Nursing home-acquired pneumonia: a review of risk factors and therapeutic approaches

Abstract

Objective:

To review the risk factors, etiologic profile, treatment approaches, and guidelines for the management of nursing home-acquired pneumonia (NHAP).

Research design and methods:

A search of the current literature was conducted using the MEDLINE and Embase databases. This search, limited to studies performed in humans and published in English between January 1, 1990 and October 31, 2009, included the terms ‘acquired pneumonia’, ‘associated pneumonia’, ‘nursing home’, ‘long-term care’, ‘institution’, and ‘healthcare’.

Results:

Older age, male gender, swallowing difficulty, and inability to take oral medications are all significant risk factors for pneumonia. Medications such as antipsychotics and anticholinergics, histamine receptor blockers and proton pump inhibitors have also been linked to higher risk of pneumonia. The etiology of NHAP overlaps with that of community-acquired pneumonia (CAP), with Streptococcus pneumoniae and Haemophilus influenzae as predominant pathogens in long-term care facilities. In patients who require hospitalization, Chlamydophila pneumoniae, Staphylococcus aureus, and influenza virus have also been identified. In contrast, the etiology of severe NHAP overlaps with that of hospital-acquired pneumonia (HAP), with S. aureus, including methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, and enteric Gram-negative bacilli as important causative pathogens. Therapy is dependent on disease severity and, on the treatment setting. Respiratory fluoroquinolones or β-lactams plus a macrolide are recommended in patients with NHAP. Patients hospitalized with severe NHAP may require triple combination therapy that covers both MRSA and P. aeruginosa. However, there is little evidence of the clinical superiority of one regimen over another, making it challenging to establish guidelines for the treatment of NHAP in the nursing home setting.

Conclusion:

There is a pressing need for clinical trials of antibiotic therapy in nursing home patients that would help establish uniform guidelines to standardize therapy in the nursing home setting.

Key words:

• Nursing home
• Pneumonia
• Treatment
• Scoring

Transparency

Declaration of funding

Support for editorial assistance was provided by Merck. The sponsor did not have any role in the content of this manuscript. The authors accept full responsibility for the contents of this manuscript.

Declaration of financial/other relationships

A.A.E. and P.D. have disclosed no relevant financial relationships. M.S.N. has disclosed that he has received honoraria or consulted for Bayer, Ceragenix, Abbott, Schering-Plough, Merck, Pfizer, Johnson and Johnson and Nektar, and has received grants from Nektar and Bayer. Peer reviewers may receive honoraria from CMRO for their review work. The peer reviewers have disclosed no relevant financial relationships.

Acknowledgments

The authors would like to acknowledge the editorial assistance of Dr Greg Thompson and Dr Ching-Ling Chen in the preparation of this manuscript. Support for this assistance was provided by Merck.