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Practical Tips for Diagnosing and Treating Bacterial Pneumonia in the Nursing Home

      Graphical abstract

      A clinical diagnosis of bacterial pneumonia in nursing home residents most often can be treated with a single oral course of antibiotic therapy targeted toward community-acquired pneumonia pathogens, Ghinwa Dumyati, MD, said at the AMDA — The Society for Post-Acute and Long-Term Care Medicine’s annual conference.
      Dr. Dumyati, an infectious disease specialist, serves as a professor of medicine at the University of Rochester Medical Center and directs the Rochester (NY) Nursing Home Collaborative (http://www.rochesterpatientsafety.com). In formulating pneumonia treatment guidelines (http://bit.ly/2J7dcjf) several years ago for nursing home residents, “we decided we’d treat this population as community-acquired pneumonia (CAP), but we’d also look at the severity of illness and the follow-up,” Dr. Dumyati said. “If patients were not getting better and we’d started with a narrow agent for CAP, then we’d broaden.”
      A major goal, she said, was to reduce the use of quinolones. Cefpodoxime is the recommended first-line agent for uncomplicated bacterial pneumonia with mild to moderate pneumonia symptoms, with amoxicillin/clavulanate as an option if aspiration is suspected. Doxycycline is another first-line alternative — for instance, for patients who are “highly” allergic to beta-lactam antibiotics, she said. Levofloxacin or moxifloxacin are reserved as second-line agents.
      When pneumonia symptoms are severe or fail to respond to initial therapy, intramuscular ceftriaxone and oral doxycycline are recommended — unless there’s a high likelihood of Pseudomonas aeruginosa, in which case levofloxacin is the recommendation. Based on the guidelines and the best available evidence, “this is what we decided to do [in our community],” said Dr. Dumyati.
      The guidelines also recommend a treatment duration of 5 days, provided the patient has been afebrile for 48 to 72 hours, is breathing without supplemental oxygen, and has no more than one symptom of clinical instability (heart rate > 100 beats/minute, respiratory rate >24 breaths/minute, and systolic blood pressure of 90 mm Hg or less). “We’ve significantly reduced antibiotic use in [our] nursing homes [overall] with just going to 5 days’ duration for bacterial pneumonia if patients improve, because it’s such a common infection,” she said.
      A diagnosis of pneumonia generally requires a combination of respiratory and constitutional symptoms. Mobile chest X-rays are not only hard to obtain in nursing home residents, but the images have relatively poor quality, and radiologists disagree frequently on the presence or absence of infiltrates, pleural effusions, and other findings, she said. Also, previous films are often unavailable for comparison, which can be a problem because many older adults have abnormal chest X-rays. Given these challenges, “as a group in Rochester, we decided that we will not look at the chest X-ray alone,” she said.
      Differentiating bacterial from nonbacterial etiologies is important, though it still is “not easy,” Dr. Dumyati said. A white blood cell count of 14,000 cell/mm3 or greater, or left shift, is suggestive of a bacterial infection. But with respect to other tests, there are no clear winners. Serum procalcitonin levels can be helpful in differentiating bacterial and viral respiratory infections, for instance, but the test is “expensive, and there’s a delay in results,” she said. She noted that in Rochester, “there’s more use of it in the hospital.”
      Sputum cultures may yield the culprit pathogen, but the cultures are “usually colonized with multi-drug-resistant organisms” and tend not be used in many nursing homes. “It’s a dilemma,” she said. “If the sputum is contaminated with MRSA [methicillin-resistant Staphylococcus aureus], you might treat for MRSA when it’s not really the [pneumonia-causing] pathogen.”
      Dr. Dumyati also said she generally doesn’t advise ordering a full respiratory viral panel “unless there is an outbreak,” in which case she would order the panel for a couple of residents. More often, “we get a viral PCR [polymerase chain reaction] for flu and respiratory syncytial virus,” which can be helpful and “is much cheaper,” she said, noting that she pushes for routine 48-hour post–antibiotic initiation reviews.
      The Rochester treatment guidelines do not address MRSA because it’s preferred overall that MRSA pneumonia be treated in the hospital, she noted.
      Empiric treatment of pneumonia should consider risk factors for multi-drug-resistant pathogens, such as antibiotics in the prior 90 days, recent hospitalization, poor functional status, and immune suppression, Dr. Dumyati said. In general, underlying resident characteristics are a more important risk for multi-drug-resistant organisms than exposure to a specific health care facility, she said.
      Christine Kilgore is a freelance writer in Falls Church, VA.