Common Questions About Pneumonia in Nursing Home Residents

 


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Am Fam Physician. 2015 Oct 1;92(7):612-620.

Author disclosure: No relevant financial affiliations.

Pneumonia in older adults residing in nursing homes can be challenging to diagnose and treat. Pneumococcal and influenza immunizations decrease the risk of pneumonia and are recommended for all nursing home patients. Older adults with pneumonia may not display classic signs and symptoms of infection, although most have at least one respiratory symptom. Suspicion of pneumonia is heightened if pulse oximetry measurements are low. The diagnosis of pneumonia is confirmed by chest radiography. To determine whether treatment is necessary and where treatment should occur, the patient's overall prognosis should be considered. If treatment is to occur, antibiotics should be administered as soon as possible for a duration of five to eight days; however, treatment may be extended in the absence of clinical resolution or in the presence of Pseudomonas aeruginosa. Oral antibiotics may be administered in the nursing home, whereas hospitalized patients should initially receive intravenous antibiotics and transition to oral antibiotics after clinical improvement. Antibiotic regimens for patients treated in the nursing home include a respiratory fluoroquinolone, or a beta-lactam antibiotic with a macrolide. Hospitalized patients may receive the same regimens, although several other oral and intravenous options are acceptable. Patients' prognosis can be accurately estimated using the SOAR score (which uses systolic blood pressure, oxygenation, age, and respiratory rate).

Pneumonia is a common problem in nonventilated adults older than 65 years residing in long-term care facilities, such as nursing homes. The median reported incidence of pneumonia in this population is 1 to 1.2 per 1,000 patient-days.1,2 This article summarizes evidence behind answers to the most common questions on diagnosing and treating pneumonia in this patient population. There is controversy, however, about whether the evaluation and treatment of pneumonia in nursing home patients should follow guidelines for health care–associated pneumonia, as suggested by the Infectious Diseases Society of America (IDSA), or for community-acquired pneumonia (CAP), as recommended by the U.K.'s National Institute for Health and Care Excellence (NICE).3,4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Nursing home residents should be immunized with the 23-valent pneumococcal polysaccharide vaccine (Pneumovax).

A

5, 7

Nursing home residents should be immunized with the seasonal influenza vaccine.

C

9

Physicians should obtain chest radiography and pulse oximetry measurement in nursing home residents who have signs and symptoms of a pulmonary infection and who are candidates for treatment.

C

10

Antibiotics should be administered as soon as possible after diagnosing pneumonia in a nursing home patient.

C

20, 25, 26

Oral antibiotics can be used in patients with nursing home–acquired pneumonia who are treated in the nursing home.

C

21, 26, 4245, 51

Patients with nursing home–acquired pneumonia should be treated for a total of five to eight days, unless they have Pseudomonas aeruginosa infection, are medically unstable, or demonstrate an inadequate clinical response to therapy.

C

3, 5355

Patient and family wishes, goals of care, and availability of diagnostic tests and therapies should be considered when deciding whether or where to treat pneumonia in nursing home residents.

C

52, 59


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Nursing home residents should be immunized with the 23-valent pneumococcal polysaccharide vaccine (Pneumovax).

A

5, 7

Nursing home residents should be immunized with the seasonal influenza vaccine.

C

9

Physicians should obtain chest radiography and pulse oximetry measurement in nursing home residents who have signs and symptoms of a pulmonary infection and who are candidates for treatment.

C

10

Antibiotics should be administered as soon as possible after diagnosing pneumonia in a nursing home patient.

C

20, 25, 26

Oral antibiotics can be used in patients with nursing home–acquired pneumonia who are treated in the nursing home.

C

21, 26, 4245, 51

Patients with nursing home–acquired pneumonia should be treated for a total of five to eight days, unless they have Pseudomonas aeruginosa infection, are medically unstable, or demonstrate an inadequate clinical response to therapy.

C

3, 5355

Patient and family wishes, goals of care, and availability of diagnostic tests and therapies should be considered when deciding whether or where to treat pneumonia in nursing home residents.

C

52, 59


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented

The Authors

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CATHERINE CASEY, MD, is an associate professor in the Department of Family Medicine at the University of Virginia School of Medicine in Charlottesville....

MELISSA J. FULLERTON, MD, is an assistant professor and the associate family medicine residency program director at the University of Virginia School of Medicine.

NICHOLAS SOMERVILLE, MD, MPH, is chief resident in the Department of Family Medicine at the University of Virginia School of Medicine.

Address correspondence to Catherine Casey, MD, University of Virginia, 375 Four Leaf Lane, Ste. 103, Charlottesville, VA 22903 (e-mail: cc5ds@virginia.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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