The Role Of a Typical Pathogens in Nursing Home Pneumonia

Abstract

The empiric coverage of atypical pathogens (Legionella, Chlamydia pneumoniae, and Mycoplasma pneumoniae) in nursing home pneumonia is a controversial area. Relatively recent reviews of nursing home pneumonia do not include recommendations for such empiric coverage. This includes recommendations from the Long-Term Care Committee of the Society for Healthcare Epidemiology in America (SHEA) published in 2000. 1 Nicolle LE Bentley DW Garibaldi R SHEA Long-Term-Care Committee et al. Antimicrobial use in long-term care facilities. Infect Control Hosp Epidemiol. 2000; 21: 537-545 Crossref PubMed Scopus (211) Google Scholar , 2 Muder RR Pneumonia in residents of long-term care facilities: Epidemiology, etiology, management and prevention. Am J Med. 1998; 105: 319-330 Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar , 3 Medina-Walpole AM Katz PR Nursing home-acquired pneumonia. J Am Geriatr Soc. 1999; 47: 1005-1015 Crossref PubMed Scopus (76) Google Scholar Data on the role of atypical pathogens in nursing homes is limited. Coverage of “atypicals” is not proven to be necessary and could contribute to the emergence of resistant pathogens. The Infectious Disease Society of America (IDSA) however, recommends that without a quality gram stain and/or laboratory evidence of a “strongly suspected” specific pathogen that empiric coverage of community-acquired pneumonia include atypical pathogens. 4 Bartlett JG Dowell SF Mandell LA et al. Practice Guidelines for the management of community-acquired pneumonia in adults. Clin Infect Dis. 2000; 31: 347-382 Crossref PubMed Scopus (1433) Google Scholar Current American Thoracic Society (ATS) guidelines for community-acquired pneumonia state that, “A sputum gram stain cannot be used to focus initial empiric antibiotic therapy (contrary to ISDA), but could be used to broaden initial therapy.” Committee members were concerned about co-infections with bacteria and atypical pathogens. Gram stain and culture was recommended if a resistant organism not covered by empiric treatment was suspected. Resistant organisms such as methicillin resistant Staphylococcus aureus (MRSA) are endemic in many nursing homes. Recommended empiric coverage includes atypical pathogens. 5 Official statement of the American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia: Diagnosis, assessment of severity, antimicrobial therapy and prevention. Am J Resp Crit Care Med. 2001; 163: 1730 Crossref PubMed Scopus (2022) Google Scholar The Canadian guidelines recommend obtaining a quality sputum specimen in hospitalized patients stating, “Once an etiologic agent has been appropriately identified, the in vitro susceptibility of the pathogen has been confirmed, and infection with a co-pathogen has been excluded, initial empirical therapy should be modified so that treatment is directed at the specific pathogen(s) involved.” 6 Mandell LA Marrie TJ Grossman RF the Canadian Community-Acquired Pneumonia Working Group et al. Canadian guidelines for the initial management of community-acquired pneumonia: An evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. Clin Infect Dis. 2000; 31: 383-421 Crossref PubMed Scopus (623) Google Scholar However, exclusion of a co-pathogen (ie, an atypical) is seldom accomplished. Recommended empiric coverage includes the atypical pathogens. 6 Mandell LA Marrie TJ Grossman RF the Canadian Community-Acquired Pneumonia Working Group et al. Canadian guidelines for the initial management of community-acquired pneumonia: An evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. Clin Infect Dis. 2000; 31: 383-421 Crossref PubMed Scopus (623) Google Scholar