ReviewPneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention
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 >38oC 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.
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