Nhap.pmd

The Diagnosis and Management of
Nursing Home Acquired Pneumonia (NHAP)
This clinical practice guideline (CPG) was developed by
an Alberta CPG Working Group.
EXCLUSIONS
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- DEFINITIONS
♦ 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.
PREVENTION
♦ 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- DIAGNOSIS
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 Tachypnea
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 MANAGEMENT
Respiratory rate ≥ 40 may be an indication fortransfer to hospital Notes:Respiratory rate must be counted for a full minute
Assessment
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.
♦ Fever
- 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 ♦ Cough
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
increased mortality
Parenteral (IM) treatment may be considered if ♦ New onset delirium and/or decreased level of
consciousness, increased confusion
- Sensitive but not specific for pneumonia.
♦ Dyspnea
Ensure adequate hydration (1 litre in a 24 hourperiod is required to replace insensible losses ♦ Tachycardia
♦ 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
Practice Point
deficit.
In the presence of the above signs &/or symptoms administration of antibiotics should NOT be delayed
pending the results of any diagnostic tests COMMENTS
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 ACUTE CARE
O
Ampicillin
Cefuroxime sodium
TRANSFERRED
RECOMMENDED THERAPY
Immediate administation of antibiotics (prior to transfer) Blood culture if available and not going to delay treatment TIENTS BEING
A
P
Amoxicillin
(Macrolide
Doxycycline)
Cefuroxime axetil
(Macrolide
Doxycycline)
Qinolone
Cefotaxime
Macrolide
transfer)
(Consider
gy
THE NURSING
INDEPENDENTL
ABLE 1: MANAGEMENT
RECOMMENDED THERAPY
If minimal comorbidities and totally mobile, refer to recommendations contained in the Guideline for the Management of Commu Administer antibiotics as soon as possible TIENTS LIVING
Amoxicillin
(Macrolide
Doxycycline)
Cefuroxime axetil
(Macrolide
Doxycycline)
Doxycycline
Quinolone
General Management
BACKGROUND
♦ Analgesics/antipyretics for pain and fever Introduction
♦ Cough suppressants are not routinely recommended Nursing home-acquired pneumonia (NHAP) is defined aspneumonia occurring in a resident of a Long Term Care CONTINUING MANAGEMENT
(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.
Risk Factors
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.
Decision-making
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 Differential Diagnosis
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 H. influenzae and M. catarrhalis. Less common patho- will have a redistribution of vasculature to the upper gens in NHAP are Legionella and Chlamydophilia lobes, usually accompanied by cardiomegaly. Pre-existing pneumoniae, 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 Diagnosis
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 Blood cultures
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 Oxygen saturation
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 Investigations
important indicators of acute severity and short termmortality in CAP and NHAP.23 Chest X-Ray
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 Legionella spp 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 recommended.
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 Management
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 Sputum collection
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 Hospitalisation
M. pneumoniae 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: Amoxicillin
This provides very effective activity against
• Respiratory distress (e.g. respiratory rate over 40) S. pneumoniae even in cases of high level resistance to Macrolide
• 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, Mycoplasma pneumoniae or Legionella. 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.
Cefuroxime
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 Doxycycline
months. Hospitalization of this population may often S. pneumoniae resistance is known to be low (Capital Health authority 5%) and makes this an excellent choice.
Many physicians have reported excellent clinical results Continuing Management
using doxycycline in the management of NHAP.
In the LTC setting key management teams should be Respiratory fluoroquinolones
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, S. pneumoniae, 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 Prevention
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 REFERENCES
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
Definitions
•
Aspiration pneumonitis: chemical injury caused by the inhalation of gastric contents, resulting in inflammatory reaction.
No antibiotic therapy recommended in aspiration pneumonitis
Aspiration pneumonia: development of radiographically evident infiltrate following the aspiration of colonized
oropharyngeal material
Risk Factors for Aspiration Pneumonia
•
Anatomic abnormality of the upper GI tract Mechanical interference of the GI tract (ET/NG tubes) Clinical Picture
•
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 Etiology
•
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 Prevention
• 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 Usual Pathogens
Recommended Therapy
Duration
Comments
Nursing Home Acquired
Cefuroxime IV/PO
Levofloxacin
Nursing Home Acquired with
Amoxicillin-clavulanate
poor oral hygiene/severe
periodontal disease
Cefuroxime IV/PO
Metronidazole IV/PO
Levofloxacin
500mg PO daily
PLUS
Metronidazole IV/PO
500mg IV/PO q12h
APPENDIX 2: INFLUENZA AND PNEUMOCOCCAL VACCINES30-32
Influenza vaccine should be given annually to:
High Risk:
• 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 Others:
• 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 disease
Notes
Where possible give vaccine 10 to 14 days prior to splenectomy or at beginning of chemotherapy for
Hodgkin’s disease.
*
Vaccine failures may occur in this group - advise counselling (re: fulminant pneumococcal sepsis and need
to seek early medical advise with fever).
Recommended:
• 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.
Note
Vaccine may be administered simultaneously with influenza vaccine (separate injection site).
Not Recommended:
• 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.

Source: http://www.cmda.info/NHAP_guideline.pdf