Nursing Home Acquired Pneumonia
Dr. AVI ISHAAYAResource Center Medical Director
It is estimated that the number of older people who will require a SNF will reach 5.3 million by 2030
NHAP will approach 1.9 M episodes annually
.3-2.3 per 1000 resident care days
Definition Inflammation of the lung
parenchyma
Consolidation of the affected part and a filling of the alveolar air spaces with exudate, inflammatory cells, and fibrin
Patterns of Pneumonia Lobar
Focal or nonsegmental One or multiple lobes Larger bronchi remain patent
Bronchopneumonia Multifocal or lobular Patchy appearance with peribronchial thickening and poorly
defined air-space opacities Usually very destructive (progresses to abcessess,
pneumatoceles, pulmonary gangrene) Inflammation of large airways and lobular involvement
Interstitial pneumonia Focal or diffuse Results from edema and inflammatory cellular infiltrate Could be insidious or rapidly progressive Reticular or reticulonodular pattern
BackgroundNursing home-acquired pneumonia (NHAP) is defined as pneumonia occurring in a resident of a chronic care facility or nursing home.
Significant cause of mortality and morbidity
Less likely to present with classic signs and symptoms of the typical presentation Often present with delirium and altered
mental status
Clinical assessment Hampered by impaired
communication Non-localization symptoms Limited access to diagnostic tests
Conflicting interpretations CXR with chronic changes Sputum contaminated
Pathophysiology NHAP may result when a patient
aspirated oropharyngeal contents into one or more lung segments or lobes
NHAP may also occur if a distant focus of infection hematogenously disseminated to the lungs.
Hematogenously acquired pneumonia
Epidemiology NHAP is one of the most common causes
of infection in chronic care facilities. NHAP is one of the most significant
infection-related causes of mortality and morbidity in such facilities.
NHAP primarily afflicts elderly individuals. Increases mortality Over 65, 6th leading cause of death in 2005
No predominate age/sex African Americans males 14% more likely
to die than white males
Patients may complain of fever, cough, chest pain, or rapid respiration.
Patients with chronic bronchitis, or have a history of CNS, esophageal disease, or decreased gag reflex that predisposes them to recurrent aspiration are more prone to developing pneumonias.
symptoms Cough, productive Rust colored (S. Pneumoniae) Currant jelly (Klebsiella) Foul smelling or bad tasting sputum (anerobic)
Chest pain, dyspnea, hemoptysis Decreased exercise tolerance, abdominal pain,
pleuritis Fevers, rigors, shaking chills, malaise Myalgias, headaches, nausea, vomiting, diarrhea Altered level of consciousness
Hyperthermia (>38C) or hypothermia (<35C)
Tachypnea (<18) Use of accessory muscles Tachycardia (>100) or
bradycardia (<60) Central cyanosis Altered mental status Exam
Rales, ronchi, egophony, dull to percussion, tracheal deviation
Physical exam
Aspiration risk Alcoholism Decreased host defenses Impaired swallowing Sedative hypnotic drugs Altered mental status Dysphagia GERD Seizure disorders
Classically in the recumbent patients (posterior segments of the upper lobes) and the upright patients (basal segments of the lower lobes)
Aspiration pneumonia Development of an infectious infiltrate in patients
who are at increased risk of oropharyngeal aspiration Decreased ability to clear secretions
Poor cough or gag Impaired swallowing mechanism Impaired ciliary transport (smokers) Increased volume of secretions Increased bacterial burden Other comorbidities (achalasia, GERD)
Critically ill Gastroparesis/dysmotility Impaired cough/gag Immune impairment
Causes The most common pathogens that cause
NHAP and are S pneumoniae, H influenzae, S. aureus, Enterococcus, , Pseudomonas, Klebsiella, E. coli, Moraxella catarrhalis, Acinetobacter
Atypical organisms that cause NHAP are Mycoplasma pneumoniae, Legionella, and C pneumoniae.
Differentiation between community acquired vs. healthcare vs hospital acquired pneumonia is critical
Laboratory Studies
Blood Cultures Obtain blood cultures from all patients
with CAP and NHAP CBC count Sputum staining and culture Multiple pathogens are not a
feature of NHAP.
Imaging Studies Chest radiography is the
primary tool to differentiate the mimics of pneumonia from NHAP.
Lobar S pneumoniae, K pneumoniae, L
pneumophilia Bronchopneumonia
S aureus, P aeruginosa, H influenzae
Medical Care
Medication Summary The goals of pharmacotherapy
are to reduce morbidity, to eradicate the infection, and to prevent complications.
Antibiotics Levofloxacin (Levaquin)
Second-generation quinolone Highly active against gram-negative and gram-positive
organisms Cetriazone (Rocephin)
Third-generation cephalosporin Higher efficacy against resistant organisms
Vancomycin Bactericidal; inhibits cell wall and RNA synthesis
Cefepime (Maxipime) Fourth-generation cephalosporin with good gram negative
coverage
Empiric therapy At risk for Pseudomonas
Aminoglycoside, beta lactam Quinolone Aztreonam
Aspiration pneumonia Zosyn Imipenam Clinamycin or flagyl +quinolone plus Rocephin
MRSA Vancomycin or Linezolid Clindamycin, Bactrim, Gentamicin, Cipro, Rifampin
Supportive measures Analgesia and antipyretics CPT IV fluids Monitoring and pulse oxymetry Positioning of the patient for
aspiration Respiratory therapy (including
Mucomyst) Suctioning Ventilation
Clinical response Evaluate within 48-72 hours
Improvement should be noted If not, consider resistance or development
of empyema or abcess Consider other differential diagnosis
Non-infectious (malignancy, inflammatory, CHF)
Cough resolves within 8 days Crackles clear within 3 weeks Chest xr usually clears within 4 weeks in
those <50 and up to 12 weeks in older
Further Inpatient Care Transfer patients to an acute care
hospital for reasons other than antibiotic administration. Clinically unstable Critical diagnostic testing not
available Comfort measures cannot be ensured Specific infection control measures
are not available Pulmonary toilet Cardiac adjustment
Guidelines for hospitalizing NHAP Presence of any two symptoms
02 saturation <90% RA SBP<90 or 20 <baseline RR>30 or 10>baseline Increase 02 by 3L more Uncontrolled COPD, CHF, DM ALOC New or increased agitation
Transfer to hospital if the facility cannot provide: VS every 4 hours Lab access Parenteral hydration Two licensed nurses/shift
Inpatient & Outpatient Medications Physicians typically treat patients
with NHAP for 2 weeks with antibiotics.
If pulmonary infiltrates do not resolve after 2 weeks, the physician should initiate further diagnostic studies to determine the cause.
Transfer back to SNF Make certain that the patient’s
pneumonia is resolving and they are clinically stabilized before returning them back to the chronic care facility.
Deterrence/Prevention
Keep patients who are predisposed to aspiration pneumonia in a semi upright position at night.
Take care when feeding patients with gag reflex or neurologic disorder
Isolation Influenza vaccination (reduce hospitalization by 47-
57%) Pneumococcal vaccine (anyone >65) Hand washing Nutritional support Hydration Reducing bacterial colonization of the oropharynx
Complications Empyema Pleural effusions Lung collapse Bronchospasm Bronchiectasis Necrotizing pneumonia Pulmonary abcess ARDS Ventilator dependence death
Prognosis Depends on host immune system, preexisting
cardiopulmonary reserve status, extent of lobar involvement resulting from pneumonia.
The recurrence of pneumonia is not the result of antibiotic failure but the result of the underlying predisposing factors to aspiration.
Advanced age, aggressive organisms (Klebsiella, Legionella, S pneumoniae),comorbidity, respiratory failure, neutropenia, and features of sepsis, all increase mortality and morbidity
ALL INFORMATION WAS TAKEN FROM MEDSCAPE
Cunha MD, Burke A. “Nursing Home Acquired Pneumonia”. Medscape.
And Management of Pneumonia in the Nursing Home, Chest 2010 138(6):1480-1485