Nursing Home Acquired Pneumonia

Dr. AVI ISHAAYAResource Center Medical Director

It is estimated that the number of older people who will require a SNF will reach 5.3 million by 2030

NHAP will approach 1.9 M episodes annually

.3-2.3 per 1000 resident care days

Definition Inflammation of the lung

parenchyma

Consolidation of the affected part and a filling of the alveolar air spaces with exudate, inflammatory cells, and fibrin

Patterns of Pneumonia Lobar

Focal or nonsegmental One or multiple lobes Larger bronchi remain patent

Bronchopneumonia Multifocal or lobular Patchy appearance with peribronchial thickening and poorly

defined air-space opacities Usually very destructive (progresses to abcessess,

pneumatoceles, pulmonary gangrene) Inflammation of large airways and lobular involvement

Interstitial pneumonia Focal or diffuse Results from edema and inflammatory cellular infiltrate Could be insidious or rapidly progressive Reticular or reticulonodular pattern

BackgroundNursing home-acquired pneumonia (NHAP) is defined as pneumonia occurring in a resident of a chronic care facility or nursing home.

Significant cause of mortality and morbidity

Less likely to present with classic signs and symptoms of the typical presentation Often present with delirium and altered

mental status

Clinical assessment Hampered by impaired

communication Non-localization symptoms Limited access to diagnostic tests

Conflicting interpretations CXR with chronic changes Sputum contaminated

Pathophysiology NHAP may result when a patient

aspirated oropharyngeal contents into one or more lung segments or lobes

NHAP may also occur if a distant focus of infection hematogenously disseminated to the lungs.

Hematogenously acquired pneumonia

Epidemiology NHAP is one of the most common causes

of infection in chronic care facilities. NHAP is one of the most significant

infection-related causes of mortality and morbidity in such facilities.

NHAP primarily afflicts elderly individuals. Increases mortality Over 65, 6th leading cause of death in 2005

No predominate age/sex African Americans males 14% more likely

to die than white males

Patients may complain of fever, cough, chest pain, or rapid respiration.

Patients with chronic bronchitis, or have a history of CNS, esophageal disease, or decreased gag reflex that predisposes them to recurrent aspiration are more prone to developing pneumonias.

http://upload.wikimedia.org/wikipedia/commons/2/20/Symptoms_of_pneumonia.svg

symptoms Cough, productive Rust colored (S. Pneumoniae) Currant jelly (Klebsiella) Foul smelling or bad tasting sputum (anerobic)

Chest pain, dyspnea, hemoptysis Decreased exercise tolerance, abdominal pain,

pleuritis Fevers, rigors, shaking chills, malaise Myalgias, headaches, nausea, vomiting, diarrhea Altered level of consciousness

Hyperthermia (>38C) or hypothermia (<35C)

Tachypnea (<18) Use of accessory muscles Tachycardia (>100) or

bradycardia (<60) Central cyanosis Altered mental status Exam

Rales, ronchi, egophony, dull to percussion, tracheal deviation

Physical exam

Aspiration risk Alcoholism Decreased host defenses Impaired swallowing Sedative hypnotic drugs Altered mental status Dysphagia GERD Seizure disorders

Classically in the recumbent patients (posterior segments of the upper lobes) and the upright patients (basal segments of the lower lobes)

Aspiration pneumonia Development of an infectious infiltrate in patients

who are at increased risk of oropharyngeal aspiration Decreased ability to clear secretions

Poor cough or gag Impaired swallowing mechanism Impaired ciliary transport (smokers) Increased volume of secretions Increased bacterial burden Other comorbidities (achalasia, GERD)

Critically ill Gastroparesis/dysmotility Impaired cough/gag Immune impairment

Causes The most common pathogens that cause

NHAP and are S pneumoniae, H influenzae, S. aureus, Enterococcus, , Pseudomonas, Klebsiella, E. coli, Moraxella catarrhalis, Acinetobacter

Atypical organisms that cause NHAP are Mycoplasma pneumoniae, Legionella, and C pneumoniae.

Differentiation between community acquired vs. healthcare vs hospital acquired pneumonia is critical

Laboratory Studies

Blood Cultures Obtain blood cultures from all patients

with CAP and NHAP CBC count Sputum staining and culture Multiple pathogens are not a

feature of NHAP.

Imaging Studies Chest radiography is the

primary tool to differentiate the mimics of pneumonia from NHAP.

Lobar S pneumoniae, K pneumoniae, L

pneumophilia Bronchopneumonia

S aureus, P aeruginosa, H influenzae

Medical Care

Medication Summary The goals of pharmacotherapy

are to reduce morbidity, to eradicate the infection, and to prevent complications.

Antibiotics Levofloxacin (Levaquin)

Second-generation quinolone Highly active against gram-negative and gram-positive

organisms Cetriazone (Rocephin)

Third-generation cephalosporin Higher efficacy against resistant organisms

Vancomycin Bactericidal; inhibits cell wall and RNA synthesis

Cefepime (Maxipime) Fourth-generation cephalosporin with good gram negative

coverage

Empiric therapy At risk for Pseudomonas

Aminoglycoside, beta lactam Quinolone Aztreonam

Aspiration pneumonia Zosyn Imipenam Clinamycin or flagyl +quinolone plus Rocephin

MRSA Vancomycin or Linezolid Clindamycin, Bactrim, Gentamicin, Cipro, Rifampin

Supportive measures Analgesia and antipyretics CPT IV fluids Monitoring and pulse oxymetry Positioning of the patient for

aspiration Respiratory therapy (including

Mucomyst) Suctioning Ventilation

Clinical response Evaluate within 48-72 hours

Improvement should be noted If not, consider resistance or development

of empyema or abcess Consider other differential diagnosis

Non-infectious (malignancy, inflammatory, CHF)

Cough resolves within 8 days Crackles clear within 3 weeks Chest xr usually clears within 4 weeks in

those <50 and up to 12 weeks in older

Further Inpatient Care Transfer patients to an acute care

hospital for reasons other than antibiotic administration. Clinically unstable Critical diagnostic testing not

available Comfort measures cannot be ensured Specific infection control measures

are not available Pulmonary toilet Cardiac adjustment

Guidelines for hospitalizing NHAP Presence of any two symptoms

02 saturation <90% RA SBP<90 or 20 <baseline RR>30 or 10>baseline Increase 02 by 3L more Uncontrolled COPD, CHF, DM ALOC New or increased agitation

Transfer to hospital if the facility cannot provide: VS every 4 hours Lab access Parenteral hydration Two licensed nurses/shift

Inpatient & Outpatient Medications Physicians typically treat patients

with NHAP for 2 weeks with antibiotics.

If pulmonary infiltrates do not resolve after 2 weeks, the physician should initiate further diagnostic studies to determine the cause.

Transfer back to SNF Make certain that the patient’s

pneumonia is resolving and they are clinically stabilized before returning them back to the chronic care facility.

Deterrence/Prevention

Keep patients who are predisposed to aspiration pneumonia in a semi upright position at night.

Take care when feeding patients with gag reflex or neurologic disorder

Isolation Influenza vaccination (reduce hospitalization by 47-

57%) Pneumococcal vaccine (anyone >65) Hand washing Nutritional support Hydration Reducing bacterial colonization of the oropharynx

Complications Empyema Pleural effusions Lung collapse Bronchospasm Bronchiectasis Necrotizing pneumonia Pulmonary abcess ARDS Ventilator dependence death

Prognosis Depends on host immune system, preexisting

cardiopulmonary reserve status, extent of lobar involvement resulting from pneumonia.

The recurrence of pneumonia is not the result of antibiotic failure but the result of the underlying predisposing factors to aspiration.

Advanced age, aggressive organisms (Klebsiella, Legionella, S pneumoniae),comorbidity, respiratory failure, neutropenia, and features of sepsis, all increase mortality and morbidity

ALL INFORMATION WAS TAKEN FROM MEDSCAPE

Cunha MD, Burke A. “Nursing Home Acquired Pneumonia”. Medscape.

And Management of Pneumonia in the Nursing Home, Chest 2010 138(6):1480-1485