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Semin Respir Crit Care Med 2009; 30(1): 016-025
DOI: 10.1055/s-0028-1119805
© Thieme Medical Publishers

Nursing Home–Acquired Pneumonia

Ali A. El Solh1 , 2
  • 1Western New York Respiratory Research Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York
  • 2Veterans Affairs Western New York Healthcare System, Buffalo, New York
Further Information

Publication History

Publication Date:
06 February 2009 (online)

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ABSTRACT

Nursing home–acquired pneumonia (NHAP) was first described in 1978. Since then there has been much written regarding NHAP and its management despite the lack of well-designed studies in this patient population. The most characteristic features of patients with NHAP are the atypical presentation, which may lead to delay in diagnosis and therapy. The microbial etiology of pneumonia encompasses a wide spectrum that spans microbes recovered from patients with community-acquired pneumonia to organisms considered specific only to nosocomial settings. Decision to transfer a nursing home patient to an acute care facility depends on a host of factors, which include the level of staffing available at the nursing home, patients' advance directives, and complexity of treatment. The presence of risk factors for multidrug-resistant pathogens dictates approach to therapy. Prevention remains the cornerstone of reducing the incidence of disease. Despite the advance in medical services, mortality from NHAP remains high.

KEYWORDS

Nursing home pneumonia - healthcare-associated pneumonia - antibiotic - hospital transfer

REFERENCES

  • 1 Ronald L A, McGregor M J, McGrail K M, Tate R B, Broemling A M. Hospitalization rates of nursing home residents and community-dwelling seniors in British Columbia.  Can J Aging. 2008;  27 109-115
    CrossrefPubMedGoogle Scholar
  • 2 Kerr H D, Byrd J C. Nursing home patients transferred by ambulance to a VA emergency department.  J Am Geriatr Soc. 1991;  39 132-136
    PubMedGoogle Scholar
  • 3 Marrie T J, Durant H, Yates L. Community-acquired pneumonia requiring hospitalization: 5-year prospective study.  Rev Infect Dis. 1989;  11 586-599
    PubMedGoogle Scholar
  • 4 Muder R R. Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention.  Am J Med. 1998;  105 319-330
    CrossrefPubMedGoogle Scholar
  • 5 Muder R R. Approach to the problem of pneumonia in long-term care facilities.  Compr Ther. 2000;  26 255-262
    CrossrefPubMedGoogle Scholar
  • 6 Marrie T J. Pneumonia in the long-term-care facility.  Infect Control Hosp Epidemiol. 2002;  23 159-164
    CrossrefPubMedGoogle Scholar
  • 7 Thompson R S, Hall N K, Szpiech M, Reisenberg L A. Treatments and outcomes of nursing-home-acquired pneumonia.  J Am Board Fam Pract. 1997;  10 82-87
    PubMedGoogle Scholar
  • 8 Mehr D R, Zweig S C, Kruse R L et al.. Mortality from lower respiratory infection in nursing home residents: a pilot prospective community-based study.  J Fam Pract. 1998;  47 298-304
    PubMedGoogle Scholar
  • 9 Loeb M, McGeer A, McArthur M, Walter S, Simor A E. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.  Arch Intern Med. 1999;  159 2058-2064
    CrossrefPubMedGoogle Scholar
  • 10 Beck-Sague C, Banerjee S, Jarvis W R. Infectious diseases and mortality among US nursing home residents.  Am J Public Health. 1993;  83 1739-1742
    CrossrefPubMedGoogle Scholar
  • 11 Magaziner J, Tenney J H, DeForge B et al.. Prevalence and characteristics of nursing-home acquired infections in the aged.  J Am Geriatr Soc. 1991;  39 1071-1078
    PubMedGoogle Scholar
  • 12 Jacobson C, Strausbaugh L J. Incidence and impact of infection in a nursing home care unit.  Am J Infect Control. 1990;  18 151-159
    CrossrefPubMedGoogle Scholar
  • 13 Setia U, Serventi I, Lorenz P. Nosocomial infections among patients in a long-term care facility: spectrum, prevalence, and risk factors.  Am J Infect Control. 1985;  13 57-62
    CrossrefPubMedGoogle Scholar
  • 14 Vergis E N, Brennen C, Wagener M, Muder R R. Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival.  Arch Intern Med. 2001;  161 2378-2381
    CrossrefPubMedGoogle Scholar
  • 15 Rantanen T K, Salo J A. Gastroesophageal reflux disease as a cause of death: analysis of fatal cases under conservative treatment.  Scand J Gastroenterol. 1999;  34 229-233
    CrossrefPubMedGoogle Scholar
  • 16 Marrie T J, Blanchard W. A comparison of nursing home-acquired pneumonia patients with patients with community-acquired pneumonia and nursing home patients without pneumonia.  J Am Geriatr Soc. 1997;  45 50-55
    PubMedGoogle Scholar
  • 17 Lim W S, Macfarlane J T. A prospective comparison of nursing home acquired pneumonia with community acquired pneumonia.  Eur Respir J. 2001;  18 362-368
    CrossrefPubMedGoogle Scholar
  • 18 Gross P A, Van Antwerpen C. Nosocomial infections and hospital deaths: a case-control study.  Am J Med. 1983;  75 658-662
    CrossrefPubMedGoogle Scholar
  • 19 Garb J L, Brown R, Garb J R et al.. Differences in etiology of pneumonias in nursing home and community patients.  JAMA. 1978;  240 2169-2172
    CrossrefPubMedGoogle Scholar
  • 20 Troy C J, Peeling R W, Ellis A G, Hockin J C, Bennett D A, Murphy M R, Spika J S. Chlamydia pneumoniae as a new source of infectious outbreaks in nursing homes.  JAMA. 1997;  277 1214-1218
    CrossrefPubMedGoogle Scholar
  • 21 Orr P H, Peeling R W, Fast M, Brunka J, Duckworth H, Harding G K, Nicolle L E. Serological study of responses to selected pathogens causing respiratory tract infection in the institutionalized elderly.  Clin Infect Dis. 1996;  23 1240-1245
    PubMedGoogle Scholar
  • 22 Maruyama T, Niederman M S, Kobayashi T et al.. A prospective comparison of nursing home-acquired pneumonia with hospital-acquired pneumonia in non-intubated elderly.  Respir Med. 2008;  102 1287-1295
    CrossrefPubMedGoogle Scholar
  • 23 Maesaki S, Kohno S, Kog H et al.. An outbreak of Legionnaires' pneumonia in a nursing home.  Intern Med. 1992;  31 508-512
    PubMedGoogle Scholar
  • 24 Loeb M, Simor A E, Mandell L et al.. Two nursing home outbreaks of respiratory infections with Legionella sainthelensi .  J Am Geriatr Soc. 1999;  47 547-552
    PubMedGoogle Scholar
  • 25 Seenivasan M H, Yu V L, Muder R R. Legionnaires' disease in long-term care facilities: overview and proposed solutions.  J Am Geriatr Soc. 2005;  53 875-880
    CrossrefPubMedGoogle Scholar
  • 26 Falsey A R, Treanor J J, Betts R F, Walsh E E. Viral respiratory infections in institutionalized elderly: clinical and epidemiologic findings.  J Am Geriatr Soc. 1992;  40 115-119
    CrossrefPubMedGoogle Scholar
  • 27 El Solh A A, Sikka P, Ramadan F, Davies J. Etiology of severe pneumonia in the very elderly.  Am J Respir Crit Care Med. 2001;  163 645-651
    PubMedGoogle Scholar
  • 28 El Solh A A, Aquilina A T, Dhillon R S, Ramadan F, Nowak P, Davies J. Impact of invasive strategy on management of antimicrobial treatment failure in institutionalized older people with severe pneumonia.  Am J Respir Crit Care Med. 2002;  166 1038-1043
    CrossrefPubMedGoogle Scholar
  • 29 El Solh A A, Pietrantoni C, Bhat A, Bhora M, Berbary E. Indicators of potentially drug-resistant bacteria in severe nursing home-acquired pneumonia.  Clin Infect Dis. 2004;  39 474-480
    CrossrefPubMedGoogle Scholar
  • 30 Metlay J P, Kapoor W N, Fine M J. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination.  JAMA. 1997;  278 1440-1445
    CrossrefPubMedGoogle Scholar
  • 31 Bentley D W. Bacterial pneumonia in the elderly: clinical features, diagnosis, etiology and treatment.  Gerontology. 1984;  30 297-307
    PubMedGoogle Scholar
  • 32 Mubareka S, Duckworth H, Cheang M et al.. Use of diagnostic tests for presumed lower respiratory tract infection in long-term care facilities.  J Am Geriatr Soc. 2007;  55 1365-1370
    CrossrefPubMedGoogle Scholar
  • 33 Degelau J, Guay D, Straub K, Luxenberg M. Effectiveness of oral antibiotic treatment in nursing home acquired pneumonia.  J Am Geriatr Soc. 1995;  43 245-251
    PubMedGoogle Scholar
  • 34 Thompson R S, Hall N K, Szpiech M. Hospitalization and mortality rates for nursing home acquired pneumonia.  J Fam Pract. 1999;  48 291-293
    PubMedGoogle Scholar
  • 35 Loeb M, Carusone S C, Goeree R et al.. Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial.  JAMA. 2006;  295 2503-2510
    CrossrefPubMedGoogle Scholar
  • 36 Fried T R, Gillick M, Lipsitz L A. Whether to transfer? Factors associated with hospitalization and outcome of elderly long-term care patients with pneumonia.  J Gen Intern Med. 1995;  10 246-250
    PubMedGoogle Scholar
  • 37 Fried T R, Gillick M R, Lipsitz L A. Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer.  J Am Geriatr Soc. 1997;  45 302-306
    PubMedGoogle Scholar
  • 38 Intrator O, Castle N, Mor V. Facility characteristics associated with hospitalization of nursing home residents: results of a national study.  Med Care. 1999;  37 228-237
    CrossrefPubMedGoogle Scholar
  • 39 Fine M J, Auble T E, Yealy D M et al.. A prediction rule to identify low-risk patients with community-acquired pneumonia.  N Engl J Med. 1997;  336 243-250
    CrossrefPubMedGoogle Scholar
  • 40 Mehr D R, Binder E F, Kruse R L et al.. Predicting mortality in nursing home residents with lower respiratory tract infection.  JAMA. 2001;  286 2427-2436
    CrossrefPubMedGoogle Scholar
  • 41 Bentley D W, Bradley S, High K et al.. Practice guideline for evaluation of fever and infection in long-term care facilities.  Clin Infect Dis. 2000;  31 640-653
    CrossrefPubMedGoogle Scholar
  • 42 Intrator O, Mor V. Effect of state Medicaid reimbursement rates on hospitalizations from nursing homes.  J Am Geriatr Soc. 2004;  52 393-398
    CrossrefPubMedGoogle Scholar
  • 43 Mandell L A, Marrie T J, Grosman R F, Chow A W, Hyland R H. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society.  Clin Infect Dis. 2000;  31 383-421
    CrossrefPubMedGoogle Scholar
  • 44 Mandell L A, Bartlett J G, Dowell S F, File Jr T M, Musher D M, Whitney C. Infectious Diseases Society of America . Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults.  Clin Infect Dis. 2003;  37 1405-1433
    CrossrefPubMedGoogle Scholar
  • 45 American Thoracic Society and Infectious Diseases Society of America . Guidelines for the management of adults with hospital acquired, ventilator-associated, and health care associated pneumonia.  Am J Respir Crit Care Med. 2005;  171 388-416
    CrossrefPubMedGoogle Scholar
  • 46 Chen D K, McGeer A, de Azavedo J C, Low D E. Decreased susceptibility of Streptococcus pneumoniae to fluoroquinolones in Canada.  N Engl J Med. 1999;  341 233-239
    CrossrefPubMedGoogle Scholar
  • 47 Cohen A E, Lautenbach E, Morales K H, Linkin D R. Fluoroquinolone-resistant Escherichia coli in the long-term care setting.  Am J Med. 2006;  119 958-963
    CrossrefPubMedGoogle Scholar
  • 48 Medina-Walpole A M, Katz P R. Nursing home–acquired pneumonia.  J Am Geriatr Soc. 1999;  47 1005-1015
    PubMedGoogle Scholar
  • 49 Peterson P K, Stein D, Guay D R et al.. Prospective study of lower respiratory tract infections in an extended-care nursing home program: potential role of oral ciprofloxacin.  Am J Med. 1988;  85 164-171
    PubMedGoogle Scholar
  • 50 Naughton B J, Mylotte J M. Treatment guideline for nursing home–acquired pneumonia based on community practice.  J Am Geriatr Soc. 2000;  48 82-88
    PubMedGoogle Scholar
  • 51 Hirata-Dulas C A, Stein D J, Guay D R, Gruninger R P, Peterson P K. A randomized study of ciprofloxacin versus ceftriaxone in the treatment of nursing home-acquired lower respiratory tract infections.  J Am Geriatr Soc. 1991;  39 979-985
    PubMedGoogle Scholar
  • 52 Yakovlev S V, Stratchounski L S, Woods G L et al.. Ertapenem versus cefepime for initial empirical treatment of pneumonia acquired in skilled-care facilities or in hospitals outside the intensive care unit.  Eur J Clin Microbiol Infect Dis. 2006;  25 633-641
    CrossrefPubMedGoogle Scholar
  • 53 Vanderkooi O G, Low D E, Green K, Powis J E, McGeer A. Toronto Invasive Bacterial Disease Network . Predicting antimicrobial resistance in invasive pneumococcal infections.  Clin Infect Dis. 2005;  40 1288-1297
    CrossrefPubMedGoogle Scholar
  • 54 Waterer G W, Somes G W, Wunderink R G. Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia.  Arch Intern Med. 2001;  161 1837-1842
    CrossrefPubMedGoogle Scholar
  • 55 Waterer G W. Optimal antibiotic treatment in severe pneumococcal pneumonia: time for real answers.  Eur J Clin Microbiol Infect Dis. 2005;  24 691-692
    CrossrefPubMedGoogle Scholar
  • 56 Chastre J, Wolff M, Fagon J Y et al.. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial.  JAMA. 2003;  290 2588-2598
    CrossrefPubMedGoogle Scholar
  • 57 Muder R R, Brennen C, Swenson D L, Wagener M. Pneumonia in a long-term care facility: a prospective study of outcome.  Arch Intern Med. 1996;  156 2365-2370
    CrossrefPubMedGoogle Scholar
  • 58 Mehr D R, Zweig S C, Kruse R L et al.. Mortality from lower respiratory infection in nursing home residents: a pilot prospective community-based study.  J Fam Pract. 1998;  47 298-304
    PubMedGoogle Scholar
  • 59 Degelau J, Guay D, Straub K, Luxenberg M G. Effectiveness of oral antibiotic treatment in nursing home-acquired pneumonia.  J Am Geriatr Soc. 1995;  43 245-251
    PubMedGoogle Scholar
  • 60 Mehr D R, Foxman B, Colombo P. Risk factors for mortality from lower respiratory infections in nursing home patients.  J Fam Pract. 1992;  34 585-591
    PubMedGoogle Scholar
  • 61 Chan Carusone S B, Walter S D, Brazil K, Loeb M B. Pneumonia and lower respiratory infections in nursing home residents: predictors of hospitalization and mortality.  J Am Geriatr Soc. 2007;  55 414-419
    CrossrefPubMedGoogle Scholar
  • 62 Meehan T P, Fine M J, Krumholz H M et al.. Quality of care, process, and outcomes in elderly patients with pneumonia.  JAMA. 1997;  278 2080-2084
    CrossrefPubMedGoogle Scholar
  • 63 Houck P M, Bratzler D W, Nsa W, Ma A, Bartlett J G. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community acquired pneumonia.  Arch Intern Med. 2004;  164 637-644
    CrossrefPubMedGoogle Scholar
  • 64 Quagliarello V, Ginter S, Han L, Van Ness P, Allore H, Tinetti M. Modifiable risk factors for nursing home-acquired pneumonia.  Clin Infect Dis. 2005;  40 1-6
    CrossrefPubMedGoogle Scholar
  • 65 Russell S L, Boylan R J, Kaslick R S et al.. Respiratory pathogen colonization of the dental plaque of institutionalized elders.  Spec Care Dentist. 1999;  19 128-134
    CrossrefPubMedGoogle Scholar
  • 66 El-Solh A A, Pietrantoni C, Bhat A et al.. Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders.  Chest. 2004;  126 1575-1582
    CrossrefPubMedGoogle Scholar
  • 67 Hawkins R J, Main P A, Locker D. Oral health status and treatment needs of Canadian adults aged 85 years and over.  Spec Care Dentist. 1998;  18 164-169
    PubMedGoogle Scholar
  • 68 Wyatt C C. Elderly Canadians residing in long-term care hospitals, I: Medical and dental status.  J Can Dent Assoc. 2002;  68 353-358
    PubMedGoogle Scholar
  • 69 Bryant S R, MacEntee M I, Browne A. Ethical issues encountered by dentists in the care of institutionalized elders.  Spec Care Dentist. 1995;  15 79-82
    PubMedGoogle Scholar
  • 70 Loeb M B, Becker M, Eady A, Walker-Dilks C. Interventions to prevent aspiration pneumonia in older adults: a systematic review.  J Am Geriatr Soc. 2003;  51 1018-1022
    CrossrefPubMedGoogle Scholar
  • 71 Shay K. Infectious complications of dental and periodontal diseases in the elderly population.  Clin Infect Dis. 2002;  34 1215-1223
    CrossrefPubMedGoogle Scholar
  • 72 Yoneyama T, Yoshida M, Ohrui T Oral Care Working Group et al. Oral care reduces pneumonia in older patients in nursing homes.  J Am Geriatr Soc. 2002;  50 430-433
    CrossrefPubMedGoogle Scholar
  • 73 Adachi M, Ishihara K, Abe S, Okuda K. Professional oral health care by dental hygienists reduced respiratory infections in elderly persons requiring nursing care.  Int J Dent Hyg. 2007;  5 69-74
    CrossrefPubMedGoogle Scholar
  • 74 Gross P A, Hermogenes A W, Sacks H S, Lau J, Levandowski R A. The efficacy of influenza vaccine in elderly persons: a meta-analysis and review of the literature.  Ann Intern Med. 1995;  123 518-527
    PubMedGoogle Scholar
  • 75 Saito R, Suzuki H, Oshitani H et al.. The effectiveness of influenza vaccine against influenza A (H3N2) virus infections in nursing homes in Niigata, Japan during the 1998–1999 and 199–2000 seasons.  Infect Control Hosp Epidemiol. 2002;  23 82-86
    CrossrefPubMedGoogle Scholar
  • 76 Deguchi Y, Takasugi Y, Nishimura K. Vaccine effectiveness for influenza in the elderly in welfare nursing homes during an influenza A (H3N2) epidemic.  Epidemiol Infect. 2000;  125 393-397
    CrossrefPubMedGoogle Scholar
  • 77 Ohmit S E, Arden N H, Monto A S. Effectiveness of inactivated influenza vaccine among nursing home residents during an influenza type A (H3N2) epidemic.  J Am Geriatr Soc. 1999;  47 165-171
    PubMedGoogle Scholar
  • 78 Centers for Disease Control and Prevention . Update: influenza activity: United States, 1997–98 season.  MMWR Morb Mortal Wkly Rep. 1998;  47 196-200
    PubMedGoogle Scholar
  • 79 Health Canada . Effectiveness of inactivated trivalent influenza vaccine in long-term care institutions, Toronto, 2003–2004.  Can Commun Dis Rep. 2004;  30 109-116
    PubMedGoogle Scholar
  • 80 Centers for Disease Control and Prevention . Outbreaks of pneumococcal pneumonia among unvaccinated residents of a nursing home-New Jersey, April 2001.  MMWR Morb Mortal Wkly Rep. 2001;  50 707-710
    PubMedGoogle Scholar
  • 81 Gaillat J, Zmirou D, Mallaret M R et al.. Clinical trial of an antipneumococcal vaccine in elderly subjects living in institutions [in French].  Rev Epidemiol Sante Publique. 1985;  33 437-444
    PubMedGoogle Scholar
  • 82 Kaufman P. Pneumonia in old age.  Arch Intern Med. 1947;  79 518-531
    PubMedGoogle Scholar
  • 83 Rubins J B, Puri A KG, Loch J et al.. Magnitude, duration, quality, and function of pneumococcal vaccine responses in elderly patients.  J Infect Dis. 1998;  178 431-440
    PubMedGoogle Scholar
  • 84 Nuorti J P, Butler J C, Crutcher J M et al.. An outbreak of multidrug-resistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents.  N Engl J Med. 1998;  338 1861-1868
    CrossrefPubMedGoogle Scholar
  • 85 Centers for Disease Control and Prevention (CDC) . Outbreak of pneumococcal pneumonia among unvaccinated residents of a nursing home—New Jersey, April 2001.  MMWR Morb Mortal Wkly Rep. 2001;  50 707-710
    PubMedGoogle Scholar
  • 86 Valenzuela M T, Altuzarra R H, Trucco O A et al.. Immunogenicity of a 23-valent pneumococcal polysaccharide vaccine in elderly residents of a long-term care facility.  Braz J Infect Dis. 2007;  11 322-326
    PubMedGoogle Scholar
  • 87 Loeb M, McGeer A, McArthur M, Peeling R W, Petric M, Simor A E. Surveillance for outbreaks of respiratory tract infections in nursing homes.  CMAJ. 2000;  162 1133-1137
    PubMedGoogle Scholar

Ali A El SolhM.D. M.P.H. 

Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Western New York Healthcare System

3495 Bailey Ave., Buffalo, NY 14215-1199

Email: solh@buffalo.edu

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