The Diagnosis and Management of
Nursing Home Acquired Pneumonia (NHAP)
This clinical practice guideline (CPG) was developed by
an Alberta CPG Working Group.
To enhance an earlier detection and treatment ofNHAP
♦ Hospital acquired pneumonia (onset within 14
♦ To increase the accuracy of the clinical diagnosis
days of discharge from an acute care facility)
♦ Aspiration pneumonia (see Appendix 1)
♦ To optimise the appropriate use of laboratory and
♦ Patients with cystic fibrosis, tuberculosis, or
♦ To optimise the use of antibiotics in the treat-
♦ To foster teamwork in the evaluation and
♦ Pneumonia in a patient residing in a nursing
♦ To optimise the decision for patient transfer to
* This applies to any congrgate residential setting for
older and disabled patients that have high personal and
professional care needs. These are sometimes known as
long term care facilities, auxiliary hospitals, chronic
care centres, or continuing care centres.
♦ Limit the spread of infections (e.g., hand
♦ Treatment for NHAP should take into account
washing and attention to outbreak management
♦ There is a lack of well designed studies in this
♦ Influenza and pneumococcal vaccines are
♦ Chest radiography is not widely available or
♦ Smoking cessation and avoidance of environ-
significant limitations and as such, treatmentof NHAP is usually empiric
Although a new infiltrate seen on chest X-ray withcompatible clinical signs is the gold standard for the
♦ Delay in administration of antibiotics for the
diagnosis of NHAP, in nursing home settings the
diagnosis must often be made on clinical grounds
increased patient morbidity and mortality
alone. The physical examination must include bloodpressure, heart rate, respiratory rate and auscultation
♦ Inappropriate use of antibiotics may adversely
affect patient outcomes and may increaseantimicrobial resistance
The above recommendations are systematically developed statements to assist practitioner and
patient decisions about appropriate health care for specific clinical circumstances.
They should be used as an adjunct to sound clinical decision making.
♦ Ideally the diagnosis of pneumonia should be
Symptoms & Signs Cluster
supported with chest X-ray, oxygen saturation,complete blood count and differential, blood
If chest X-ray is not available, tachypnea and at least
cultures, and sputum cultures. As these tests are
1 of the following signs and symptoms should be
frequently unavailable in the nursing home setting,
present to make a diagnosis of probable NHAP
Note:: There is still value in performing these tests even after
Most important clinical predictive factor
treatment has been initiated.
Respiratory rate ≥ 25 is associated withincreased morbidity and mortality
Respiratory rate ≥ 40 may be an indication fortransfer to hospital
Notes:Respiratory rate must be counted for a full minute
An elevated respiratory rate has a high sensitivity andspecificity for the diagnosis of pneumonia.
♦ Determine the degree of medical treatment desired
by the patient or legal decision maker such as a
AND AT LEAST ONE OF THE FOLLOWING
guardian or agent named in an enacted personaldirective.
- Temperature of 37.8 C or greater is both a
sensitive and specific predictor of infection
Consider transfer to hospital if impending
(positive predictive value of 55% in nursing
temperature therefore fever may be presentwhen the temperature >1.5ºC higher than
Oxygen therapy is indicated for hypoxemia
Note: Rigors are an important marker for bacteremia.
If oxymetry is not available consider oxygen at 2
Note: COPD baseline oxygenation may be lower and therefore
must be individually assessed
- Unproductive cough is not uncommon in this
♦ Pleuritic chest pain
Ideally antibiotic therapy should be initiated as
- Pleuritic chest pain is a specific sign for
soon as possible (within 4 hours) after diagnosis
pneumonia (also watch for pulmonary embolus)
Note: Initiation of antibiotics after 8 hours is associated with an
♦ Crackles, wheezes or bronchial breath sounds
Parenteral (IM) treatment may be considered if
♦ New onset delirium and/or decreased level of
consciousness, increased confusion
- Sensitive but not specific for pneumonia.
Ensure adequate hydration (1 litre in a 24 hourperiod is required to replace insensible losses
♦ New or worsening hypoxemia
Note: Consider hypodermoclysis
Note: Fluid requirement for older persons without cardiac or
renal failure is 30ml/kg/day in addition to estimated fluid
In the presence of the above signs &/or symptoms
administration of antibiotics should NOT
pending the results of any diagnostic tests
Azithromycin 500mg PO 1st day then 250mg PO
Amoxicillin retains the best coverage of all oral beta-
If patient unable to tolerate oral medication use IM.
Consider adding a macrolide or doxycycline if there is
Note: For other erythromycin formulations give at
least 1 gram per day (preferably 2 grams)
Cefuroxime provides better coverage of H. influenzae
and M. catarrhalis in patients with COPD. Cefuroxime
may be preferred in patients post influenza as it
Note: Amoxicillin-clavulanate provides similar
coverage and may be considered in patients with
Quinolones should be given with caution if the
patient has received quinolone therapy within the
Immediate administation of antibiotics (prior to transfer)
Blood culture if available and not going to delay treatment
ABLE 1: MANAGEMENT
If minimal comorbidities and totally mobile, refer to recommendations contained in the Guideline for the Management of Commu
Administer antibiotics as soon as possible
♦ Analgesics/antipyretics for pain and fever
♦ Cough suppressants are not routinely recommended
Nursing home-acquired pneumonia (NHAP) is defined aspneumonia occurring in a resident of a Long Term Care
(LTC) facility. Prevalence ranges between 1.1 to 2.5% in
chronic care facilities , has an incidence of 13 - 48% ofall LTC infections and is a common cause for transfer to
♦ In the nursing home setting, the care team needs to
be involved in daily assessments to alert the physician
pneumonia are very common infectious disorders in LTC
to significant changes in patient status:
facilities. In one region 8% of all transfers to hospital
were diagnosed in the emergency department with
pneumonia, 20% of whom were transferred back to LTC
for further treatment. NHAP mortality may be as high as
44%. Higher mortality rates ( two to threefold)
weight loss of >5-10% is related to increased
morbidity (Significant weight loss in the
NHAP was first described in 1978. Since then there has
nursing home >5% in 30 days or >10% in 6
been much written regarding NHAP and its management
but there has been a lack of well-designed studies in this
Review medication profile and consider holding
patient population. In the absence of randomized
controlled trial data for empiric drug therapy, many
clinicians have extrapolated findings from community
acquired pneumonia (CAP) clinical pathways and guide-
lines. There is little, if any, evidence to support the
Review antibiotic treatments at 48 to 72 hours
application of CAP guidelines to nursing homes primarily
due to advanced patient age and disease complexity in the
risk stratification process. Recent work by Loeb and
colleagues in Ontario have demonstrated that the use of aclincal pathway reduced the number of transfers to
♦ If failure of therapy occurs, consider change in
hospital and had comparable clinical outcomes to a
LTC is a unique health care delivery setting with many,
often complex, considerations when it comes to clinical
decision-making. There are few guidelines that exist to
No improvement after completion of antibiotic
assist physicians in prescribing for LTC patients.
following key elements impact the assessment andmanagement of NHAP in this setting.
Nursing home patients have lower levels of functioning,are at an advanced age and have significant co-morbid
conditions, e.g., COPD, dementia and atherosclerotic
heart disease. Other risk factors identified for death from
nursing home acquired pneumonia include aspiration,
bed-fast state, cerebrovascular accident, difficulty with
oropharyngeal secreations, dysphagia, feeding tube,
frailty, incontinence, and sedative hypnotic use.
The high prevalence of dementing illness in LTC is a
further limitation on good and reliable decision-making.
Many patients and families do not wish to pursue life
supporting or life prolonging therapies. In LTC, palliative
important host defences, including ciliary activity,
treatment options are often preferred overaggressive life
neutrophil function, and other lung defence
supporting therapies. Understanding a patient’s wishes is
mechanisms. Cigarette smoke compromises mucociliary
often very challenging and it is imperative that all health
function and macrophage activity. Alcohol impairs the
care professionals understand how decisions are made
cough reflex, increases oropharyngeal colonization with
regarding individual patient care. It is important that every
gram-negative bacilli, and may inhibit immune
effort is made to determine a patient’s wishes regarding
mechanisms. Elderly patients are at increased risk of
treatment. An enacted personal directive will greatly assist
developing pneumonia due to multiple factors: increased
health care providers make the correct decisions where
number and severity of co morbidities, decreased
the patient is unable to direct care.
mucociliary clearance, diminished cough reflex, increasedaspiration, increased colonisation with gram-negatives,
Etiology and pathophysiology
The microbiological demographics in LTC are not well
understood and will vary between centres. Streptococcuspneumoniae (S. pneumoniae) is recognized as the most
The most common causes of diagnostic confusion in this
common organism in NHAP. One recent prospective
population are non-infectious cardiac and pulmonary
study found a prevalance of 55% in patients transferred
disorders. Congestive heart failure (CHF) is a common
to hospital with NHAP.11 There are concerns with the
disorder resembling NHAP. CHF may represent an
development of penicillin resistant S. pneumoniae and the
exacerbation of a pre-existing CHF resulting in shortness
true prevalance of atypical pathogens is not known.
of breath for the patient thus resembling the presentationof NHAP. It may also co-exist with NHAP.
NHAP more closely resembles community-acquiredpneumonia (CAP) than nosocomial pneumonia.The
Chest radiographs are the best way to diagnose NHAP.
pathophysiology of NHAP is the same as for CAP. The
Patients with NHAP have segmental or lobar distribution
most common pathogens are S. pneumoniae,
of infiltrates as seen on chest X-rays. Patients with CHF
and M. catarrhalis
. Less common patho-
will have a redistribution of vasculature to the upper
gens in NHAP are Legionella
lobes, usually accompanied by cardiomegaly. Pre-existing
, although C. pneumoniae
is emerging as a
chest X-rays may reveal previous interstitial lung disease
that can be confused with the appearance of NHAP.
Elderly patients are also more likely to be colonized with
Fever of 38OC or more accompanied by pulmonary
gram-negative organisms (especially if decreased
symptoms suggests NHAP, especially when accompanied
functional status, institutionalized and multiple co-morbid
by a productive cough. However, in elderly patients, the
febrile response may be blunted. Thus, the absence offever is unhelpful in making the differential diagnosis.
Tuberculosis (TB) should always be considered(especially in the elderly) given that there is a 10 to 30
Pleural effusions can also cause diagnostic confusion in
times increased incidence of TB in long term care
the diagnosis of pneumonia. Bacterial pneumonias,
residents. LTC residents account for 20% of all TB cases
particularly due to S. pneumoniae
and H. influenzae
in older people.12,1 There is a need to be mindful of TB
may be accompanied by pleural effusion. Pleural
admission screening findings such as old TB on chest
effusions without associated infiltrates are not
Anerobes are not important pathogens in CAP. Although
the elderly and patients in LTC have a higher incidence ofaspiration, the role of anaerobes in this setting remains
Diagnosis of pneumonia is based on a patient’s history,
controversial. Anaerobic coverage is not recommended in
co-morbidities, physical findings, and chest X-ray.
NHAP unless there is severe periodontal disease, putrid
Symptoms of NHAP most commonly include fever, chills,
sputum, or evidence of necrotizing pneumonia or lung
dyspnea, pleuritic chest pain, and cough. With increasing
age, symptoms of infection may not be as apparent andphysical signs may be diminished. Fever may be less
In up to 50% of cases, a viral infection precedes the
commonly observed but delirium and confusion may be
development of pneumonia and undoubtedly plays a role
more common in this population. Delirium or acute confusionis found in 44.5% of elderly patients with pneumonia.16
Tachypnea is the only physical sign for which a
be paid to the Gram stain especially if intracellular organisms
predictive value can be calculated for LTC residents.
Normal respiratory rate in the elderly is 16 to 25 breaths
per minute.10 A respiratory rate of > 25 breaths per
minute has a sensitivity of 90% and a specificity of 95%
Blood cultures should be drawn in all cases of suspectedNHAP if available. Blood cultures should be done prior to
A single temperature of 38.3oC has a sensitivity of only
the initiation of antibiotics if possible. However treatment
40% for predicting infection. Lowering the threshold to
should not be delayed for tests or results. Obtaining a blood
37.8oC increases the sensitivity to 70% while maintaining
culture within 24 hours of presentation has been associated
specificity at 90%. A temperature of 37.8oC or greater is
with improved 30 day survival in patients with community
both a sensitive and specific predictor of infection (positive
predictive value of 55% in nursing home residents). Basalbody temperature in the frail elderly is lower than 37oC
An increase of 1.5oC over baseline on at least
two occasions may be a better temperature criterion in the
Oxygen saturation should be assessed by pulse oximetry.
elderly. Regular vital signs are an essential component of
If O sat < 89% or patient has COPD, arterial blood gas
initial and continuing assessment of all patients with NHAP.
should be drawn on room air, or on baseline O if patient is
receiving chronic oxygen. Hypoxemia is one of the
important indicators of acute severity and short termmortality in CAP and NHAP.23
Serology and invasive testing
Chest X-ray (CXR) is the gold standard for diagnosis of
Serology is not
routinely recommended. Legionella
NHAP and should be done in all patients with findings
urinary antigen testing is not recommended routinely as
consistent with pneumonia where possible. There is
is rare locally.
considerable variability in performing CXR in LTC.
Evidence of acute pneumonia i.e. new infiltrate is present
Routine use of invasive testing (bronchoscopy,
in 75% to 90% of CXRs done in LTC.18 It is recognised
bronchoalveolar lavage, etc.) is not
however that many centres do not have access to CXRsand the diagnosis must be made based on clinical findings.
The presence of recurrent pneumonia should lead toinvestigation for immune system disorders or structural
Some radiographic patterns suggest certain infections and
abnormalities and antibiotic resistance.
may help to support a diagnosis of pneumonia versus analternate cause. Comorbid lung or cardiovascular disease
can be identified and the severity of the illness may be judgedby the extent of lung involvement on CXR.
Complete blood count (CBC)
Adequate hydration of patients with NHAP is essential. Manypatients with pneumonia are dehydrated due to increased
CBC with differential is recommended for all patients. In
insensible water loss. Nutritional status, especially in the
the elderly, the total WBC count and number of bands are
elderly, is a very important factor. (Significant weight loss
one of the best indicators of bacterial infection.
in the nursing home setting is defined as >5% loss in body
Hospitalised patients admitted from the nursing home may
weight in 30 days or 10% in 6 months). Weight loss of >5-
need additional tests including: glucose, electrolytes, cre-
10% can result in increased mortality.1 Oxygen is often
not available in the LTC setting and the need for suchtherapeutic support may be an indication for transfer to
Collection of sputum for Gram stain and culture is
Antibiotic Therapy (see Table 1)
recommended if the patient has a productive cough.
However, most sputums taken in long term care are of
It is critical that antibiotics be given as soon as possible
poor quality because of poor expectoration and an inability
after the diagnosis of pneumonia is made. Most patients
to provide an adequate sample.21 Although sputum
with NHAP can be managed with oral antibiotics.25,26 The
collections may be of limited value, special attention should
choice of empiric therapy is based on the likely
fluoroquinolone group of antibiotics has contributed to
microorganism, severity of illness, allergies, recent
the development of resistance due to their widespread
treatment failure and ability to swallow. There is little
empiric use.27 Antibiotic resistant organisms are currently
evidence to differentiate in terms of efficacy between the
felt to be a less significant issue in Canadian centres due
antibiotics suggested in Table 1 for NHAP. However it is
in large part to the restricted use of fluoroquinolones.
felt that empiric therapy of NHAP should always coverS. pneumoniae
, and intracellular pathogens such as
and C. pneumoniae
. Antibiotics of initialchoice for NHAP are listed in Table 1. Monotherapy is not
Thirty-three out of 1000 nursing home residents are
recommended in severe pneumonia. It should also be
hospitalised with NHAP versus 1.14 per 1000 population
noted that the appropriate use of antibiotics within
who require hospitalisation due to CAP.14
nursing homes mitigates against the development ofantimicrobial resistance and problems such as
For patients with NHAP, referral to acute care for a more
supported treatment environment should be considered inthe following circumstances:
This provides very effective activity against
• Respiratory distress (e.g. respiratory rate over 40)
even in cases of high level resistance to
• Signs of impending hemodynamic instability
A macrolide may be added if there is underlying lung
disease such as COPD or in severe pneumonia.
Macrolides are also effective against atypical pneumonia
• Clinical judgement of the attending physician at any
such as Chlamydophilia pneumoniae
. However, macrolide
• Level of acuity that cannot be managed at the facility
resistance in S. pneumoniae
exceeds 10% and coverage
• Limited capacity to support the illness at the facility
of Haemophilus spp
may not be optimal. Azithromycin
has no appreciable serum concentrations and should notbe used in patients with rigors/chills as this may indicatebacteremia.
All patients diagnosed with NHAP should receive oral orparenteral antibiotics within 4 to 8 hours of diagnosis.
Even those patients that require admission to hospital for
May be considered in cases of penicillin allergy or post
treatment of pneumonia. If antibiotic therapy is delayed
influenza pneumonia where Staph aureus
may be a
for more than 8 hours, the mortality rate is much higher
than if antibiotics are given within 8 hours.28 Recovery isoften prolonged in the elderly and may take up to several
months. Hospitalization of this population may often
resistance is known to be low (Capital
Health authority 5%) and makes this an excellent choice.
Many physicians have reported excellent clinical results
using doxycycline in the management of NHAP.
In the LTC setting key management teams should be
involved in the daily reassessment of patients. The
Levofloxacin and moxifloxacin provide excellent
monitoring of vital signs and the communication of
coverage of the pathogens involved, but because of their
changes in vital signs are key to successful NHAP
broad spectrum and potential for increasing resistance in
management. This requires the involvement of nursing,
, they should be reserved for patients who
pharmacy, dietitians, occupational therapy and
1) have failed first line therapy or 2) are elderly and have
physiotherapy staff to monitor mobility, eating and
co morbidities. Ciprofloxacin does not have adequate
response to antibiotics. Medication profiles need to be
coverage of S. pneumoniae
and should not be used in the
reviewed as often as the need for psychoactive
medication changes during an acute infectious diseasesuch as NHAP.
Antibiotic resistance has become a significant issueamong US nursing homes. Heavy utilization of the
13. Marik P. Aspiration pneumonitis and aspiration
• Smoking cessation and avoidance of environmental 14. Mandell L, Marrie T, Grossman R, et al. Canadian
tobacco smoke. Smoking is the strongest independent
guidelines for the initial management of community
risk factor for invasive pneumococcal disease in adults.
acquired pneumonia: an evidence based update by the
• Limit the spread of viral infections (e.g., hand
Canadian Infectious Diseases Society and the
washing). Hand washing can prevent up to 80%
Canadian Thoracic Society. Clin Infect Dis, 2000; 31:
of the most common infectious diseases (mostly
viral) which may predispose to pneumonia.
15. Marrie T. Treating community acquired pneumonia in
• Influenza vaccine is recommended annually for
elderly women: disease severity dictates optimal
management approach. Women’s Health in Primary
• Pneumococcal vaccine is recommended for high
16. Riquieleme R, Torres A, el-Ebiary M, et al.
• Rehabilitation (occupational therapy and/or
Community acquired pneumonia in the elderly.
physiotherapy) and nutritional programs where
Clinical and nutritional aspects. Am J Respir Crit Care
17. McFadden JP, Eastwood HD, Briggs RS Raised
respiratory rate in elderly dehydrated patients
18. Bentley D. Bacterial pneumonia in the elderly: clinical
Marrie T. Community acquired pneumonia in the
features, diagnosis, etiology and treatment.
elderly. Clin Infect Dis, 2000 Oct; 31(4): 1066-1078.
Muder AR, Brennan C, Serenson D, Wagener M.
19. Castle S, Norman D, Miller D, Yoshikawa T. Fever
Pneumonia in a long term care facility: a prospective
response in elderly nursing home residents: are the
study of outcome. Arch Intern Med, 1996; 156:
older truly colder? J Am Geriatr Soc 1991
Nicolle L, McIntyre M, Zacharias H, et al. Twelve
20. Wasserman M, et al. Utility of fever, white blood cells
month surveillance of infections in institutionalized
and differential count in predicting bacterial infections
elderly men. J Am Geriatr Soc, 1984 July; 32(7):
in the elderly. J Am Geriatric Soc, 1989; 37: 537-43.
21. Geckler R, Gremillion D, McAllister C, Ellenbogen C.
Utilization Improvement Project Care Centre Leaves.
Microscopic and bacteriological comparison of paired
sputa and transtracheal aspirates. J Clin Microbiol,
Naughton B, Mylotte J, Tayara A. Outcome of
Nursing Home Acquired Pneumonia: Derivation and
22. Arbo M, Snydman D. Influence of blood culture
Application of a practical model to predict 30 day
results on antibiotic choice in the treatment of
mortality. J Am Geriatr Soc, 2000; 48: 1292-1299.
Garb J, Brown R, Garb JR, Tuthill R. Differences in
etiology of pneumonias in nursing home and
23. Fine M, Smith M, Carson C, et al. Efficacy of
community patients. JAMA, 1978 Nov; 240(20):
pneumococcal vaccination in adults: a meta analysis
of randomized controlled trials. Arch Intern Med,
Mylotte J Nursing Home Acquired Pneumonia Drugs
24. Houck P Bratzler D Administration of first hospital
Marrie T, Lau C, Wheeler S. A controlled trial of a
antibiotics for community-acquired pneumonia: does
clinical pathway for treatment of community
timeliness affect otucomes? Curr Opin Infect Dis
acquired pneumonia. JAMA 2000; 283: 749-755.
Loeb M Carusone S, Goeree R et al Effect of a
Clinical Pathway to Reduce Hospitilizations in
25. Degelau J, Guay D, Straub K. Effectiveness of oral
Nursing Home Residents with Pneumonia. JAMA.
antibiotic treatment in nursing home acquired
pneumonia. J. Am Geriatr Soc, 1995; 43: 245-251.
10. McGeer A. Antibiotic use in continuing care. A short
26. Fried T, Gillick M, Lipsitz L. Whether to transfer?
sighted view that needs correction. Drug Use in the
Factors associated with hospitalisation and outcomes
in elderly long term care patients with pneumonia. J
11. Lim WS, Macfarlane JT A prospective comparison of
nursing home acquired pneumonia with community
27. Bonomo R. Multiple antibiotic resistant bacteria in
acquired pneumonia Eur Respir J 2001;18: 362-368.
long term care facilities: an emerging problem in the
12. Narain J, Lofgren J, Warren E, Stead W. Epidemic
practice of infectious diseases. Clin Infect Dis, 2000;
tuberculosis in a nursing home: a retrospective cohort
study. J Am Geriatr Soc, 1985; 33: 258-262.
28. Meehan T, Fine M, Krumholz H, et al. Quality of care,
Toward Optimized Practice (TOP)
process, and outcomes in elderly patients with
pneumonia. JAMA, 1997; 278: 2080-2084.
29. Blondel-Hill E, Fryters S. Bugs and Drugs:2001
Antimicrobial Pocket Reference, 2001. Capital Health
Arising out of the 2003 Master Agreement, TOP suc-
ceeds the former Alberta Clinical Practice Guidelines
30. Canada Communicable Diseases Report 2000;
program, and maintains and distributes Alberta CPGs.
TOP is a health quality improvement initiative that fits
31. Canada Immunization Guide - Health Canada, 5th
within the broader health system focus on quality and
complements other strategies such as Primary Care
32. Communication from Disease Control and
Initiative and the Physician Office System Program.
Prevention - Alberta Health, October 1998.
The TOP program supports physician practices, and theteams they work with, by fostering the use of evidence-based best practices and quality initiatives in medical carein Alberta. The program offers a variety of tools andout-reach services to help physicians and their colleaguesmeet the challenge of keeping practices current in anenvironment of continually emerging evidence.
TOP Leadership Committee
Alberta Health and WellnessAlberta Medical AssociationRegional Health AuthoritiesCollege of Family Physicians of Canada,
To Provide Feedback
The Working Group for NHAP is a multi-disciplinaryteam composed of family physicians, infectious diseasesspecialists, pediatricians, hospital and communitypharmacists.The team encourages your feedback. If youhave difficulty applying this guideline, if you find therecommendations problematic, or if you need moreinformation on this guideline, please contact:
Toward Optimized Practice Program12230 - 106 Avenue NWEDMONTON, AB T5N 3Z1T
Nursing Home Acquired Pneumonia, September 2002
APPENDIX 1: ASPIRATION PNEUMONIA29
: chemical injury caused by the inhalation of gastric contents, resulting in inflammatory reaction.No
antibiotic therapy recommended in aspiration pneumonitis
development of radiographically evident infiltrate following the aspiration of colonized
Risk Factors for Aspiration Pneumonia
Anatomic abnormality of the upper GI tract
Mechanical interference of the GI tract (ET/NG tubes)
Usually older patient with above risk factors
Infiltrates in dependent lung segments, especially RLL
Episode of aspiration often not witnessed
May progress to abscess/empyema within 1-2 weeks
Gram stain may be helpful in diagnosis and decision to use anti-anaerobic therapy
Choice of antibiotic dependent on clinical situation- Cefuroxime has good activity against most oral anaerobes
• Bedside swallowing assessment and modified barium swallow if indicated
• Staff education to identify residents at risk or with dysphagia
• Ensure appropriate diet and liquid consistency
• Address positioning issues eg hyper-extended neck
• Ensure upright position with meals and tube feeds
• Routine dental evaluations and oral hygiene especially in patients with xerostomia
Nursing Home Acquired
Nursing Home Acquired with
poor oral hygiene/severe
500mg PO daily
500mg IV/PO q12h
APPENDIX 2: INFLUENZA AND PNEUMOCOCCAL VACCINES30-32
Influenza vaccine should be given annually to:
• Adults and children with chronic cardiac or pulmonary disorders (bronchopulmonary dysplasia, cystic
• Adults and children with chronic conditions: diabetes and other metabolic diseases, cancer,
immunodeficiency (including HIV), immunosuppression (including renal transplants), renal disease, anemia,hemoglobinopathy
• Residents of nursing homes or long term care facilities
• Children and adolescents treated with long term ASA
• People at high risk of influenza complications travelling to foreign destinations where influenza is likely to be
People capable of transmitting influenza to those at high risk:
• Health care workers and other personnel who have continuous, direct care contact with people in high risk
• Household contacts (including children) of people at high risk who cannot be immunized or are
• People who provide essential community services and other adults who wish to reduce their chances of
acquiring infection and consequently missing work
• Pregnant women in high risk groups (vaccine is considered safe for pregnant women, regardless of stage of
Protection begins 2 weeks post vaccination and lasts up to 6 months (may be less in the elderly).
Pneumococcal polysaccharide vaccine
Strongly recommended - High Risk*:
• Asplenia (traumatic/surgical/congenital)
• Sickle-cell diseaseNotes
Where possible give vaccine 10 to 14 days prior to splenectomy or at beginning of chemotherapy for
Vaccine failures may occur in this group - advise counselling (re: fulminant pneumococcal sepsis and need
to seek early medical advise with fever).
• All persons ≥ 65 years old
• All residents of long term care facilities
• Patients with chronic cardiovascular/pulmonary disease, cirrhosis, alcoholism, chronic
renal disease, diabetes mellitus, HIV infection, and other conditions associated withimmunosuppression, chronic cerebrospinal fluid leak.
Vaccine may be administered simultaneously with influenza vaccine (separate injection site).
• Children < 2 years of age
• Asthma (as the single underlying condition)
• Otitis media (as the single underlying condition)
• Severe allergy to any component of the vaccine.
CIVIL AVIATION REGULATIONS SURINAME PART 10 - COMMERCIAL AIR TRANSPORT BY FOREIGN AIR CARRIERS WITHIN SURINAME VERSION 4.0 June 2006 AMENDMENTS Location Amended by Description Certificate changed to operations specificationsCertificate changed to operations specificationsForeign Air Operator Operations SpecificationsForeign Air Operator Operations SpecificationsOp
Leipzig, Universitätsbibliothek, Katalog der mittelalterlichen theologischen Handschriften, Bd. 2, 3: Ms 751-869. Vorläufige spätmittelalterlicher heller Ledereinband, Langriemenschließe und Kette entfernt, fol. 7 / 8 Falzverstärkung mit Rubrizierungsrest Bastarda verschiedener Hände, 1. Hälfte 15. Jh. Papierreste eines spätmittelalterlichen Titelschilds im Zuge der Säkularisation der