Evidence-based guidelines for management of nursing home-acquired pneumonia

Antibiotic use

Extrapolating from studies of hospital- and community-acquired pneumonia indicating a survival benefit for patients who receive antibiotics within 8 hours of arrival in hospital or symptom onset,⁴⁰ the panel made the following recommendations, which do not conflict with 3 recently published guidelines on use of antibiotics in long-term care facilities.¹⁶

1. Patients being sent immediately to the hospital should receive 1 dose of parenteral antibiotics prior to leaving the nursing home unless this treatment would delay transport for more than 1 hour. The hospital should be notified of the antibiotic given. (B/II/4.4)⁴⁰
2. A single dose of antibiotics should be ordered immediately (simultaneously with the chest x-ray order) if the patient has any of the following: systolic blood pressure < 90 mm Hg or 20 mm Hg less than baseline; oxygen saturation < 90% on room air at sea level; pulse > 130 beats per minute; respiratory rate > 30 breaths per minute; or temperature > 101.5°F. (B/II/4.5)^40,41
3. For patients with probable pneumonia who are stable (oxygen saturation > 90%, systolic blood pressure > 90 mm Hg, pulse < 120 beats per minute, and respiratory rate < 30 beats per minute), a decision to use antibiotics may await results of the chest x-ray if they will be available within 24 hours. (C/III/3.8)^40,41 If the chest x-ray does not confirm the suspicion of pneumonia, consideration should be given to stopping antibiotic treatment.
4. Antibiotics, if ordered, should be delivered to the patient within 4 hours of the orders being given by the physician. (B/II/4.5)^40,41
5. If the patient is able to take oral medication, that route is preferred, except that patients being sent to the hospital should have 1 parenteral dose. (A/I/4.7)^4,42,43

Because it is difficult to obtain a bacteriologic diagnosis in most nursing home residents, the initial choice of antibiotic must be empiric. Based on the published studies of nursing home-acquired pneumonia bacteriology, half of which used high-quality sputum samples (> 25 white blood cells per low-power field and < 10 squamous epithelial cells per low-power field, (see Table 1), the panel recommended a broad-spectrum antibiotic covering S pneumoniae, Haemophilus influenzae, gram-negative rods, and Staphylococcus aureus. In areas or facilities where resistance of S pneumoniae to penicillin is known to be high, treatment should be modified accordingly. These recommendations differ from those proposed by the Society of Health Care Epidemiology of America in their 2000 position paper,¹⁶ but are similar to those proposed by Naughton and Mylotte¹⁸ in their guideline derived from current community practice in Buffalo, New York, except that the current panel recommends the addition of a macrolide. These differences are driven by controversy over the relative importance of gram-negative rods as etiologic vs colonizing organisms in nursing home-acquired pneumonia; the relative importance of atypical organisms; and by the current panel’s concern that an important percentage of bacteria in long-term care facilities may already be resistant to many of the antibiotics endorsed by the Society of Health Care Epidemiology of America. Moreover, 3 studies have suggested a survival benefit of broader-spectrum empiric treatment in nursing home-acquired pneumonia.^11,44,45

1. The antibiotic chosen as empiric therapy needs to cover S pneumoniae, H influenzae, gram-neg-ative rods, and S aureus. (B/II/4.5)^{37,31,39,44-51}
2. Currently acceptable choices for empiric treatment include: antipneumococcal quinolones or an extended-spectrum beta-lactam plus a macrolide other than erythromycin. (C/III/4.5)^45,52,53
3. Treat for 10 to 14 days. (B/II/4.4)^18,25

Conclusions

A multidisciplinary, multispecialty panel of nationally recognized experts in nursing home-acquired pneumonia achieved consensus in proposing guidelines and a care pathway to prevent, recognize, evaluate, and treat nursing home-acquired pneumonia. For immunization and use of oral antibiotics when possible, evidence was sufficient to make a strong (A/I) recommendation. Even in areas in which evidence was lacking, the panel agreed readily. Thus for most of the 25 proposed guidelines, strong evidence and/or ready consensus existed among national experts from many disciplines.

The process of guideline development that we followed was systematic and meticulous. The panel was diverse, including nurses and pharmacologists, nationally recognized experts in infectious disease, nursing home care, geriatrics, and pulmonology. The breadth of the panel’s collective experience, and the rigor of the Delphi process we followed, lend face validity to the proposed guidelines despite some differences with other guidelines, as noted above.^45,53

These guidelines are uniquely comprehensive. They address management of pneumonia from prevention through diagnosis, the decision to hospitalize, and treatment. Such a comprehensive approach is essential given the many people and systems that interact in the care of nursing home residents, a uniquely frail and vulnerable population. Evidence from our work and others^11,13 suggests that only a comprehensive approach will, over time, improve the outcome of this important illness.