II. Epidemiology

  1. Pneumonia is second most common Nursing Home acquired infection
    1. Incidence: 1 per 1000 patient-days

III. Pathophysiology

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

IV. Risk Factors

  1. Community acquired Pneumonia (CAP) - uncomplicated approach
    1. Not in hospital or Nursing Home within prior 14 days
  2. Health-care associated Pneumonia (HCAP) - Atypical, multi-drug resistant (e.g. MRSA, DRSP, gram neg)
    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 (Streptococcus Pneumoniae)
  2. Common (approach one quarter to one third of isolates in some centers)
    1. Staphylococcal Pneumonia (associated with most serious cases, includes MRSA)
    2. Haemophilus Influenzae Pneumonia
    3. Chlamydophila pneumoniae (Chlamydia pneumoniae or TWAR, more common in Nursing Home)
  3. Less common (10% or less of isolates)
    1. Viral Pneumonia (especially Influenza A Virus, 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. Findings: Probable Pneumonia in elderly (>1)

  1. Precautions
    1. Pneumonia may present atypically in older patients (especially in Nursing Home)
      1. See Signs of Infection in the Nursing Home Resident
    2. Even Nursing Home patients with Pneumonia have at least 1 respiratory symptom (92% cases)
      1. Mehr (2001) J Fam Pract 50(11): 931-7 [PubMed]
  2. New or worsening cough
  3. Newly Purulent Sputum
  4. Respiratory Rate >25 breaths per minute (bpm)
  5. Tachycardia
  6. New or worsening Hypoxia
  7. Pleuritic Chest Pain
  8. Cognitive or functional decline
  9. Change in Respiratory Exam (e.g. rales or rhonchi)
  10. 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
  11. Oxygen Saturation (O2 Sat)
    1. O2 Sat <94% in Nursing Home residents with signs of infection predicts Pneumonia
      1. Test Sensitivity: 80%
      2. Test Specificity: 91%
      3. Kaye (2002) Am J Med Sci 324(5): 237-42 [PubMed]

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 (Test Sensitivity 74%, Test Specificity 97-99%)
    1. Pneumococcal urine antigen test
    2. Legionella pneumophila urine antigen test
  5. Blood Culture indications
    1. Intensive care unit admission
    2. Cavitary lung infiltrates
    3. Leukopenia
    4. Active Alcohol Abuse
    5. Chronic severe liver disease
    6. Asplenia
    7. Pleural Effusion

IX. Criteria: Poor prognostic signs favoring hospitalization in Elderly

  1. Nursing Home resident
    1. SOAR Score is most predictive of 30 day mortality for Pneumonia in Nursing Home residents
    2. El-Solh (2010) Chest 138(6): 1371-6 [PubMed]
  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. Most nursing patients who meet stable criteria may be safely treated at Nursing Home
    1. Loeb (2006) JAMA 295(21): 2503-10 [PubMed]
    2. Kruse (2004) Med Care 42(9): 860-70 [PubMed]
  2. Determine if patient is willing to be hospitalized
    1. Review Advanced Directives, POLST form
    2. Confer with patient or their Durable Power of Attorney
  3. Indications for hospitalization (2 or more)
    1. Respiratory Rate >30 bpm or 10 bpm over baseline
    2. Heart Rate >100/min
    3. Oxygen Saturation <90% on room air
    4. Systolic BP <90 mmHg or 20 mm Hg below baseline
    5. Oxygen requirement >3 LPM over baseline
    6. Uncontrolled comorbidity
      1. Uncontrolled Chronic Obstructive Pulmonary Disease
      2. Uncontrolled Congestive Heart Failure
      3. Uncontrolled Diabetes Mellitus
    7. Altered Level of Consciousness
      1. New Somnolence
      2. New or increased agitation
    8. Facility unable to care for patient
      1. Vital Signs every 4 hours
      2. Lab access (not typically needed in uncomplicated cases)
      3. Parenteral hydration (patient unable to eat and drink)
      4. Licensed nursing available
  4. References
    1. Hutt (2002) J Fam Pract 51:709-16 [PubMed]

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. Severe illness (Mechanical Ventilation, ICU admission, failure to improve after 72 hours)
    4. Airway Foreign Body
    5. Chronic wounds
    6. Very low functional status
  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
  7. Do not delay antibiotics after diagnosis
    1. Lower 30 day mortality when antibiotics are started within 4 hours of hospital diagnosis
    2. Houck (2004) Arch Intern Med 164(6): 637-44 [PubMed]

XII. Management: Empiric Therapy

  1. Antibiotic course
    1. Continue antibiotics for 7-10 days (7-8 days is sufficient in most cases) 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 above
    1. Ceftriaxone (Rocephin) IM every 24 hours or
    2. Cefepime (Maxipime) IM every 24 hours
  5. Hospitalized cases: Moderate
    1. High risk patients for multi-drug resistance (see above) should be treated as below
    2. Nursing Home residents
      1. May be initially treated as community acquired Pneumonia
      2. Start with parenteral antibiotics with early transition to oral antibiotics
      3. Transition to broader coverage based if poor response to antibiotics at 72 hours
  6. Hospitalized cases: Severe (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
    1. Give both Prevnar and Pneumovax to over age 65 years
  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 [PubMed]

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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