Pneumonia in nursing homes

Nursing home pneumonia is caused by gram-negative bacilli, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, anaerobes, and influenza virus. Symptoms are similar to those of other types of pneumonia, except that many elderly patients have less pronounced vital sign abnormalities. Diagnosis is based on clinical presentation and chest radiography, which is not always available in nursing homes.

In less severe forms of the disease, pneumonia in nursing homes is treated on site with available antibiotics; in more severe infections, patients are hospitalized. Mortality is moderately high, but may occur due to concomitant pathology.

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Causes pneumonia in nursing homes

In terms of etiology and treatment tactics, pneumonia in nursing homes and institutions is midway between community-acquired and hospital-acquired pneumonia. Pneumococci and gram-negative bacteria can cause most infections with approximately equal frequency, although the question of whether gram-negative bacteria are pathogens or simply saprophytes remains controversial. Next come H. influenzae and Moraxella catarrhalis; chlamydia, mycoplasma, and legionella are rarely identified.

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Risk factors

Risk factors are frequently found in these patients: poor functional status; decreased mood, mental status and difficulty swallowing; presence of a tracheostomy.

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Symptoms pneumonia in nursing homes

Symptoms often resemble those of community-acquired or hospital-acquired pneumonia but may be less severe; cough and altered mental status are common, as are vague symptoms of anorexia, weakness, restlessness and fidgeting, falls, and uncooperativeness. Subjective dyspnea occurs but is less common. 1 include decreased or absent reactivity, fever, tachycardia, tachypnea, stridor or wheezing, and gurgling, moist breath sounds.

Diagnostics pneumonia in nursing homes

Diagnosis is based on clinical presentation and chest radiography. Radiography is often difficult to obtain in this type of setting, so hospitalization may be necessary, at least for initial evaluation. In some cases, treatment may be started without radiographic confirmation. Nursing home patients may initially not have radiographic infiltrates, presumably because of the dehydration that commonly accompanies fever in pneumonia in the elderly and/or a delayed immune response, although this phenomenon has not been proven. Because physical changes may be delayed and the risk of complications is high, hypoxemia should be assessed with pulse oximetry, and blood urea nitrogen (BUN) and creatinine should be measured to detect hypovolemia.

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Treatment pneumonia in nursing homes

Few studies have been done to determine the need for site selection for nursing home pneumonia treatment, but in general, patients should be hospitalized if they have two or more unstable vital signs and if acute care cannot be provided in the nursing home. Some patients do not require hospitalization. A single dose of an antibiotic that is active against S. pneumoniae, H. influenzae, common gram-negative bacteria, and S. aureus should be given before transport; an oral antipneumococcal fluoroquinolone (eg, levofloxacin 750 mg once daily, moxifloxacin 400 mg once daily, or gemifloxacin 320 mg once daily) is usually recommended.

Forecast

Mortality in patients requiring hospitalization is 13-41%, compared with 7-19% in patients treated for pneumonia in nursing homes. Mortality exceeds 30% with more than two of the following: respiratory rate >30/min, heart rate >125/min, acute mental status change, and history of dementia. An alternative predictive index includes laboratory data. Physicians should follow all medical guidelines because pneumonia in nursing homes is often a terminal episode in debilitated nursing home patients.

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