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e convened a multidisciplinary, multispecialty panel to develop comprehensive evidence and consensus-based guidelines for managing nurs- ing home-acquired pneumonia. The panel began with explicit criteria for process of care quality meas- ures, performed a comprehensive review of the English-language literature, evaluated the quality of the evidence, and drafted a set of proposed guide- lines. The panel reviewed the draft, an annotated bibliography, and data from a study of 30-day sur- vival from nursing home-acquired pneumonia, and then participated in an all-day meeting in January
- Using a modified Delphi process, the panel refined the guidelines and developed a care path- way. The guidelines recommend a comprehensive approach, including immunization of staff and resi- dents, and communication between nursing staff and the attending physician within 2 hours of symp- tom onset. Probable pneumonia was defined. An algorithm was delineated for assessing the patient’s wishes for hospitalization and aggressive care, and deciding on hospitalization based on the severity of the illness as well as the capacity of the nursing home to provide acute care. The timing and extent of evaluation in a nursing home relative to the rapid initiation of antibiotics should depend on whether the patient has any unstable vital signs. An antibiot- ic covering Streptococcus pneumoniae , Haemophilus influenzae , common gram-negative rods, and Staphylococcus aureus should be given for 10 to 14 days, orally if the patient is able to take medications by mouth. ■ K E Y W O R D S Pneumonia; nursing home; long-term care. ( J Fam Pract 2002; 51:xxx–xxx )
“Keep an open mind toward pneumonia. Our grand- children will be interested and are likely to have as many differences of opinion as we have.” —William Osler, ca 1900
Mortality from nursing home-acquired pneumonia is as high as 44%,^1 and nearly a third of those who sur- vive suffer significant functional decline.^2 Nursing home-acquired pneumonia is an entity distinct from community-acquired pneumonia in the elderly and nosocomial pneumonia. Older adults in nursing homes are more likely than community-dwelling
older persons, but less likely than hospitalized eld- erly patients, to be colonized with gram-negative rods and pathogens with multiple antibiotic resist- ance.3–8^ Inappropriate use of antibiotics in long-term care facilities contributes significantly to the growing problem of antibiotic resistance generally.^9 In addi- tion, most nursing home residents are cognitively impaired, immunocompromised, have multiple func- tional deficits, or have dysphagia, which further con- tributes to their vulnerability.^10 In recent work^11 with a national nursing home sample, we showed that high quality care, including appropriate antibiotic use, hospitalization when indi- cated, and rapid identification of and response to respiratory symptoms, is associated with improved survival of residents who acquire pneumonia. Unfortunately, we also found that many of the 58 nursing homes in our study provided less than ade- quate care; for example, only 31% of residents received antibiotics within one 8-hour shift of symp- tom onset.^11 Convincing evidence indicates that treatment guidelines improve pneumonia outcomes in acute care settings,12,13^ and preliminary indications suggest that they may have a positive impact on processes of care in nursing facilities.^14 Three guidelines on diag- nosis and treatment of infections in nursing homes have been published in the last 2 years,15–17^ but these guidelines are not specific to pneumonia. The only guideline specific to nursing home-acquired pneu- monia used current community practice in 1 metro- politan area to define guidelines for antibiotic use.^18 The outline specifically does not address issues of diagnostic work-up, decision to hospitalize, or timing of initial antibiotic treatment. We therefore convened a national panel of experts in infectious disease, phar- macology, pulmonology, geriatrics, and nursing to develop comprehensive evidence-based guidelines for management of nursing home-acquired pneu-
Evidence-based guidelines for management
of nursing home-acquired pneumonia
EVELYN HUTT, MD; AND ANDREW M. KRAMER, MD
Denver, Colorado
From the Center on Aging Research Section, University of Colorado Health Sciences Center, Denver, CO. This work was funded by Merck & Co., Inc. through the Quality Care Research Fund and the Academic Medicine and Managed Care Forum sponsored by Aetna. The contract number is Merck PN9910 046. Address reprint requests to Evelyn Hutt, MD, Assistant Professor, Center on Aging Research Section, University of Colorado Health Sciences Center, Campus Box B179, 3570 East 12th Avenue, Suite 300, Denver, CO 80206. E-mail: Evelyn.Hutt@uchsc.edu.
S P E C I A L A R T I C L E
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monia. The guidelines address immunization, infec- tion control, timing and thoroughness of nurse and physician evaluation of lower respiratory tract infec- tions, criteria for hospitalization, and criteria for antibiotic spectrum, timing, route, and duration.
G U I D E L I N E
D E V E L O P M E N T
LITERATURE REVIEW
A comprehensive literature review was undertaken using Ovid (http://www.ovid.com/) and the “explode” version of each of the following key words: nursing homes, long-term care facilities, skilled nursing facilities, and pneumonia, to search MEDLINE from 1975 through 2000. Only studies published in English and germane to nursing home residents in the United States and Canada were examined. Results of the search were augmented by a local multidisciplinary team, consisting of faculty in geriatric studies, infectious disease, pulmonology, and pharmacology at the University of Colorado Health Sciences Center, an internist who practices exclusively in nursing homes, and a nursing home nurse consultant. This team developed explicit crite- ria for nursing home-acquired pneumonia processes of care, as described previously.^11
CONSTRUCTION OF DRAFT GUIDELINES Working with the explicit criteria developed by the local team, the data from our retrospective study of process of care and survival, and the published liter- ature on nursing home-acquired pneumonia, we drafted an initial set of comprehensive guidelines. We then graded the recommendations according to a standard system for defining quality, with 3 cate- gories for recommendation strength (A, good evi- dence; B, moderate evidence; C, poor evidence) and
3 grades for quality of evidence (I, at least 1 proper- ly randomized, controlled trial; II, at least 1 well- designed clinical trial without randomization from cohort or case-controlled analytic studies, multiple time series, or dramatic results in uncontrolled experiments; III, opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees).^19 Published Canadian and American guidelines for treatment of communi- ty-acquired and nosocomial pneumonia formed a template for the antibiotic recommendations.20,
MODIFIED DELPHI PROCESS A multidisciplinary, multispecialty panel was recruit- ed from nationally recognized experts in nursing home-acquired pneumonia, geriatric and infectious disease pharmacology, pneumonia treatment guide- line development, and nursing home nurses (see Appendix). Panel members received an annotated version of the draft guidelines with a bibliography and the questionnaire described below. A table of the activity spectrum of currently available antibi- otics, a table summarizing published reports on the microbiology of nursing home-acquired pneumonia (see Table 1), and tables summarizing our retrospec- tive study of care processes in nursing homes and 30-day survival^11 were also included in that mailing. The questionnaire asked whether each proposed guideline was clear, specific, feasible, measurable, and commensurate with his or her usual practice. Panelists were also asked to score each proposed guideline on its importance in determining the out- come of a nursing home-acquired pneumonia episode on a 5-point Likert scale, with 1 being not important and 5 being extremely important. Suggestions for substantive changes were elicited. The questionnaires were returned 2 weeks before an
TA B L E 1 Nursing home pneumonia etiology according to studies using verified sputum or blood culture Streptococcus Staphylococcus Gram-negativeHaemophilus Multiple Study N Year pneumoniae (%) aureus (%) rods (%) influenzae (%) Anerobes (%) organisms (%)* Alvarez 3 414 1988 32 — 29 — — 22% Peterson 4 123 1988 10 3 21 9 — — Marrie 5 131 1989 16 13 13 — 4 — Hirata-Davis^6 50 1991 12 4 15 10 — — Drinka^7 17 1994 30 6 — 25 — (Atypicals = 0) Marrie and Blanchard^51 71 1997 2/5 — 2/5 — — — Pick^8 (98 Group B aspirations) 1996 3 38 6 3 — streptococci 43% *Expectorated sputum with > 25 white blood cells per low-power field and < 10 squamous epithelial cells per low-power field.
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the revised guidelines and care pathway was sent to the panelists for further review and comment after the meeting. At that time, they were asked to rate each guideline on how confident they were that the recommendation should be included as part of the proposed guidelines using a 5-point Likert scale, with 1 denoting not confident and 5 denoting very confident. Because the lowest mean confidence rat- ing was 3.4 after this iterative process, no guidelines were dropped from the set agreed upon at the meet- ing. Final revisions were made to the guidelines and their respective strength-and-quality-of-evidence grades, and approved by the panel.
R E C O M M E N D A T I O N S
Each of the 25 guidelines is presented below. The strength and quality of evidence rating and panelists’ mean confidence score are shown in parentheses.
PREVENTION
- Residents should be vaccinated against Streptococcus pneumoniae at admission unless there is documentation of vaccination within 5 years preceding admission or they were allergic to previous pneumococcal vaccine. (A/I/4.7)22–
- Residents should be vaccinated against influenza by December of each year if they are not allergic to eggs or previous influenza vaccine. Residents admitted between December and March should be vaccinated if not already immunized for the current influenza season, and they are not aller- gic as described above. (A/I/5.0)27,
- The nursing facility should provide and strongly recommend immunization against influenza for all employees by December of each year if the employee is not allergic to eggs or previous vac- cine. (A/I/4.9)29,
INITIAL EVALUATION OF RESIDENTS WITH RESPIRATORY IMPAIRMENT Once a resident has been noted to have a significant change in respiratory status, the clinician should use the care pathway outlined in Figure 1. The panel believed that nurse practitioners and physician assis- tants with appropriate supervision could substitute for physician care in all pathway activities. Guideline recommendations 4 through 8 address the rapid recognition and physician notification of serious res- piratory symptoms:
- Physicians with nursing home residents should be available or have cross-coverage by pager 24 hours/day, 7 days/week. (Absent/Absent/4.8)
- Nursing home staff should page the physician within 1 hour when a resident is noted to have any 2 of the following signs or symptoms: new
or worsening cough; increased or newly purulent sputum; decline in cognitive, physical, or func- tional status; fever; hypothermia; dyspnea; tachypnea; chest pain; or new or worsening hypoxemia. (Absent/Absent/4.3)
- Nurse evaluation at symptom onset should include, at least, vital signs (temperature, pulse rate, respiratory rate, and blood pressure) and oxygen saturation if a pulse oximeter is available in the facility. (Absent/Absent/4.5)
- When notified as in guideline #5, the physician should call back within 1 hour. (Absent/Absent/4.3)
- If the nurse does not hear back from the physi- cian within 1 hour, he or she should notify the director of nurses or designee. The nurse and the director of nurses should agree on a plan to noti- fy the medical director or designee and ask him or her to assume care of that episode until the medical director can contact the attending physi- cian. (Absent/Absent/3.5) Once the physician has been notified, he or she must decide whether pneumonia is a leading con- sideration in the diagnosis of the reported change.
- The physician and nursing home staff should concur that pneumonia is a leading consideration in the diagnosis of the change noted in guideline #5 above, if the patient has 2 or more of the fol- lowing signs or symptoms: new or worsening cough; newly purulent sputum; fever of 100.5°F or 2°F more than baseline; hypothermia < 96°F; dyspnea; respiratory rate > 25 breaths per minute; tachycardia; new or worse hypoxemia; pleuritic chest pain; a decline in cognitive or functional status; or new rales or rhonchi on chest examination. Such patients will be referred to in the remainder of the guidelines as having “probable pneumonia.” (C/III/4.1)5,
VENUE OF CARE Once pneumonia is considered likely, the physician must decide whether to hospitalize the resident. Because nursing home-acquired pneumonia is fre- quently the terminal event of a long and debilitating illness, this decision is especially important.
- The patient’s desire for hospitalization and aggressive care should be assessed directly if possible, or by chart review or discussion with the patient’s health care proxy. Patients with prior orders for no hospitalization or who refuse hos- pitalization (personally or by proxy) should not be hospitalized. (Absent/Absent/4.8)^32 For patients willing to be hospitalized, the panel sug- gested categorization into 1 of 3 groups: patients whose severity of illness mandates hospitalization;
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patients whose severity of illness is such that the nursing home’s capac- ity to deliver acute care should be considered; and patients so stable that treatment in the nursing home is preferable. This set of recommenda- tions is based on 2 retrospective series which suggest that only patients with elevated respiratory rates benefit from hospitalization^2 and that patients hospitalized according to criteria similar to these tended to have better survival.^11 These recommendations are mod- eled after Fine’s prediction rule to identify low-risk patients with com- munity-acquired pneumonia,^33 and take into account the mortality pre- diction model of Naughton and coworkers 34 for nursing home- acquired pneumonia.
- Patients with 2 or more of the following symptoms should be hospitalized (C/III/4.1)2,11:
- Oxygen saturation < 90% on room air at sea level
- Systolic blood pressure < 90 mm Hg or 20 mm Hg less than baseline
- Respiratory rate > 30 breaths per minute or 10 breaths per minute more than baseline
- Requiring 3 liters per minute O 2 more than baseline
- Uncontrolled chronic obstructive pulmonary disease, congestive heart failure, or diabetes mellitus
- Unarousable if previously conscious
- New or increased agitation.
- If the nursing home cannot provide vital sign assessment every 4 hours, laboratory access, par- enteral hydration, and 2 licensed nurses per shift in the facility, serious consideration should be given to hospitalizing patients with any one of the above. (C/III/4.1)11,35,
- Patients with none of the above should be treat- ed in the nursing home unless the patient or proxy insists on hospitalization. (B/II/4.5)2,11,33,
EVALUATING AND MONITORING PATIENTS WHO REMAIN IN NURSING HOMES
- Nurse evaluation each shift should include, at least, vital signs with measured respiratory rate and oxygen saturation until symptoms resolve. (C/III/4.5)16,17,
Although a study published by Mehr and col- leagues^38 after the panel proceedings suggested that patients with multiple signs and symptoms of nurs- ing home-acquired pneumonia are so likely to have an infiltrate on chest x-ray that treating without first obtaining an x-ray may be acceptable, the panel recommended that:
- Patients with probable pneumonia should have a chest x-ray. (C/III/4.2)15,
- Patients with probable pneumonia should be eval- uated in person by the physician, ideally within 24 hours and certainly within 72 hours. (Absent/Absent/4.5)
- Because of the issue of antibiotic resistance, and not because of anticipated direct patient benefit, patients for whom antibiotics are ordered should have 1 blood culture drawn if this can be accom- plished without delaying initiation of antibiotics longer than 1 hour. (C/III/3.4)37, The panel did not recommend sputum Gram’s stain and culture even though 2 recent guidelines on eval- uating infection in long-term care facilities did.15,
TA B L E 2 Key recommendations
Strength/quality Guideline of evidence 1, 2, 3: Vaccinate staff and residents against influenza and residents againstStreptococcus pneumoniae. A/I 4, 5, 6, 7, 8: Nursing assessment of change in condition should include a full set of vital signs with oxygen saturation. Initial communication with the physician should be completed within 2 hours of symptom onset. Absent 9: Probable pneumonia is defined as 2 or more of the following: new or worsening cough; newly purulent sputum; temperature > 100.5°F, < 96°F, or 2°F more than baseline; respiratory rate > 25 breaths per minute, tachycardia; new or worsening hypoxia; pleuritic chest pain; decline in cognitive or functional status; physical findings on chest examination such as rales or rhonchi. C/III 10: Patient’s desire for hospitalization and aggressive care should be assessed at the onset of the episode and directly with the patient, if possible. Absent 11, 12, 13: The decision to hospitalize should be based on a combination of vital sign criteria, active comorbidity, and nursing home capabilities. C/III 23: The antibiotic chosen as empiric therapy should cover S pneumoniae,Haemophilus influenzae, common gram-negative rods, andStaphylococcus aureus. B/II 25: Use oral antibiotics if the patient can take oral medication. A/I
Recommendations were graded according to a standard system,^19 with 3 categories for recommendation strength (A, good evidence; B, moderate evidence; C, poor evidence) and 3 grades for quality of evidence (I, at least 1 properly randomized, controlled trial; II, at least 1 well-designed clinical trial without randomization from cohort or case -controlled analytic studies, multiple time series, or dramatic results in uncontrolled experiments; III, opinions of respected authorities based on clinical experience, descriptive studies, or reports of expert committees).
management program for antibiotics and other antiinfective agents. N Engl J Med 1998; 338:232–8.
- Dempsey CL. Nursing home-acquired pneumonia: outcomes from a clinical process improvement program. Pharmacotherapy 1995; 15:33S–38S.
- Naughton BJ, Mylotte JM, Ramadan F, Karuza J, Priore RL. Antibiotic use, hospital admissions and mortality before and after implementing guidelines for nursing home-acquired pneumonia. J Am Geriatr Soc 2001; 49:1020–4.
- Bentley DW, Bradley S, High K, Schoenbaum S, Taler G, Yoshikawa TT. Practice guideline for evaluation of fever and infec- tion in long-term care facilities. J Am Geriatr Soc 2001; 49:210–22.
- Nicolle LE, Bentley DW, Garibaldi R, Neuhaus E, Smith PW. Antimicrobial use in long-term care facilities. Infect Control Hosp Epidemiol 2000; 21:537–45.
- Loeb M, Bentley DW, Bradley S, et al. Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference. Infec Control Hosp Epidemiol 2001; 22:120–4.
- Naughton B, Mylotte JM. Treatment guideline for nursing home- acquired pneumonia based on community practice. J Am Geriatr Soc 2000; 48:82–8.
- Gross PA, Swenson DL, Dellinger EP, et al. Purpose of quality stan- dards for infectious diseases. Clin Infect Dis 1994; 18:421.
- Niederman MS, Bass JB, Campbell GD, et al. Guidelines for the ini- tial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. Am Rev Respir Dis 1993; 148:1418–26.
- Campbell GD, Niederman MS, Broughton WA, et al. Hospital- acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies. Am J Respir Crit Care Med 1995; 153:1711–25.
- Fine MJ, Smith MA, Carson CA, et al. Efficacy of pneumococcal vaccination in adults: a meta-analysis of randomized controlled tri- als. Arch Intern Med 1994; 154:2666–77.
- Ortqvist A, Hedlund J, Burman L, et al. Randomised trial of 23- valent pneumococcal capsular polysaccharide vaccine in preven- tion of pneumonia in middle-aged and elderly people. Lancet 1998; 351:399–403.
- Koivula I, Sten M, Leinonen M, Makela PH. Clinical efficacy of pneumococcal vaccine in the elderly: a randomized, single-blind population-based trial. Am J Med 1997; 103:281–90.
- Quick RE, Hoge CW, Hamilton DJ, Whitney CJ, Borges M, Kobayashi JM. Underutilization of pneumococcal vaccine in nurs- ing homes in Washington state: report of a serotype-specific out- break and a survey. Am J Med 1993; 94:149–52.
- Nuorti JP, Butlere JC, Crutcher JM, et al. An outbreak of multidrug- resistant pneumococcal pneumonia and bacteremia among unvac- cinated nursing home residents. N Engl J Med 1998; 338:1861–8.
- Loeb M, McGeer A, McArthur M, Walter S, Simor AE. Risk factors for pneumonia and other lower respiratory tract infections in eld- erly residents of long-term care facilities. Arch Intern Med 1999; 159:2058–64.
- Gross PA, Hermogenes AW, Sacks HS, Lau J, Levandowski RA. The efficacy of influenza vaccine in elderly persons. Ann Intern Med 1995; 123:518–27.
- Potter J, Stott DJ, Roberts MA, et al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. J Infect Dis 1997; 175:1–6.
- Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vac- cination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 2000; 355:93–7.
- McGeer A, Campbell B, Emori TG, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control 1991; 19:1–7.
- Mehr DR. Nursing home acquired pneumonia: how and where to treat? J Am Board Fam Pract 1997; 10:168–70.
- Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336:243–50.
- Naughton BJ, Mylotte JM, Tayara A. Outcome of nursing home- acquired pneumonia: derivation and application of a practical model to predict 30 day mortality. J Am Geriatr Soc 2000; 48:1292–9.
- Li J, Birkhead GS, Strogatz DS, Coles FB. Impact of institution size, staffing patterns, and infection control practices on communicable disease outbreaks in New York state nursing homes. Am J
interact in the care of nursing home residents, a uniquely frail and vulnerable population. Evidence from our work and others11,13^ suggests that only a comprehensive approach will, over time, improve the outcome of this important illness. The guidelines have 2 important limitations. They have not yet been approved by any official profes- sional society, nor have they been tested prospec- tively. Prospective testing is required to validate whether, in fact, the proposed guidelines can be implemented and, if implemented, they will improve mortality, function, cost of care, rehospitalization rates, and community discharge rates. We chose not to seek official approval of the guidelines until they can be proven effective. We believe the proposed guidelines can and should be used to the fullest extent possible by nurs- ing homes and physicians who practice there, because the combination of evidence and consensus is strong. Nursing home-acquired pneumonia causes excess mortality and functional loss. The proposed guidelines, based as they are in empiric evidence, common sense, and expert consensus, offer some hope of decreasing rehospitalization and cost, miti- gating functional decline, and improving survival.
A C K N O W L E D G M E N T S · The authors acknowledge the members of the panel for their thoughtful participation and willingness to review multiple drafts of the guidelines and manuscript; Steven Teutsch, MD, Senior Director, Outcomes Research and Management, Merck & Co., Inc., for his support and advice; Lisa Lampinen for manuscript preparation; and Merck & Co., Inc., for funding.
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- Troy CJ, Peeling RW, Ellis AG, et al. Chlamydia pneumoniae as a new source of infectious outbreaks in nursing homes. JAMA 1997; 277:1214–8. A P P E N D I X : PA N E L M E M B E R S · Diana Blake, RN, Western Hills Health Care Center, Lakewood, CO; JoAnn G. Congdon, RN, PhD, University of Colorado HSC, Denver, CO; Douglas Fish, PharmD, University of Colorado, Denver, CO; Evelyn Hutt, MD, University of Colorado HSC, Denver, CO; Denise Iskra, RN, Life Care of Westminster, Westminster, CO; Andrew M. Kramer, MD, University of Colorado, Denver, CO; Thomas J. Marrie, MD, University of Alberta, Edmonton, Alberta, Canada; Mark Loeb, MD, McMaster University, Hamilton, Ontario, Canada; Wayne C. McCormick, MD, MPH, Harborview Medical Center, Seattle, WA; Annette M. Medina-Walpole, MD, University of Rochester, Rochester, NY; David R. Mehr, MD, MS, University of Missouri–Columbia, Columbia, MO; Michael S. Niederman, MD, State University of New York at Stony Brook, Mineola, NY; Phillip K. Peterson, MD, University of Minnesota, Minneapolis, MN; J. Mark Ruscin, PharmD, University of Colorado, Denver, CO; Thomas T. Yoshikawa, MD, Charles Drew University, Los Angeles, CA.
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