Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention

doi:10.1016/S0002-9343(98)00262-9

The American Journal of Medicine

Volume 105, Issue 4, October 1998, Pages 319-330

https://doi.org/10.1016/S0002-9343(98)00262-9 Get rights and content

Abstract

Pneumonia is a leading cause of morbidity and mortality among patients in long-term care facilities; the median reported incidence is 1 per 1,000 patient-days. Risk factors include functional dependency, chronic pulmonary disease, and conditions causing aspiration. The frequency of etiologic agents varies widely among reports; for example; Streptococcus pneumoniae ranges from 0% to 39% of cases, and gram negative bacilli ranges from 0% to 51% of reported cases. Viral respiratory infections, particularly influenza and respiratory syncytial virus, typically occur in outbreaks. Mortality varies from 5% to 40%; functional status is the major determinant of survival. Many patients receive inadequate initial evaluations, and as many as 40% receive no physician visit during the episode. Although transfer to an acute care facility occurs in 9% to 51% of cases, most transferred patients could be managed in the nursing home with minimal additional support. Appropriate evaluation includes examination by a practitioner, recording of vital signs, chest radiograph, and examination of an adequate sputum sample, if available. Patients without contraindications to oral therapy or severe abnormalities of vital signs (pulse >120 beats per minute, respirations >30 per minute, systolic blood pressure <90) may initially receive oral therapy. Appropriate oral agents include amoxicillin/clavulanate, second generation cephalosporins, quinolones active against S pneumoniae, or trimethoprim/sulfamethoxazole. Appropriate parenteral agents include beta-lactam/beta-lactamase inhibitor combinations, second or third generation cephalosporins, or quinolones. Pneumococcal and influenza vaccines should be administered to all residents. Future studies should focus on identifying risk factors for pneumonia that are amenable to intervention and to identifying highly effective, preferably oral, antimicrobial regimens in randomized trials.

Section snippets

Methods

Articles were identified by Medline search and by review of bibliographies contained in articles retrieved. Articles providing data on the incidence, epidemiology, clinical presentation, treatment, and outcome of pneumonia in long-term care patients were reviewed. With regard to microbial etiology, articles were included if etiologic data based on sputum culture, blood culture, or special tests for viral and “atypical” pathogens were provided. The criteria used for judging adequacy of the

Epidemiology

The incidence of pneumonia among long-term care patients ranges from 0.27 to 2.5 per 1,000 patient-days 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23; the median reported incidence is 1 per 1,000 patient-days. In many reports, criteria for lower respiratory infection included cases with bronchitis, as chest radiographs were not uniformly obtained. Jackson et al (19) reported each separately and found a pneumonia rate of 1.5 per 1,000 patient-days and a bronchitis rate of 1.0 per

Etiology

Although many studies have reported the etiology of pneumonia in the long-term care setting 7, 9, 15, 17, 22, 23, 26, 27, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, solid data to base treatment upon are lacking. Adequate sputum samples are difficult to obtain due to poor cough reflex and abnormal mental status. For example, Drinka et al (65) reported adequate sputum samples in only 28% of patients enrolled in a prospective nursing-home study. Another nursing-home based study reported that 42% of

Clinical presentation and outcome

Pneumonia in long-term care patients may have an atypical presentation 27, 33, 60, 61, 63, 64. Patients 65 years of age and older presenting with pneumonia tend to have fewer symptoms than do younger adults, even after controlling for severity of illness and comorbid conditions 89, 90. The elderly often have lower baseline body temperature and a lower peak temperature response to infection 90, 91. Only about two thirds of nursing home patients with pneumonia will have a temperature >38^oC at

Evaluation of patients

Patients in nursing homes often receive incomplete evaluations for episodes of infection 37, 99, 100. Many facilities do not have full time physicians; in those that do, physicians are not typically on site 24 hours a day. In a 1-year survey of infections in Maryland nursing homes, only 59% of patients with lower respiratory infection received a physician visit, and only 37% had a chest radiograph (100). Another study found that 17% of nursing home patients with pneumonia received only a

Management

As noted, 9% to 51% of patients acquiring pneumonia in long-term care facilities are transferred to hospitals 30, 31, 32, 33, 37. The decision to transfer is generally based on the judgment of a physician or other health care provider. There is no evidence that transfer improves survival. Mortality rates for patients treated in the nursing home are similar to those for patients treated in hospitals. However, direct comparisons are difficult because of several confounding factors. Transferred

Prevention

Pneumococcal infection accounts for a substantial proportion of respiratory infections among the institutionalized elderly. Residence in a nursing home is associated with an increased risk of invasive pneumococcal disease (7). This is not surprising, since advanced age and underlying illnesses, such as cardiac and pulmonary disease, increase both the risk and case-fatality ratio of pneumococcal disease (117). Furthermore, the closed environment of the nursing home facilitates patient to patient

Areas for future investigation

With the exception of pneumococcal immunization and influenza control strategies, there is little evidence on which to base preventive recommendations. As previously noted, poor functional status, tendency to aspirate, and chronic lung disease are the major risk factors for pneumonia. These factors are not readily modified. Well-conducted case-control studies to identify potentially modifiable risk factors for pneumonia are practical and relatively economical to perform. Other worthwhile

Acknowledgements

The author would like to thank Victor L. Yu, MD, for his critical review of the manuscript.

References (134)

J.M. Schicker et al.
Comparison of methods for calculation and depiction of incidence infection rates in long-term care patients
J Clin Epidemiol
(1988)
G.A. Harkness et al.
Risk factors for nosocomial pneumonia in the elderly
Am J Med
(1990)
C. Jacobson et al.
Incidence and impact of infection in a nursing home care unit
Am J Infect Control
(1990)
N. Hoffman et al.
Nosocomial infection rates during a one-year period in a nursing home care unit of a Veterans Administration hospital
Am J Infect Control
(1990)
S.B. Darnowski et al.
Two years of infection surveillance in a geriatric long-term care facility
Am J Infect Control
(1991)
M.H. Magnussen et al.
Nosocomial infections in a long-term care facility
Am J Infect Control
(1980)
M.J. Fine et al.
Validation of a pneumonia prognostic index using the MedisGroups Comparative Hospital Database
Am J Med
(1993)
R. Celis et al.
Nosocomial pneumoniaa multivariate analysis of risk and prognosis
Chest
(1988)
U. Setia et al.
Nosocomial infections among patients in a long- term care facilityspectrum, prevalence, and risk factors
Am J Infect Control
(1985)
S.R. Gambert et al.
Bacterial infections in a hospital-based skilled nursing facility
J Chron Dis
(1982)

Alvarez S, Shell CG, Woolley TW, et al. Nosocomial infections in long-term care facilities. J Gerontol...

M.M. Jackson et al.

Intensive surveillance for infections in a three-year study of nursing home patients

Am J Epidemiol

(1992)

S. Murphy et al.

Impact of vitamin A supplementation on the incidence of infection in elderly nursing home residentsa randomized controlled trial

Age Ageing

(1992)

W.A. Smith et al.

A retrospective review of nosocomial infections in an acute rehabilitative and chronic population at a large skilled nursing facility

J Am Geriatr Soc

(1994)

T.J. Marrie

Community-acquired pneumonia

Clin Infect Dis

(1994)

C. Jokinen et al.

Incidence of community-acquired pneumonia in the population of four municipalities in eastern Finland

Am J Epidemiol

(1993)

G.D. Fang et al.

New and emerging etiologies for community-acquired pneumonia with implications for therapya prospective multicenter study of 359 cases

Medicine

(1990)

T.J. Marrie et al.

Community-acquired pneumonia requiring hospitalization5–year prospective study

Rev Infect Dis

(1989)

C. Beck-Sague et al.

Infectious diseases and death among nursing home residentsresults of surveillance in 13 nursing homes

Infect Control Hosp Epidemiol

(1994)

D.R. Mehr et al.

Risk factors for mortality from lower respiratory infections in nursing home patients

J Fam Pract

(1992)

J. Degelau et al.

Effectiveness of oral antibiotic treatment in nursing home-acquired pneumonia

J Am Geriatr Soc

(1995)

T.R. Fried et al.

Whether to transfer? Factors associated with hospitalization and outcome of elderly long-term care patients and pneumonia

J Gen Intern Med

(1995)

R.R. Muder et al.

Pneumonia in a long-term care facilitya prospective study of outcome

Arch Intern Med

(1996)

C.L. Dempsey

Nursing home-acquired pneumoniaoutcomes from a clinical process improvement program

Pharmacotherapy

(1995)

R.A. Miller

The aging immune systemprimer and prospectus

Science

(1996)

C. Beck-Sague et al.

Infectious diseases and mortality among US nursing home residents

Am J Public Health

(1993)

J. Magaziner et al.

Prevalence and characteristics of nursing-home acquired infections in the aged

J Am Geriatr Soc

(1991)

J.E. Croghan et al.

Pilot study of 12-month outcomes of nursing home patients with aspiration on videofluoroscopy

Dysphagia

(1994)

N. Pick et al.

Pulmonary aspiration in a long-term care settingclinical and laboratory observations and an analysis of risk factors

J Am Geriatr Soc

(1996)

J.O. Ciocon et al.

Tube feedings in elderly patients. Indications, benefits and complications

Arch Intern Med

(1988)

J.M. Hassett et al.

No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy

Surg Gynecol Obstet

(1988)

D.E. Fay et al.

Long-term enteral feedinga retrospective comparison of delivery via percutaneous endoscopic gastrostomy and nasoenteric tubes

Am J Gastroenterol

(1991)

Cited by (277)

The safety and efficacy of Chinese herbal medicine for pneumonia prevention in high-risk elder residents in the nursing home: A randomized, double-blind clinical trial
2024, Journal of Ethnopharmacology
Nursing home-associated pneumonia (NHAP) is a common type of infection among long-term care residents. Moreover, the mortality of NHAP is also higher than community-acquired pneumonia (CAP). In traditional Chinese medicine (TCM), the decoctions of Banxia Houpo Tang (BHT) and Ding Chuan Tang (DCT) are two formulas supporting the lungs' natural defense systems, helps to expel mucus and promote detoxification.
We designed a concentrated Chinese herbal extract formula called BDT1, that combines the compounds of BHT and DCT. In this study, we evaluated the safety and efficacy of BDT1 for NHAP prevention in high-risk older residents in the nursing home.
In this randomized, double-blind, placebo-controlled trial, 160 participants aged over 65 years old living in the nursing home were randomly assigned 1:1 to the BDT1 and placebo group. Besides regular medicine, participants received either BDT1 or a placebo for 12 consecutive weeks. The primary outcome was the hospitalization rate for pneumonia in the intervention period and half-year follow-up. The microscopic examination of Gram-stained sputum was also evaluated before and after the trial. Data were analyzed by using the Chi-square test and Wilcoxon Signed Ranks Test with SPSS.
A total of 160 participants were enrolled into two study groups in this study, which was completed with 143 participants analyzed, including 70 subjects in the BDT1 group and 73 subjects in the placebo group. After the 12-week medical treatment, the hospitalization rate for pneumonia was 10.0% and 34.2% in the BDT1 and placebo group respectively. The risk of pneumonia in half a year was lower in the BDT1 group (adjusted hazard ratio = 0.422, 95% CI = 0.226–0.791). Compared to the placebo group, the level of Gram-negative bacilli in the BDT1 group is significantly declined in sputum samples (p < 0.05).
In conclusion, the cumulative incidence of pneumonia and related-hospitalization rates declined significantly after 12-weeks of BDT1 treatment. Besides, Chinese herbal medicine BDT1 is a safe therapy without hepatotoxicity or nephrotoxicity.
In healthy volunteers the Miami-J® cervical collar causes swallow dysfunction. This may increase the risk of aspiration; of particular potential consequence in older people with neck injury
2023, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
In young healthy volunteers a cervical hard collar has been shown to change swallowing physiology. The risk of aspiration pneumonia increases with age.
In this open prospective dual-arm controlled trial without randomisation there were 23 patients divided into two cohorts: 11 older (mean age 84) and 12 younger (mean age 25).
A series of video fluoroscopy (VF) swallow studies were performed without a cervical collar, followed by the same series of VF with a Miami-J® cervical collar fitted. The Modified Barium Swallow Impairment Profile (MBSImP^TM©) and Penetration-Aspiration Scale (PAS) were used to define and score swallow function and level of aspiration without and with the collar fitted.
An increase in the median MBSImP^TM© score amongst all participants in the oral phase of swallow (p = 0.01) and combined oral and pharyngeal phase of swallow (p = 0.006) was seen when volunteers were fitted with the Miami-J® collar, compared to no collar.
When wearing the collar deterioration in swallow function and small increases in PAS level were more marked in the older cohort, but these latter findings were not statistically significant.
Cervical hard collars change swallowing physiology in younger and older volunteers. Whilst we did not measure a statistically significant difference in the PAS level pre- and post- collar wearing, we feel it is important to highlight these changes in swallowing physiology and speculate that with collar use there is a potential risk of aspiration associated with these changes.
Potential risk of aspiration should be carefully balanced with the benefit gained from collar use in the management of cervical spine injury (both in conservative and postoperative management). Although this is a small study it is important to highlight an area of concern of particular importance in the older population who have physiological changes to the swallow that occur with age (presbyphagia) and where baseline risk of aspiration is higher.
Poor Oral Health in the Etiology and Prevention of Aspiration Pneumonia
2023, Clinics in Geriatric Medicine
Infections and patterns of antibiotic utilization in support and comfort care patients: A tertiary care center experience
2021, Journal of Infection and Public Health
Little is known regarding the burden of infections and clinical practice towards hospitalized patients with limits on life-sustaining measures. We aim to describe the infectious syndromes, clinical care, the emergence of multi-drug resistant organisms and outcomes in this population.
Retrospective cohort of patients labeled as support or comfort care in a tertiary care center between 2016–2019.
A total of 347 patients were included with a mean age of 68.5 years, who were predominantly males (59.94%), bedbound (69.74%), on tube feeding (66.86%), and required indwelling urinary catheters (61.96%). The total number of admissions during the first year was 498, with the mean length of stay being 30 days. The number of infectious syndromes identified during that period was 821episodes, with a mean of 2 infectious syndromes per admission. The most common infection identified was pneumonia (41.66%) followed by urinary tract infections (27.16%). A total of 3891 microbiological cultures were taken with a mean of 5 cultures per infectious syndrome. The most commonly identified pathogens were Gram-negative bacteria (61.03%), with a high rate of multidrug-resistant organisms (MDROs) (48.53%). The one-year mortality was 86.4%. Using carbapenem antibiotic and pneumonia were the independent predictors used for the MDROs.
Our study reflects the high burden of infections, antimicrobial resistance, and hospital admissions among a population with limited life expectancy. A consensus regarding investigating and managing of infectious syndromes, and antimicrobial prescription is needed to reduce the harms associated with overuse of antimicrobials.
Poor Oral Health in the Etiology and Prevention of Aspiration Pneumonia
2021, Dental Clinics of North America
Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia
2020, Journal of the American Medical Directors Association
Pneumonia is a common cause of hospitalization for nursing home residents and has increased as a cause for hospitalization during the COVID-19 pandemic. Risks of hospitalization, including significant functional decline, are important considerations when deciding whether to treat a resident in the nursing home or transfer to a hospital. Little is known about postdischarge functional status, relative to baseline, of nursing home residents hospitalized for pneumonia. We sought to determine the risk of severe functional limitation or death for nursing home residents following hospitalization for treatment of pneumonia.
Retrospective cohort study.
Participants included Medicare enrollees aged ≥65 years, hospitalized from a nursing home in the United States between 2013 and 2014 for pneumonia.
Activities of daily living (ADL), patient sociodemographics, and comorbidities were obtained from the Minimum Data Set (MDS), an assessment tool completed for all nursing home residents. MDS assessments from prior to and following hospitalization were compared to assess for functional decline. Following hospital discharge, all patients were evaluated for a composite outcome of severe disability (≥4 ADL limitations) following hospitalization or death prior to completion of a postdischarge MDS.
In 2013 and 2014, a total of 241,804 nursing home residents were hospitalized for pneumonia, of whom 89.9% (192,736) experienced the composite outcome of severe disability or death following hospitalization for pneumonia. Although we found that prehospitalization functional and cognitive status were associated with developing the composite outcome, 53% of residents with no prehospitalization ADL limitation, and 82% with no cognitive limitation experienced the outcome.
Hospitalization for treatment of pneumonia is associated with significant risk of functional decline and death among nursing home residents, even those with minimal deficits prior to hospitalization. Nursing homes need to prepare for these outcomes in both advance care planning and in rehabilitation efforts.

View all citing articles on Scopus

View full text

ReviewPneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention

Abstract

Section snippets

Methods

Epidemiology

Etiology

Clinical presentation and outcome

Evaluation of patients

Management

Prevention

Areas for future investigation

Acknowledgements

J Clin Epidemiol

Am J Med

Am J Infect Control

Am J Infect Control

Am J Infect Control

Am J Infect Control

Am J Med

Chest

Am J Infect Control

J Chron Dis

Am J Med

Am J Infect Control

Am J Med

J Infect

J Infect

Autopsy study of the elderly institutionalized patientreview of 234 autopsies

Arch Intern Med

Autopsies and death certificates in the chronic care setting

J Am Geriatr Soc

Nursing home patients transferred by ambulance to the emergency department

J Am Geriatr Soc

Causes for hospitalization of nursing home residentsthe role of infection

J Am Geriatr Soc

Appropriateness of patient transfer from a nursing home to an acute-care hospitala study of emergency room visits and hospital admissions

J Am Geriatr Soc

The increased needs of patients in nursing homes and patients receiving home health care

NEJM

Bacteremia in a long-term care facilitya five-year prospective study of 163 consecutive episodes

Clin Infect Dis

A prospective study of nosocomial infections in a chronic care facility

J Am Geriatr Soc

Twelve-month surveillance of infections in institutionalized elderly men

J Am Geriatr Soc

Infections and infection control among residents of eight rural Wisconson nursing homes

Arch Intern Med

Prevalence survey of infections and predisposing factors at a hosptial-based nursing home care unit

J Am Geriatr Soc

The incidence of nosocomial infections in a skilled nursing facility

Conn Med

Treatment decisions for infections occurring in nursing home residents

J Am Geriatr Soc

Intensive surveillance for infections in a three-year study of nursing home patients

Am J Epidemiol

Impact of vitamin A supplementation on the incidence of infection in elderly nursing home residentsa randomized controlled trial

Age Ageing

A retrospective review of nosocomial infections in an acute rehabilitative and chronic population at a large skilled nursing facility

J Am Geriatr Soc

Community-acquired pneumonia

Clin Infect Dis

Incidence of community-acquired pneumonia in the population of four municipalities in eastern Finland

Am J Epidemiol

New and emerging etiologies for community-acquired pneumonia with implications for therapya prospective multicenter study of 359 cases

Medicine

Community-acquired pneumonia requiring hospitalization5–year prospective study

Rev Infect Dis

Infectious diseases and death among nursing home residentsresults of surveillance in 13 nursing homes

Infect Control Hosp Epidemiol

Risk factors for mortality from lower respiratory infections in nursing home patients

J Fam Pract

Effectiveness of oral antibiotic treatment in nursing home-acquired pneumonia

J Am Geriatr Soc

Whether to transfer? Factors associated with hospitalization and outcome of elderly long-term care patients and pneumonia

J Gen Intern Med

Pneumonia in a long-term care facilitya prospective study of outcome

Arch Intern Med

Nursing home-acquired pneumoniaoutcomes from a clinical process improvement program

Pharmacotherapy

The aging immune systemprimer and prospectus

Review
Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention