The finding:
In this retrospective cohort study of patients with schizophrenia admitted to a psychiatric hospital, hospital acquired pneumonia (HAP) rates were higher than in the general population. Particular risk factors for HAP were treatment with clozapine, olanzapine, or quetiapine. Hospitalization for >60 days and male gender were correlated with a greater incidence of HAP in this sample of psychiatric inpatients in the Fourth People’s Hospital of Chengdu.

Strength and weaknesses:
Strengths of this study include access to a large data set from a setting that focused on elderly patients with psychosis and clear diagnostic categories. Limitations include the retrospective nature of this study, single site, lack of details about comorbidities and important confounding factors such as smoking and pulmonary illnesses. Dosage of antipsychotics was another important factor that was unexplored.

Relevance:
Patients with schizophrenia experience higher morbidity and mortality from infections, including HAP, and there is increasing awareness about the risks of pneumonia in patients on clozapine.  While there may be several factors contributing to this increased risk, ranging from disparities in access to care, to substance use, it is important that psychiatrists recognize the contributions psychotropic medications make to this problem. The ongoing pandemic makes these concerns more relevant, as age and other illnesses have been associated with greater risk of serious outcomes with COVID-19 infections. These factors seem to also increase the risk of HAP in patients with schizophrenia who are being treated with clozapine, olanzapine and quetiapine. In hospital settings, C-L psychiatrists may find themselves in a position to advocate against indiscriminate and long-term use of these agents for non-specific indications such as agitation.