II. Epidemiology

  1. Pneumonia is second most common Nursing Home acquired infection

III. Pathophysiology

  1. Micro-aspiration is common in the elderly and likely contributes to Pneumonia pathophysiology

IV. Risk Factors: Atypical or mult-drug resistant organisms (e.g. MRSA, DRSP, Gram Negative Bacterial infections)

  1. Community acquired Pneumonia (CAP)
    1. Not in hospital or Nursing Home within prior 14 days
  2. Health-care associated Pneumonia (HCAP)
    1. Hospitalized for at least 2 days in the last 90 days
    2. Immunocompromised
    3. Nursing Home resident
    4. Patients with predisposing comorbidity
      1. Dialysis
      2. Chemotherapy
      3. Chronic wound
      4. Home intravenous antibiotics

V. Causes

  1. Most common (approach half of isolates in some centers)
    1. Gram Negative Pneumonia (associated with most serious cases)
    2. Pneumococcal Pneumonia
  2. Common (approach one quarter to one third of isolates in some centers)
    1. Staphylococcal Pneumonia (associated with most serious cases)
    2. Haemophilus Influenzae Pneumonia
  3. Less common (10% or less of isolates)
    1. Viral Pneumonia (especially Influenza, RSV)
    2. Pseudomonas aeruginosa Pneumonia
    3. Legionella pneumonia (more common in community than Nursing Home)
    4. Mycoplasma pneumoniae (more common in community than Nursing Home)

VI. Signs and Symptoms: Probable Pneumonia in elderly (>1)

  1. New or worsening cough
  2. Newly Purulent Sputum
  3. Respiratory Rate >25 breaths per minute (bpm)
  4. Tachycardia
  5. New or worsening Hypoxia
  6. Pleuritic Chest Pain
  7. Cognitive or functional decline
  8. Change in Respiratory Exam (e.g. rales or rhonchi)
  9. Fever or Temperature instability
    1. Temperature >100.5 F (38.1 C) or
    2. Temperature <96 F (35.6 C) or
    3. Temperature >2 F (1.1 C) over baseline

VII. Imaging

  1. Chest XRay
    1. Less sensitive and specific in elderly
    2. Infiltrate frequently absent despite Pneumonia
      1. Decreased ability to mount inflammatory response
      2. Dehydration
    3. Infiltrate often obscured
      1. Congestive Heart Failure
      2. Chronic fibrotic changes (e.g. COPD)
  2. Chest CT
    1. Consider in unclear cases where Pneumonia suspected and definitive diagnosis will Change Management

VIII. Labs

  1. Complete Blood Count
  2. Sputum Gram Stain
  3. Sputum Culture
    1. May be difficult to obtain in elderly
    2. Adequate samples (>25 PMNs/lpf) Test Sensitivity: 75%
  4. Consider urine antigen testing for pneumococcus and Legionella pneumophila

IX. Criteria: Poor prognostic signs favoring hospitalization in Elderly

  1. Nursing Home resident
  2. Comorbid conditions
    1. Neoplasm
    2. Chronic Renal Failure
    3. Liver Failure
    4. Congestive Heart Failure
    5. Prior Cerebrovascular Accident
  3. Vital Sign Changes
    1. Tachycardia over 124 beats per minute
    2. Tachypnea over 29 breaths per minute
    3. Hypotension with systolic Blood Pressure <90 mmHg
    4. Temperature under 35 C (95 F) or over 40 C (104 F)
  4. Diagnostic Changes
    1. Arterial Blood Gas (ABG)
      1. PaO2 <60 mmHg or Oxygen Saturation below 90%
    2. Complete Blood Count (CBC)
      1. White Blood Cell count <4000/mm3 or >13000/mm3
      2. Hematocrit under 30%
    3. Electrolytes
      1. Blood Urea Nitrogen (BUN) over 29 mg/dl
      2. Serum Glucose over 250 mg/dl
      3. Serum Sodium under 130 mEq/L
    4. Chest XRay Changes
      1. Multilobar infiltrates
      2. Infiltrate progression
      3. Pleural Effusion

X. Criteria: Hospitalization Indications in Nursing Home Residents

  1. Assumes that patient is willing to be hospitalized
  2. Indications for hospitalization (2 or more)
    1. Respiratory Rate >30 bpm or 10 bpm over baseline
    2. Oxygen Saturation <90% on room air
    3. Systolic BP <90 mmhg or 20 mm Hg below baseline
    4. Oxygen requirement >3 LPM over baseline
    5. Uncontrolled comorbidity
      1. Uncontrolled Chronic Obstructive Pulmonary Disease
      2. Uncontrolled Congestive Heart Failure
      3. Uncontrolled Diabetes Mellitus
    6. Altered Level of Consciousness
      1. New Somnolence
      2. New or increased agitation
    7. Facility unable to care for patient
      1. Vital Signs every 4 hours
      2. Lab access
      3. Parenteral hydration
      4. Licensed nursing available
  3. References
    1. Hutt (2002) J Fam Pract 51:709-16

XI. Precautions

  1. Bacterial superinfection of Influenza is common
  2. Multi-drug resistance is common in the Nursing Home, especially:
    1. Antibiotic use in the previous 3 months
    2. Hemodialysis or immunosuppresion
  3. Avoid repeating antibiotics prescribed within the last 90 days
  4. MRSA colonization is common in Nursing Homes (Up to 75% in some centers)
  5. Pseudomonas is common in recently hospitalized patients and those with comorbidity
  6. Adverse Drug Reactions and drug interactions are common in Nursing Home residents

XII. Management: Empiric Therapy

  1. Antibiotic course
    1. Continue antibiotics for 7-10 days and
    2. Affebrile and improving for at least 48-72 hours
  2. Additional antibiotic coverage
    1. Aspiration Pneumonia
    2. Legionella coverage
      1. Azithromycin
    3. Influenza management (within first 48 hours)
      1. Oseltamivir (Tamiflu) or Zanamavir and
      2. Cover MRSA for staphycoccal Pneumonia superinfection
  3. Mild to moderate cases: Oral antibiotics
    1. Fluoroquinolone (e.g. Levofloxacin, Moxifloxacin) or
    2. Amoxicillin-clavulanate (Augmentin) and Azithromycin (Zithromax) or
    3. Cephalosporin (e.g. Cefuroxime, Cefpodoxime) and Azithromycin (Zithromax)
  4. Moderate cases: Initial Intramuscular Injections for 48-72 hours followed by oral therapy
    1. Ceftriaxone (Rocephin) IM every 24 hours or
    2. Cefepime (Maxipime) IM every 24 hours
  5. Severe cases requiring hospitalization: Triple antibiotic coverage
    1. Antibiotic 1: Broad-spectrum antibiotic with antipseudomonal coverage
      1. Cefepime or Ceftazidime 2 grams IV every 8 hours or
      2. Imipenem or Meropenem 1 gram IV every 8 hours or
      3. Piperacillin-tazobactam 4.5 grams IV every 6 hours
    2. Antibiotic 2: Gram-Negative and antipseudomonal coverage
      1. Levofloxacin 750 mg every 24 hours or
      2. Ciprofloxacin 400 mg IV every 8 hours or
      3. Aminoglycoside (Gentamicin, Tobramycin, Amikacin)
        1. Exercise caution with Aminoglycoside use to higher renal injury risk and higher mortality
    3. Antibiotic 3: MRSA coverage
      1. Vancomycin or
      2. Linezolid

XIII. Prevention

  1. See Influenza Vaccine
  2. See Pneumococcal Vaccine
  3. Oral care in institutionalized elderly
    1. ToothBrushing for five minutes after each meal
      1. Brush teeth and Tongue dorsum
      2. Brush Palate and mandibular mucosa
      3. Betadine applied to oropharynx if unable to brush
    2. Reduces PneumoniaIncidence and Pneumonia mortality
    3. References
      1. Yoneyama (2002) J Am Geriatr Soc 50:430-3

XIV. Prognosis

  1. Mortality rate over ensuing month: 10-30%
  2. Pneumonia in over 65 years old is responsible for 90% of Pneumonia fatalities

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