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Prevention of Hospital-Acquired Pneumonia: Measuring Effect in Ounces, Pounds, and Tons
- Donald E. Craven, MD
- Boston University Schools of Medicine and Public Health, Boston City Hospital, Boston, MA 02118 Requests for Reprints: Donald E. Craven, MD, Boston City Hospital, Thorndike Building #303, 818 Harrison Avenue, Boston, MA 02118. Acknowledgment: The author thanks Kathleen Steger, RN, MPH, Michael Niederman, MD, and Ophelia Tablan, MD, for their helpful comments.
The idea that hospitals could be dangerous places emerged in the Middle Ages, when outbreaks of puerperal fever and typhus caused high mortality in infirmaries that were part of monasteries [1]. Even before the discovery of bacteria, Holmes and Semmelweis implicated health care workers in the transmission of puerperal fever; Nightengale and Farr emphasized that safe food and water and a clean environment could substantially reduce the rate of deaths caused by infection; and Simpson concluded that “hospitalism” contributed to patient death and illness [1]. In the 20th century, nosocomial infections have changed and their numbers have increased in response to antibiotic agents, the use of invasive devices, and more aggressive medical therapy. By comparison, prevention efforts have lagged, and their effects are still being assessed in ounces rather than in pounds. This is due, in part, to a health care system that has primarily focused on diagnosis and treatment rather than on prevention.
Despite remarkable strides in our understanding of hospital-acquired infections, the diagnosis and prevention of pneumonia remain controversial [2-7]. Pneumonia is the second most common hospital-acquired infection in the United States, occurring at a frequency of 0.6 to 1.0 episodes/100 hospitalizations and with rates 6-fold to 21-fold higher in mechanically ventilated patients [2, 3]. Pseudomonas aeruginosa and Staphylococcus aureus are common causes of nosocomial pneumonia, but etiologies may vary by patient population, hospital, geographic area, and the technique used for diagnosis [2, 3]. Crude mortality rates range from 20% to 60%, but only about one third of these deaths are directly attributable to the pneumonia [2-4].
Pneumonia must be accurately diagnosed before relevant recommendations for prevention can be developed [2-7]. In this issue, Valles and coworkers [8] report that they used a clinical diagnosis of ventilator-associated pneumonia that was based …
