When pneumonia occurs in the nursing home setting, decisions about the location of treatment, as well as the route and duration, must be made. Naughton and Mylotte assessed the literature, reviewed community practice and conducted small group sessions with physicians and other medical professionals who treat nursing home–acquired pneumonia. From this research they developed a practice guideline.
Eleven skilled nursing facilities were involved in the study. Of the 171 patients who were more than 65 years of age, 239 episodes of nursing home-acquired pneumonia were analyzed. Patients were excluded if they had pneumonia associated with human immunodeficiency virus infection or if they had pneumonia within three months of a previous episode of pneumonia. Demographic information, chest radiograph results, laboratory results, location of treatment, type and duration of treatment and outcome 30 days after diagnosis were extracted from the medical record at the nursing home and, if applicable, the hospital.
Nursing home–acquired pneumonia was defined as the presence of a new radiographic infiltrate not attributable to congestive heart failure, cancer or pulmonary embolus. Diagnosis also depended on the presence of one major symptom (cough, sputum production or fever of at least 38°C [100.5°F]) or two minor symptoms (dyspnea, pleuritic chest pain, altered mental status, signs of pulmonary consolidation on examination or a white blood cell count of more than 12,000 per mm3 [12 × 109 per L]).
A preliminary guideline was based on a literature review; revisions were based on the retrospective chart review and the small group sessions with physicians and other providers. Most patients were initially treated in the nursing facility, and almost 40 percent were initially treated with an intramuscular (IM) antibiotic. Mortality rates at 30 days were not significantly different for those treated in the nursing home compared with those treated in the hospital.
Most (86 percent) of the patients who received IM treatment were given ceftriaxone or cefotaxime, so these agents were incorporated into the guideline. The community standard of treatment for patients who were treated in the nursing home was seven to 10 days. Change to an oral agent generally took place when clinical stability was achieved; this usually occurred by day 3 to day 5. In hospital-treated patients, the median duration of treatment was 10 days, with a switch to oral antibiotics when clinical stability was achieved.
Available evidence supports treating patients with nursing home–acquired pneumonia in the nursing home, because short-term outcomes seem to be superior to those occurring in patients treated in the hospital.
However, a number of factors, such as advance directives and staffing levels, will guide the physician's decision. The authors do not discuss diagnosing pneumonia in their guideline (see accompanying figure)
but do recommend taking a chest radiograph and blood urea nitrogen, complete blood count and oxygen saturation (e.g., pulse oximetry) measurements in patients suspected of having pneumonia.