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Common nursing home–acquired pneumonia pathogens are usually gram-negative bacilli, Staphylococcus aureus , Streptococcus pneumoniae , Haemophilus influenzae, anaerobes, and influenza. Symptoms and signs are similar to those of pneumonia in other settings, except many elderly patients have less prominent changes in vital signs. Diagnosis is based on clinical presentation and chest x-ray, which are often not available in nursing homes immediately. Treatment is with antibiotics provided in the nursing home for less severe illness and in the hospital for more severe infection. Mortality is moderately high but may be due in part to comorbidities.

Nursing home–acquired pneumonia falls between community- and hospital-acquired pneumonia in etiology and management. S. pneumoniae and gram-negative bacilli may be roughly equally responsible for most infections, though there is debate over whether gram-negative bacilli are pathogens or merely colonizers. H. influenzae and Moraxella catarrhalis are next most common; Chlamydia , Mycoplasma , and Legionella spp are rarely identified. Risk factors are those common among debilitated nursing home residents, such as poor functional status; impaired mood, mental status, and swallowing; and presence of a tracheostomy tube.

Symptoms, Signs, and Diagnosis

Symptoms often resemble those of community- or hospital-acquired pneumonia but may be more subtle; cough and altered mental status are common, as are nonspecific symptoms of anorexia, weakness, restlessness and agitation, falling, and incontinence. Subjective dyspnea occurs but is less common. Signs include diminished or absent responsiveness, fever, tachycardia, tachypnea, wheezes or crackles, and stentorous, wet breathing.

Diagnosis is based on clinical presentation and chest x-ray. X-rays are often difficult to obtain in nursing home patients, so it may be necessary to transfer them to a hospital at least for initial evaluation. In some cases, treatment may be started without x-ray confirmation. Nursing home residents may initially lack a radiographic infiltrate, presumably because of the dehydration that commonly accompanies febrile pneumonia in the elderly and/or a blunted immune response, although the phenomenon is not proven to occur. Because detection of physical changes may be delayed in a nursing home setting and because residents are at greater risk of complications, evaluation for hypoxemia with pulse oximetry and for decreased intravascular volume with serum BUN and creatinine should also be performed.

Prognosis

Mortality rate for patients requiring admission for treatment is 13 to 41%, whereas that for patients treated in the nursing home is 7 to 19%. Mortality rate exceeds 30% in patients with more than 2 of the following findings: respiratory rate > 30 breaths/min, heart rate > 125 beats/min, acute mental status change, and history of dementia. An alternative predictive index incorporates laboratory data (see Table 6: Pneumonia: Nursing Home−Acquired Pneumonia Risk Index). Physicians should follow all medical directives, because pneumonia is often a terminal event in debilitated nursing home patients.

Table 6
Nursing Home−Acquired Pneumonia Risk Index Variable and Value Points Assigned Serum urea nitrogen (mg/dL)* ≤16 0 16.1–27 1 27.1–38 2 38.1–49 3 49.1–60 4 60.1–71 5 > 71 6 WBC count (103/μL) ≤14 0 14.1–24 1 >24 2 Absolute lymphocyte count > 800/μL (0.8 × 109/L) 0 ≤ 800/μL (0.8 × 109/L) 1 Pulse (beats/min) ≤ 72 0 73–102 1 > 132 3 Sex Female 0 Male 1 Body mass index (kg/m2) > 31 0 25.1–31 1 19.1–25 2 13.1–19 3 ð 13 4 Activities of daily living† 0 0 1–2 1 3–4 2 Mood deterioration over last 90 days No 0 Yes 2 *To convert to mmol/L, multiply by 0.357; to convert a value in mmol/L to mg/dL, multiply by 6. †Based on grooming, using the toilet, locomotion, and eating. Each is assigned a zero if the resident is independent, requires supervision, or requires limited assistance or 1 if the resident requires extensive assistance or is totally dependent. The 4 scores are summed to derive a score of zero to 4 and assigned points as shown. Score Mortality 1–4 Low (2–3%) 5–6 Relatively low (6–7%) 7–8 Moderate (15–16%) 9–10 High (34–36%) 11–17 Very high (60–62%)

Treatment

Few data are available to guide decisions about where treatment should take place, but in general, patients should be hospitalized if they have 2 or more unstable vital signs and if the nursing home cannot administer acute care. Some nursing home residents are not candidates for hospital transfer. One dose of antibiotics to cover S. pneumoniae , H. influenzae , common gram-negative bacilli, and S. aureus should be given before transfer; a common regimen is an oral antipneumococcal quinolone (eg, levofloxacin Some Trade Names
IQUIX
LEVAQUIN
QUIXIN
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750 mg once/day, moxifloxacin Some Trade Names
AVELOX
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400 mg once/day, or gemifloxacin Some Trade Names
FACTIVE
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400 mg once/day).

Last full review/revision November 2005

Content last modified November 2005