of working hours; Grade 3,
capable of only limited self-care, confined to a bed or chair
more than 50% of working hours; Grade 4, completely disabled, cannot perform any self-care, and totally confined to
a bed or chair.
The A-DROP scale is a 5-point scoring system, similar
to the CURB-65 scale, and includes confusion, blood urea
nitrogen .20 mg/dL, percutaneous oxygen saturation ,90%,
systolic blood pressure ,90 mmHg, and age $70 years for
men or $75 years for women.
Detected typical bacterial pathogens were defined by the
following criteria: for Streptococcus pneumoniae, 3+ growth
of sputum culture or the presence of antigen in the urine; for
Legionella pneumophila, the presence of the antigen in the
urine; and for other bacteria, 3+ growth of sputum culture.
A patient was considered to have a do-not-resuscitate
order in cases where such an order was mentioned in the
medical charts. The clinical outcome was defined as death or
survival of a patient within 28 days from his or her admission.
The aim of this study was to evaluate the prognostic value
of each potential severity indicator in accordance with
the guideline of Standards for Reporting of Diagnostic
Accuracy.12

Methods
Blood urea nitrogen was measured by the enzymatic method
with urease and glutamate dehydrogenase (Shino-Test
Corporation, Tokyo, Japan). The serum C-reactive protein
(CRP) level was measured by the latex agglutination assay
(Nittobo Medical, Tokyo, Japan). The serum albumin level
was measured by the bromocresol green method (Shino-Test
Corporation) from August 2010 through December 2011 and
by the bromocresol purple method (Kainos Laboratories,
Tokyo, Japan) from January 2012 through July 2013.

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Prognostic value of severity indicators in NHAP

The normal range of the serum albumin level was the same
for both methods. Other biochemical markers were assayed
by using standard methods. To detect the causative pathogens, routine sampling included sputum and urinary antigen
tests for S. pneumoniae (Binax Inc., Portland, ME, USA) and
L. pneumophila serogroup 1 (Binax Inc.).

of being younger than 65 years (n=44) or because of having

chronic kidney disease (n=26), immunosuppression (n=6),
or advanced liver disease (n=3). In this study, 138 NHAP
patients and 307 CAP patients were ultimately enrolled
(Figure 1).

Patient characteristics in NHAP and CAP

Statistical analysis
The data are expressed as the number or as the median
(25th75th percentile range). Differences between the two
groups were tested by using the nonparametric Mann
Whitney U-test for continuous variables and the Fishers
exact test for categorical variables. Receiver-operating
characteristic (ROC) curve analysis and area under the
curve (AUC) measurements were performed to assess the
diagnostic ability of each potential indicator for predicting mortality. A two-tailed probability value of ,0.05 was
considered significant.

Results
Patient population
During the study period, 535 patients were admitted because
of pneumonia. Of these patients, 149 were defined as having
NHAP and the remaining 386 were defined as having CAP.
Eleven of the NHAP patients were excluded because
of being younger than 65 years (n=3) or because of having
chronic kidney disease (n=7) or immunosuppression (n=1).
Seventy-nine CAP patients were similarly excluded because

Table 1 lists the characteristics of the NHAP and CAP

patients. Compared to CAP patients, NHAP patients were
older (P,0.001) and had a higher 28-day mortality (18.1%
for NHAP versus 4.6% for CAP) (P,0.001). The proportion of males was less among the NHAP patients (45.7%)
than among the CAP patients (67.8%) (P,0.001). The
performance status was worse in the NHAP patients than
in the CAP patients (P,0.001). A do-not-resuscitate order
was more frequent among the NHAP patients (49.3%) than
among the CAP patients (14.3%) (P,0.001).
Heart failure and cerebrovascular diseases were more
frequently observed as a coexisting illness in NHAP
patients than in CAP patients (P=0.035 and P,0.001,
respectively). In contrast, chronic lung diseases were less
frequently observed in NHAP patients than in CAP patients
(P=0.012).
The laboratory findings on admission showed that the
values of the hematocrit and the glucose, creatinine, and
albumin levels were lower for the NHAP patients than
for the CAP patients (P,0.001, P=0.024, P,0.001, and
P,0.001, respectively). By contrast, the NHAP patients

Hospitalized patients because of pneumonia during the study period

(n=535)

Patients from nursing home

(n=149)

Met the exclusion criteria

Under 65 years old (n=3)
Kindney diseases (n=7)
Immunosuppression (n=1)
Advanced liver diseases (n=0)

Included patients as NHAP

(n=138)

Patients from community

(n=386)

Met the exclusion criteria

Under 65 years old (n=44)
Kidney diseases (n=26)
Immunosuppression (n=6)
Advanced liver diseases (n=3)

Included patients as CAP

(n=307)

Figure 1 Flow diagram of the recruitment of study population.

Abbreviations: CAP, community-acquired pneumonia; NHAP, nursing-home-acquired pneumonia.

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Table 1 Characteristics between NHAP and CAP patients

Age, years
Male patients
Performance status
Do-not-resuscitate order
Death within 28 days
Coexisting illnesses
Chronic lung diseases
Diabetes mellitus
Heart failure
Cerebrovascular diseases
Neoplastic diseases
Laboratory findings on admission
Leukocyte count, 109 cells/L
Hematocrit, %
C-reactive protein, mg/dL
Sodium, mEq/L
Glucose, mg/dL
Creatinine, mg/dL
Blood urea nitrogen, mg/dL
Albumin, g/dL
B/A ratio, mg/g
PSI class
12
3
4
5
CURB-65 scale
01
2
$3
A-DROP scale
01
2
$3
Initial antibiotic regimens
Anti-pseudomonal -lactums
Clindamycin
Fluoroquinolones
Tetracyclines

NHAP (n=138)

CAP (n=307)

P-value

85 (8190)
63 (45.7)
3 (33)
68 (49.3)
25 (18.1)

79 (7486)
208 (67.8)
1 (12)
44 (14.3)
14 (4.6)

,0.001
,0.001
,0.001
,0.001
,0.001

16 (11.6)
21 (15.2)
29 (21.0)
76 (55.1)
4 (2.9)

66 (21.5)
58 (18.9)
40 (13.0)
60 (19.5)
7 (2.3)

0.012
0.421
0.035
,0.001
0.745

11.3 (7.714.2)
35.5 (31.938.3)
12.21 (7.0518.75)
138 (133141)
124 (105148)
0.71 (0.491.03)
21.5 (16.028.1)
3.1 (2.83.5)
7.12 (5.279.43)

10.8 (8.513.6)
37.7 (34.240.5)
13.07 (6.7719.56)
138 (135141)
132 (110161)
0.85 (0.681.06)
20.0 (14.826.8)
3.5 (3.03.8)
5.81 (4.208.14)

0.85
,0.001
0.439
0.083
0.024
,0.001
0.082
,0.001
,0.001
,0.001

1 (0.7)
3 (2.2)
78 (56.5)
56 (40.6)

17 (5.5)
124 (40.4)
134 (43.6)
32 (10.4)

19 (13.8)
35 (25.4)
84 (60.9)

88 (28.7)
112 (36.4)
107 (34.9)

22 (15.9)
34 (24.6)
82 (59.4)

105 (34.2)
100 (32.6)
102 (33.2)

95 (68.8)
17 (12.3)
6 (4.3)
23 (16.7)

185 (60.3)
19 (6.2)
38 (12.4)
82 (26.7)

,0.001

,0.001

0.09
0.038
0.009
0.055

Note: Data are expressed as number (%) or median (25th75th range).

Abbreviations: A-DROP scale, age, dehydration, respiratory failure, orientation disturbance, and pressure scale; B/A ratio, blood urea nitrogen to serum albumin ratio;
CAP, community-acquired pneumonia; CURB-65 scale, confusion, urea, respiratory rate, blood pressure, and age $65 scale; NHAP, nursing-home-acquired pneumonia; PSI,
pneumonia severity index.

had a higher B/A ratio value, compared to the CAP patients

(P,0.001).
The NHAP patients had higher severity scores on the
PSI, the CURB-65 scale, and the A-DROP scale, compared
to the CAP patients (P,0.001).
For the initial antibiotic regimens, clindamycin was more
frequently administered to NHAP patients (12.3%) than to
CAP patients (6.2%) (P=0.038). Fluoroquinolones were less
frequently administered to NHAP patients (4.3%) than to
CAP patients (12.4%) (P=0.009).

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Detected pathogens in NHAP and CAP

Table 2 lists the detected typical bacterial pathogens in
NHAP and CAP patients. The typical bacterial pathogens
were more frequently detected in the NHAP patients
(56.5%) than in the CAP patients (37.1%) (P,0.001).
In particular, methicillin-resistant Staphylococcus aureus,
Klebsiella pneumoniae, and Proteus mirabilis were
more frequently detected in the NHAP patients than
in the CAP patients (P=0.004, P=0.005, and P=0.009,
respectively).

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Prognostic value of severity indicators in NHAP

Table 2 Detected typical bacterial pathogens

Microorganism

NHAP
(n=138)

CAP
(n=307)

P-value

Streptococcus pneumoniae
Klebsiella pneumoniae
MRSA
Pseudomonas aeruginosa
Staphylococcus species
Proteus mirabilis
Haemophilus influenzae
Escherichia coli
Serratia marcescens
Acinetobacter baumannii
Stenotrophomonas maltophilia
Moraxalla catarrhalis
Enterobacter species
Unknown

22 (15.9)
16 (11.6)
12 (8.7)
9 (6.5)
8 (5.8)
4 (2.9)
2 (1.4)
2 (1.4)
1 (0.7)
1 (0.7)
1 (0.7)
0
0
60 (43.5)

52 (16.9)
12 (3.9)
7 (2.3)
11 (3.6)
8 (2.6)
0
11 (3.6)
6 (2.0)
2 (0.7)
1 (0.3)
0
3 (1.0)
1 (0.3)
193 (62.9)

0.891
0.005
0.004
0.215
0.104
0.009
0.361
.0.999
.0.999
0.525
0.31
0.556
.0.999
,0.001

(95% CI 0.660.86), 0.81 for the PSI class (95% CI 0.680.93),

0.83 for the B/A ratio (95% CI 0.720.95), and 0.64 for the
CRP level (95% CI 0.470.80) (Figure 2B).
Table 3 presents the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of
the severity scales for mortality in the NHAP patients. At
the cutoff value of $10 mg/g, the B/A ratio had a sensitivity
of 36.0%, specificity of 83.2%, PPV of 32.1%, and NPV of
85.5%. At the cutoff value of class $4, the PSI had a sensitivity of 100%, specificity of 3.5%, PPV of 18.7%, and NPV
of 100%. At the cutoff value of $3 points, the CURB-65
scale had a sensitivity of 84.0%, specificity of 44.2%, PPV
of 25.0%, and NPV of 92.6%.
Table 4 presents the sensitivity, specificity, PPV, and
NPV of the severity scales for mortality in the CAP patients.
At the cutoff value of $10 mg/g, the B/A ratio had a sensitivity of 64.3%, specificity of 88.7%, PPV of 21.4%, and
NPV of 98.1%. At the cutoff value of class $4, the PSI had
a sensitivity of 85.7%, specificity of 47.4%, PPV of 7.2%,
and NPV of 98.6%. At the cutoff value of $3 points, the
CURB-65 scale had a sensitivity of 71.4%, specificity of
66.9%, PPV of 9.3%, and NPV of 98.0%.

Note: Data are expressed as number (%).

Abbreviations: CAP, community-acquired pneumonia; MRSA, methicillin-resistant
Staphylococcus aureus; NHAP, nursing-home-acquired pneumonia.

Prognostic accuracy of severity

indicators in NHAP and CAP

Discussion
The important findings of the present study in the elderly
population were as follows: 1) the 28-day mortality was
significantly higher in the NHAP patients than in the CAP
patients; 2) the patient characteristics and the detected pathogens differed greatly between the NHAP patients and the CAP

0.8

0.8

Sensitivity

Sensitivity

Figure 2 shows the ROC curves for predicting mortality

within 28 days of admission. For the NHAP patients, the AUC
was 0.70 for the A-DROP scale (95% confidence interval [CI]
0.610.80), 0.69 for the CURB-65 scale (95% CI 0.600.79),
0.67 for the PSI class (95% CI 0.570.77), 0.65 for the B/A
ratio (95% CI 0.520.78), and 0.58 for the CRP level (95%
CI 0.460.70) (Figure 2A).
For the CAP patients, the AUC was 0.73 for the A-DROP
scale (95% CI 0.610.85), 0.76 for the CURB-65 scale

0.6

AUC

0.4

0.2

CURB-65

0.69

PSI class

0.67

B/A ratio

0.65

CRP

0.58

0.6

AUC

0.4

0.2

B/A ratio

0.83

PSI class

0.81

CURB-65

0.76

CRP

0.64

0
0

0.2

0.4

0.6

1 specificity

0.8

0.2

0.4

0.6

0.8

1 specificity

Figure 2 Analysis of the receiver-operating characteristics curve for predicting mortality.

Notes: (A) In NHAP, the AUC was 0.69 for the CURB-65 scale, 0.67 for the PSI class, 0.65 for the B/A ratio, and 0.58 for the CRP level. (B) In CAP, the AUC was 0.76 for
the CUBR-65 scale, 0.81 for the PSI class, 0.83 for the B/A ratio, and 0.64 for the CRP level.
Abbreviations: AUC, area under the curve; B/A ratio, blood urea nitrogen to serum albumin ratio; CRP, C-reactive protein; CURB-65 scale, confusion, urea, respiratory
rate, blood pressure, and age $65 scale; PSI, pneumonia severity index.

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Table 3 Prognostic validity of different cutoff values of each

severity indicator in NHAP
B/A ratio
$6 mg/g
$8 mg/g
$10 mg/g
$12 mg/g
PSI
$3
$4
$5
CURB-65
$2
$3
$4
A-DROP
$2
$3
$4

Sensitivity (%) Specificity (%) PPV (%)

NPV (%)

76.0
60.0
36.0
32.0

34.5
62.8
83.2
92.9

20.4
26.3
32.1
50.0

86.7
87.7
85.5
86.1

100
100
68.0

0.9
3.5
65.5

18.2
18.7
30.4

100
100
90.2

100
84.0
40.0

16.8
44.2
80.5

21.0
25.0
31.3

100
92.6
85.8

100
84.0
40.0

19.5
46.0
81.4

21.6
25.6
32.3

100
92.9
86.0

Abbreviations: A-DROP, age, dehydration, respiratory failure, orientation

disturbance, and pressure scale; B/A ratio, blood urea nitrogen to serum albumin
ratio; CURB-65, confusion, urea, respiratory rate, blood pressure, and age $65
scale; NHAP, nursing-home-acquired pneumonia; NPV, negative predictive value;
PPV, positive predictive value; PSI, pneumonia severity index.

patients; 3) the B/A ratio and PSI were good prognostic indicators in the CAP patients, but the existing severity indicators
had a poor prognostic value in the NHAP patients.
It is an important clinical issue to extract pneumonia
patients who are likely to have poor prognosis. In 1997,
Table 4 Prognostic validity of different cutoff values of each
severity indicator in CAP
B/A ratio
$6 mg/g
$8 mg/g
$10 mg/g
$12 mg/g
PSI
$3
$4
$5
CURB-65
$2
$3
$4
A-DROP
$2
$3
$4

Sensitivity (%)

Specificity (%)

PPV (%)

NPV (%)

92.9
85.7
64.3
50.0

54.6
76.1
88.7
92.8

8.9
14.6
21.4
25.0

99.4
99.1
98.1
97.5

100
85.7
64.3

5.8
47.4
92.2

4.8
7.2
28.1

100
98.6
98.2

100
71.4
28.6

30.0
66.9
93.5

6.4
9.3
17.4

100
98.0
96.5

92.9
64.3
28.6

35.5
68.3
93.5

6.4
8.8
17.4

99.0
97.6
96.5

Abbreviations: A-DROP, age, dehydration, respiratory failure, orientation

disturbance, and pressure scale; B/A ratio, blood urea nitrogen to serum albumin
ratio; CAP, community-acquired pneumonia; CURB-65, confusion, urea, respiratory
rate, blood pressure, and age $65 scale; NPV, negative predictive value; PPV,
positive predictive value; PSI, pneumonia severity index.

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the PSI was introduced through a study that included more

than 50,000 pneumonia patients.6 Consistent with the finding
of the present study, several previous studies showed that the
PSI was a reliable predictor of mortality in CAP patients.1315
However, calculating the PSI may be complex and difficult
to implement in routine clinical practice.16 Therefore, more
simple severity indicators such as the CURB-65 scale and the
A-DROP scale have been advocated and widely used.7,8 As
a simple and objective severity indicator for CAP patients,
we introduced the B/A ratio through our previous studies.9,10
The present study also showed that the B/A ratio was a good
prognostic indicator for CAP patients through the ROC
curve analysis.
However, the present study showed that the PSI, the
CURB-65 scale, the A-DROP scale, and the B/A ratio had
less prognostic values in NHAP patients than in CAP patients.
Lee etal reported that the PSI had good predictive power for
30-day mortality in NHAP patients, but its AUC value was
only 0.73.17 Porfyridis etal similarly reported that, among
several pneumonia severity indicators, the CURB-65 scale
had the highest accuracy for predicting the mortality of
NHAP patients, but its AUC value was only 0.67.18 In short,
these existing severity indicators have only an insufficient
ability to predict the mortality of NHAP patients.
Nursing home residents often have an advanced age
and low functional status.19 The present study similarly
showed that the NHAP patients had a greater advanced age
and lower functional status than CAP patients. The increased
frequency of confusion in patients with acute illnesses has
been reported to be strongly associated with an advanced
age and low functional status.20,21 In regard to coexisting illnesses, cerebrovascular diseases and heart failure were more
frequently observed in the NHAP patients than in the CAP
patients. Moreover, malnutrition is frequently observed in
nursing home residents because of their insufficient ability
to eat.22,23 The present study also showed that the value of
the serum albumin level was lower in NHAP patients than in
CAP patients. These characteristics in NHAP patients raise
the scores of the existing severity indicators. In fact, the present study showed that the NHAP patients had higher severity
scores on the PSI, the CURB-65 scale, the A-DROP scale,
and the B/A ratio compared to the CAP patients. Because
most NHAP patients become categorized into the high risk
class of the existing severity indicators, the discriminatory
power of the indicators for predicting mortality may become
lower.
It has been reported that most long-term nursing home residents changed their code status to do-not-resuscitate orders

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during their stay.24 A former study showed that approximately

one-half of nursing home residents had a do-not-resuscitate
order.25 Similarly, in the present study, approximately onehalf of NHAP patients had do-not-resuscitate orders. The
rate was significantly higher in NHAP patients than in CAP
patients. The do-not-resuscitate order has been reported to
be an independent risk factor in mortality of patients with
pneumonia because the code status is strongly correlated with
the regulation of life-saving medical acts under a critically
ill condition.26 The difference in mortality between NHAP
and CAP patients could be influenced by the difference of
their code status.
The difference in causative pathogens between the NHAP
and CAP patients is a controversial issue. Several recent studies showed no significant differences between the NHAP and
CAP patients in etiology.4,5 However, the ATS/IDSA classifies
NHAP under the concept of HCAP but not CAP because
drug-resistant pathogens are frequently detected in patients
with NHAP.27 Residency in a nursing home is reportedly
an independent risk factor for infection by drug-resistant
pathogens.28,29 In the present study, methicillin-resistant
S. aureus and K. pneumoniae, which are potential multidrugresistant pathogens,30,31 were more frequently detected in
NHAP patients than in CAP patients. P. mirabilis, which was
more frequently detected in NHAP patients in this study, is
reportedly developing a metallo-beta-lactamase gene.32 The
present study showed that NHAP was often caused by the
potential multidrug-resistant pathogens. Although further
investigations are necessary, the empirical therapy including
these multidrug-resistant pathogens may improve the clinical
outcomes of NHAP patients.
We must discuss several limitations of the present study.
First, the study cohort involved a limited number of patients
because it was a single-center study. A large-scale multicenter
study is necessary to determine the differences between
NHAP patients and CAP patients. Second, to assess the prognostic value of serum biomarkers, especially the B/A ratio,
this study excluded patients who had chronic kidney diseases
and advanced liver diseases. Therefore, it is uncertain whether
the results of the present study are applicable to all NHAP and
CAP patients. Third, the information concerning antibiotic
administration based on the national guidelines was lacking.
Fluoroquinolones were less frequently administered to NHAP
patients than to CAP patients as the initial antibiotic regimen
in the present study; a similar tendency has been observed
in former prospective studies.5,33
In conclusion, NHAP should be managed as a category of
pneumonia that is unlike CAP in terms of patient characteristics,

Clinical Interventions in Aging 2014:9

Prognostic value of severity indicators in NHAP

code status, and causative pathogens. Clinicians should be

careful in evaluating the severity of illness in patients with
NHAP because existing severity indicators are not useful
for predicting mortality in these patients, as compared to
patients with CAP.

Disclosure
The authors report no conflicts of interest in this work.

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