Common nursing home–acquired pneumonia pathogens include gram-negative bacilli, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, anaerobes, and influenza viruses. Symptoms and signs are similar to those of pneumonia that occurs 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 is often not immediately available in nursing homes. Treatment is with antibiotics provided in the nursing home for less severe illness and in the hospital for more severe illness. Mortality is moderately high but may be due in part to comorbidities.

Nursing home–acquired pneumonia falls between community-acquired and hospital-acquired pneumonia in etiology and management. Streptococcus 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. Haemophilus influenzae and Moraxella catarrhalis are next most common; Chlamydia, Mycoplasma, and Legionella spp are rarely identified. Risk factors are common among debilitated nursing home residents; they include poor functional status, mood disorder, altered mental status, difficulty swallowing, immunosuppression, older age, use of tube feedings, influenza or other viral respiratory infections, conditions that predispose to bacteremia (eg, indwelling bladder catheter, pressure ulcers), and presence of a tracheostomy tube.

Symptoms and Signs

Symptoms often resemble those of community-acquired 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 stertorous, wet breathing.

Diagnosis

• Clinical manifestations
• Chest x-ray
• Assessment of renal function and oxygenation

Diagnosis is based on clinical manifestations and chest x-ray. Because detection of physical changes may be delayed in a nursing home setting and because these patients 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 done.

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 (eg, if clinical diagnosis is clear, if illness is mild, or if aggressive care is not the goal), treatment may be started without x-ray confirmation. It is thought that nursing home patients may initially lack a radiographic infiltrate, presumably because of the dehydration that commonly accompanies febrile pneumonia in the elderly or a blunted immune response, although the phenomenon is not proved to occur.

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 > 2 of the following findings:

• Respiratory rate > 30 breaths/min
• Heart rate > 125 beats/min
• Acute mental status change
• 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
PrintOpen table
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 ≤ 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 0 if the resident is independent, requires supervision, or requires limited assistance or a 1 if the resident requires extensive assistance or is totally dependent. The 4 scores are summed to derive a score of 0 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%) 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 ≤ 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 0 if the resident is independent, requires supervision, or requires limited assistance or a 1 if the resident requires extensive assistance or is totally dependent. The 4 scores are summed to derive a score of 0 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

• Antibiotics given before hospitalization in patients being hospitalized

Few data are available to guide decisions about where treatment should take place. In general, patients should be hospitalized if they have ≥ 2 unstable vital signs and if the nursing home cannot administer acute care. Some nursing home patients are not candidates for aggressive treatment or hospital transfer under any circumstances. In patients who are to be hospitalized, one dose of antibiotics that are effective against S. pneumoniae, H. influenzae, and common gram-negative bacilli should be given before transfer; a common regimen is an oral antipneumococcal quinolone (eg, levofloxacin 750 mg once/day or moxifloxacin 400 mg once/day). Ceftriaxone, ertapenem, and ampicillin/sulbactam (each as monotherapy) are alternatives.

Last full review/revision May 2008 by John G. Bartlett, MD