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Background Community acquired pneumonia(CAP)is one of the most common infectious disease in emergency department.In 2005 the concept of healthcare associated pneumonia(HCAP)was proposed by the ATS/IDSA guidelines.The clinical features and microbiology of HCAP are different from CAP, however the initial antimicrobial treatment is still controversial.We aimed to compare the clinical efficacy between HCAP patients treated initially with HCAP guideline-concordant antimicrobial agents and those with CAP guideline-concordant antimicrobial agents.Methods We conducted a retrospective observational study including HCAP patients admitted to emergency department between December 2011 and December 2012.Patients were divided into 2 groups according to the different initial antimicrobial treatment.We compared clinical features, distribution of pathogen, severity, days and spending on intravenous antimicrobial, length and charge of hospitalization and clinical outcomes, analyzed the clinical efficacy as well.Results Of 125 HCAP patients, 55 patients received CAP guideline-concordant antimicrobial agents and 70 received HCAP agents.The 2 groups were similar at baseline, including old age, comorbidities, Pneumonia Severity Index scores, APACHE II scores, length of stay and in-hospital mortality.The major pathogens were Klebsiella pneumoniae, methicillin-resistant staphylococcus aureus(MRSA), Pseudomonas aeruginosa and Escherichia coli.Overall efficacy rate occurred in 70.0% of HCAP agent patients and 50.9% of CAP agent patients (p =0.029).Conclusions Initial treatment of HCAP patients in emergency department with HCAP guideline-concordant antimicrobial could increase clinical efficacy rate, but was not associated with shorter length of stay, decreased cost or lower in-hospital mortality.