Nursing Home-acquired Pneumonia Research Articles

Development and verification of a prediction model for outcomes of elderly patients with nursing home-acquired pneumonia

BackgroundAmong all infections in nursing homes, pneumonia has the highest mortality. Nurses have a 24-h relationship with patients and have a key role in identifying and preventing adverse outcomes. However, tools to engage nurses in pneumonia patient outcomes evaluation have not occurred. PurposeThis study aimed to develop and validate a prediction model to predict the outcome of elderly patients with nursing home-acquired pneumonia (NHAP). MethodologyA retrospective observational study was conducted with 219 elderly NHAP patients. Baseline characteristics, health history, and treatment/nursing status were collected. Variables for constructing nomograms were screened by univariate and multivariate analysis. The nomogram model was evaluated using the concordance index (C-index), decision curve analysis (DCA) curves, and receiver operating characteristic (ROC) curves. Results9 independent risk factors were identified and assembled into the nomogram. The nomogram exhibited reasonably accurate discrimination (area under the receiver operating characteristic curve (AUC-ROC): 0.931, P < 0.05) and calibration (C-index: 0.931, 95 % CI: 0.898–0.964) in the validation cohort. DCA and clinical impact curves demonstrated that the nomogram was clinically beneficial. ConclusionsA visualization nomogram model was successfully established for predicting the outcome of the NHAP elderly patients. The model has extremely high reliability, extremely high predictive ability, and good clinical applicability.

Oral care measures for preventing nursing home-acquired pneumonia.

Pneumonia in residents of nursing homes can be termed nursing home-acquired pneumonia (NHAP). NHAP is one of the most common infections identified in nursing home residents and has the highest mortality of any infection in this population. NHAP is associated with poor oral hygiene and may be caused by aspiration of oropharyngeal flora into the lung. Oral care measures to remove or disrupt oral plaque might reduce the risk of NHAP. This is the first update of a review published in 2018. To assess effects of oral care measures for preventing nursing home-acquired pneumonia in residents of nursing homes and other long-term care facilities. An information specialist searched CENTRAL, MEDLINE, Embase, one other database and three trials registers up to 12 May 2022. We also used additional search methods to identify published, unpublished and ongoing studies. We included randomised controlled trials (RCTs) that evaluated the effects of oral care measures (brushing, swabbing, denture cleaning mouthrinse, or combination) in residents of any age in nursing homes and other long-term care facilities. At least two review authors independently assessed search results, extracted data, and assessed risk of bias in the included studies. We contacted study authors for additional information. We pooled data from studies with similar interventions and outcomes. We reported risk ratios (RRs) for dichotomous outcomes, mean differences (MDs) for continuous outcomes, and hazard ratios (HRs) or incidence rate ratio (IRR) for time-to-event outcomes, using random-effects models. We included six RCTs (6244 participants), all of which were at high risk of bias. Three studies were carried out in Japan, two in the USA, and one in France. The studies evaluated one comparison: professional oral care versus usual oral care. We did not include the results from one study (834 participants) because it had been stopped at interim analysis. Consistent results from five studies, with 5018 participants, provided insufficient evidence of a difference between professional oral care and usual (simple, self-administered) oral care in the incidence of pneumonia. Three studies reported HRs, one reported IRRs, and one reported RRs. Due to the variation in study design and follow-up duration, we decided not to pool the data. We downgraded the certainty of the evidence for this outcome by two levels to low: one level for study limitations (high risk of performance bias), and one level for imprecision. There was low-certainty evidence from meta-analysis of two individually randomised studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24 months' follow-up (RR 0.43, 95% CI 0.25 to 0.76, 454 participants). Another study (2513 participants) reported insufficient evidence of a difference for this outcome at 18 months' follow-up. Three studies measured all-cause mortality and identified insufficient evidence of a difference between professional and usual oral care at 12 to 30 months' follow-up. Only one study (834 participants) measured the adverse effects of the interventions. The study identified no serious events and 64 non-serious events, the most common of which were oral cavity disturbances (not defined) and dental staining. No studies evaluated oral care versus no oral care. Although low-certainty evidence suggests that professional oral care may reduce mortality compared to usual care when measured at 24 months, the effect of professional oral care on preventing NHAP remains largely unclear. Low-certainty evidence was inconclusive about the effects of this intervention on incidence and number of first episodes of NHAP. Due to differences in study design, effect measures, follow-up duration, and composition of the interventions, we cannot determine the optimal oral care protocol from current evidence. Future trials will require larger samples, robust methods that ensure low risk of bias, and more practicable interventions for nursing home residents.

Protein C activity as a potential prognostic factor for nursing home-acquired pneumonia.

IntroductionDespite the poor prognosis for nursing home acquired pneumonia (NHAP), a useful prognostic factor is lacking. We evaluated protein C (PC) activity as a predictor of in-hospital death in patients with NHAP and community-acquired pneumonia (CAP).MethodsThis prospective, observational study included all patients hospitalized with pneumonia between July 2007 and December 2012 in a single hospital. We measured PC activity at admission and investigated whether it was different between survivors and non-survivors. We also examined whether PC activity < 55% was a predictor for in-hospital death of pneumonia by logistic regression analysis with CURB-65 items (confusion, blood urea >20 mg/dL, respiratory rate >30/min, and blood pressure <90/60 mmHg, age >65). When it was a useful prognostic factor for pneumonia, we combined PC activity with the existing prognostic scores, the pneumonia severity index (PSI) and CURB-65, and analyzed its additional effect by comparing the areas under the receiver operating characteristic curves (AUCs) of the modified and original scores.ResultsParticipants comprised 75 NHAP and 315 CAP patients. PC activity was lower among non-survivors than among survivors in NHAP and all-pneumonia (CAP+NHAP). PC activity <55% was a useful prognostic predictor for NHAP (Odds ratio 7.39 (95% CI; 1.59–34.38), and when PSI or CURB-65 was combined with PC activity, the AUC improved (from 0.712 to 0.820 for PSI, and 0.657 to 0.734 for CURB-65).ConclusionsPC activity was useful for predicting in-hospital death of pneumonia, especially in NHAP, and became more useful when combined with the PSI or CURB-65.

Impact of nursing home-acquired pneumonia on the domains of the novel construct of intrinsic capacity: The INCUR study.

Nursing home-acquired pneumonia (NHAP) and related hospitalizations might lead to abrupt functional declines, especially among nursing home residents. Intrinsic capacity is a novel construct proposed by the World Health Organization specifically designed to capture the physical and cognitive capacities of the aging individual to design personalized interventions. This study aimed to investigate the associations of NHAP and related hospitalizations with several intrinsic capacity domains among nursing home residents. We used data from the INCUR study (n=754; mean age=86.1 ± 7.4; 75.2% female). Four intrinsic capacity domains were assessed through the Short Physical Performance Battery (SPPB, locomotion), Abbreviated Mental Test (cognition), 10-items Geriatric Depression scale (GDS-10, mood), the Mini-Nutritional Assessment Short-Form (vitality) at three time-points along 1-year. Linear mixed models were used to analyze longitudinal evolution in the intrinsic capacity domains according to NHAP diagnosis and hospitalization. A total of 161 (21.4%) were diagnosed with NHAP, and 46 of them (28.6%) required hospitalization. NHAP was significantly associated with declines in the intrinsic capacity vitality domain (β=-0.51; 95% CI -0.84; -0.18). The association was also found for NHAP-related hospitalization (β=-0.97; 95% CI -1.46; -0.48). NHAP-related hospitalization was also associated with worsening in the psychological domain (β=0.56; 95% CI 0.08; 1.04). No other significant associations were found. NHAP and related hospitalization are associated with the deterioration of intrinsic capacity vitality and psychology domains. Prevention of pneumonia may result in better functional evolution in very old and vulnerable nursing home residents.

Incidence of Antibiotic Treatment Failure in Patients with Nursing Home-Acquired Pneumonia and Community Acquired Pneumonia.

Purpose: Nursing home-acquired pneumonia (NHAP) patients are at higher risk of multi-drug resistant infection (MDR) than those with community-acquired pneumonia (CAP). Recent evidence suggests a single risk factor for MDR does not accurately predict the need for broad-spectrum antibiotics. The goal of this study was to compare the rate antibiotic failure between NHAP and CAP patients. Methods: Demographic characteristics, co-morbidities, clinical and laboratory variables, antibiotic therapy, and mortality data were collected retrospectively for all patients with pneumonia admitted to an Internal Medicine Service between April 2017 and April 2018. Results: In total, 313 of 556 patients had CAP and 243 had NHAP. NHAP patients were older, and were more likely to be dependent, to have recent antibiotic use, and to experience treatment failure (odds ratio (OR) 1.583; 95% CI 1.102–2.276; p = 0.013). In multivariate analysis, patient’s origin did not predict treatment failure (OR 1.083; 95% CI 0.726–1.616; p = 0.696). Discussion: Higher rates of antibiotic failure and mortality in NHAP patients were explained by the presence of other risk factors such as comorbidities, more severe presentation, and age. Admission from a nursing home is not a sufficient condition to start broader-spectrum antibiotics.

The Use of Inappropriate Antibiotics in Patients Admitted to Intensive Care Units with Nursing Home-Acquired Pneumonia at a Korean Teaching Hospital.

BackgroundUse of appropriate antibiotics for the treatment of pneumonia is integral in patients admitted to intensive care units (ICUs). Although it is recommended that empirical treatment regimens should be based on the local distribution of pathogens in patients with suspected hospital-acquired pneumonia, few studies observe patients admitted to ICUs with nursing home–acquired pneumonia (NHAP). We found factors associated with the use of inappropriate antibiotics in patients with pneumonia admitted to the ICU via the emergency room (ER).MethodsWe performed a retrospective cohort study of 83 pneumonia patients with confirmed causative bacteria admitted to ICUs via ER March 2015–May 2017. We compared clinical parameters, between patients who received appropriate or inappropriate antibiotics using the Mann-Whitney U, Pearson's chi-square, and Fisher's exact tests. We investigated independent factors associated with inappropriate antibiotic use in patients using multivariate logistic regression.ResultsAmong 83 patients, 30 patients (36.1%) received inappropriate antibiotics. NHAP patients were more frequently treated with inappropriate antibiotics than with appropriate antibiotics (47.2% vs. 96.7%, p<0.001). Methicillin-resistant Staphylococcus aureus was more frequently isolated from individuals in the inappropriate antibiotics–treated group than in the appropriate antibiotics–treated group (7.5% vs. 70.0%, p<0.001). In multivariate analysis, NHAP was independently associated with the use of inappropriate antibiotics in patients with pneumonia admitted to the ICU via ER.ConclusionNHAP is a risk factor associated with the use of inappropriate antibiotics in patients with pneumonia admitted to the ICU via the ER.

Risk score-guided treatment for hospitalized pneumonia in older patients.

Initial intravenous antibiotic treatment strategy for pneumonia is debated in older people living in nursing homes. Guidelines of the American Thoracic Society identified American Health-Care Associated Pneumonia (HCAP) which covered Nursing Home-Acquired Pneumonia (NHAP) and can be used as a score. The Complicated Pathogen Risk Assessment Score (CPRS) focuses on comorbidities and clinical past history. This study assesses the usefulness of HCAP score and CPRS in choosing initial empiric therapy while comparing their predictive value for a required change in initial antibiotic regimen and for mortality in hospitalized older patients. This is a retrospective analysis of 175 patients aged 75years or more hospitalized for pneumonia from 2014 to 2015. They were treated according to the French guidelines as community-acquired pneumonia. The HCAP score and the CPRS were analyzed retrospectively. They were matched to in-hospital mortality and to change in initial antibiotic regimen rates. Therapy as recommended for CAP was started in all 175 patients. A change in antibiotic regimen was noted in 17% of patients: 30% of those with a CPR score > 2 and 20% of those with an HCAP score ≥ 1. The global mortality rated 11% for all patients, 20.5% for those with a CPRS score > 2, and 16.5% for those with an HCAP score ≥ 1. Both changes for antibiotic regimen (p < 0.001) and mortality ( p< 0.001) rates were more closely associated with a CPRS > 2 than with an HCAP score ≥ 1. Multidrug-resistant risk scores are useful in optimizing initial empirical therapy for NHAP in the elderly.

Significance of blood cultures in nursing home-acquired pneumonia.

The significance of blood cultures in nursing home-acquired pneumonia (NHAP) is incompletely understood. We retrospectively analyzed the clinical and laboratory features of 515 patients with NHAP admitted to our hospital over an 11-year period. Blood cultures were obtained from 336 patients (65.2%). We compared 13 and 323 patients with positive and negative blood cultures, respectively. The former showed lower systolic blood pressure and higher blood urea nitrogen (BUN), creatinine, C-reactive protein (CRP), and A-DROP scores than the latter. With regard to A-DROP parameters, patients with positive blood cultures showed significantly higher rates of dehydration (BUN≥21mg/dL) and low blood pressure (systolic blood pressure≤90mmHg). Multivariate analysis identified CRP values and low blood pressure as independent predictors of bacteremia: CRP (odds ratio [OR] 1.11; 95% confidence interval [CI] 1.04-1.19, P=0.003) and low blood pressure (OR 6.03; 95% CI 1.06-34.25, P=0.04). A receiver operating characteristic curve indicated that CRP was of moderate accuracy (area under the curve=0.75), and its diagnostic accuracy was optimal at a cut-off point of 19.2mg/dL (sensitivity 69%, specificity 87%). Since the probability of true bacteremia is very low in NHAP, obtaining blood cultures from all patients with NHAP is unnecessary. However, our results suggest blood cultures are warranted from patients with high CRP values (≥20mg/dL) or low blood pressure.

Professional oral health care for preventing nursing home-acquired pneumonia: A cost-effectiveness and value of information analysis.

Professional oral health care (POHC) prevents nursing home-acquired pneumonia (NHAP) and its related mortality. We assessed the cost-effectiveness of POHC versus no POHC (nPOHC) and the monetary value of eliminating uncertainty by future research. A German public-private payer perspective was adopted. A Markov model was used, following long-term care residents from admission to death. Cost-effectiveness was estimated as Euro/disability-adjusted life year (DALY) using Monte Carlo microsimulations. Value-of-information analyses were performed. The willingness-to-pay threshold/DALY was assumed to be 66% (range 50%-100%) of per-capita gross domestic product (GDP). nPOHC was less costly (€3,024) but also less effective (0.89 DALYs) than POHC (€10,249, 0.55 DALYs). For most presumed payers, POHC was cost-effective. The cost-effectiveness of POHC was higher in smokers, underweight or pulmonary disease patients. Eliminating uncertainty about the NHAP costs, NHAP incidence/mortality, and POHC effectiveness would result in an expected net value of 47million €/year (and even higher values at lower GDP thresholds), and is likely to decrease with time. Within the chosen setting and on the basis of current evidence, POHC was cost-effective. Given the detected uncertainty, further research seems warranted.

Antimicrobial Resistance and Clinical Outcomes in Nursing Home-Acquired Pneumonia, Compared to Community-Acquired Pneumonia.

PurposePatients with nursing home-acquired pneumonia (NHAP) should be treated as hospital-acquired pneumonia (HAP) according to guidelines published in 2005. However, controversy still exists on whether the high mortality of NHAP results from multidrug resistant pathogens or underlying disease. We aimed to outline differences and factors contributing to mortality between NHAP and community-acquired pneumonia (CAP) patients.Materials and MethodsWe retrospectively evaluated patients aged 65 years or older with either CAP or NHAP from 2008 to 2014. Patients with healthcare-associated pneumonia other than NHAP or HAP were excluded.ResultsAmong 317 patients, 212 patients had CAP and 105 had NHAP. Patients with NHAP had higher mortality, more frequently used a ventilator, and had disease of higher severity than CAP. The incidences of aspiration, tube feeding, and poor functional status were higher in NHAP. Twenty three out of 54 NHAP patients and three out of 62 CAP patients had multidrug resistant pathogens (p<0.001). Eleven patients with NHAP died at discharge, compared to 7 patients with CAP (p=0.009). However, there was no association between mortality rate and presence of multidrug-resistant pathogens. The number of involved lobes on chest X-ray [odds ratio (OR)=1.708; 95% confidence interval (CI), 1.120 to 2.605] and use of mechanical ventilation (OR=9.537; 95% CI, 1.635 to 55.632) were significantly associated with in-hospital mortality.ConclusionPatients with NHAP had higher mortality than patients with CAP. The excess mortality among patients with NHAP and CAP was related to disease severity but not to the presence of multidrug resistant pathogens.

Role of Atypical Bacteria in Hospitalized Patients With Nursing Home-Acquired Pneumonia.

Background: Nursing home-acquired pneumonia (NHAP) has been identified as one of the leading causes of mortality and hospitalization for long-term care residents. However, current and previous pneumonia guidelines differ on the appropriate management of NHAP in hospitalized patients, specifically in regard to the role of atypical bacteria such as Chlamydiae pneumonia, Mycoplasma pneumoniae, and Legionella. Objectives: The purpose of this review is to evaluate clinical trials conducted in hospitalized patients with NHAP to determine the prevalence of atypical bacteria and thus the role for empiric antibiotic coverage of these pathogens in NHAP. Methods: Comprehensive MEDLINE (1966-April 2016) and Embase (1980-April 2016) searches were performed using the terms "atypical bacteria", "atypical pneumonia", "nursing-home acquired pneumonia", "pneumonia", "elderly", "nursing homes", and "long term care". Additional articles were retrieved from the review of references cited in the collected studies. Thirteen published clinical trials were identified. Results: In the majority of studies, atypical bacteria were infrequently identified in patients hospitalized with NHAP. However, when an active community-acquired pneumonia (CAP) cohort was available, the rate of atypical bacteria between NHAP and CAP study arms was similar. Only 3 studies in this review adhered to recommended strategies for investigating atypical bacteria; in 2 of these studies, C. pneumoniae was the most common pathogen identified in NHAP cohorts. Conclusion: Although atypical bacteria were uncommon in most NHAP studies in this review, suboptimal microbial investigations were commonly performed. To accurately describe the role of atypical bacteria in NHAP, more studies using validated diagnostic tests are needed.

Nursing home-acquired pneumonia presenting at the emergency department.

Nursing home-acquired pneumonia (NHAP) is one of the most common infections arising amongst nursing home residents, and its incidence is expected to increase as population ages. The NHAP recommendation for empiric broad-spectrum antibiotic therapy, arising from the concept of healthcare-associated pneumonia, has been challenged by recent studies reporting low rates of multidrug-resistant (MDR) bacteria. This single center study analyzes the results of NHAP patients admitted through the Emergency Department (ED) at a tertiary center during the year 2010. There were 116 cases, male gender corresponded to 34.5% of patients and median age was 84years old (IQR 77-90). Comorbidities were present in 69.8% of cases and 48.3% of patients had used healthcare services during the previous 90days. In-hospital mortality rate was 46.6% and median length-of-stay was 9days. Severity assessment at the Emergency Department provided CURB65 index score and respective mortality (%) results: zero: n=0; one: n=7 (0%); two: n=18 (38.9%); three: n=26 (38.5%); four: n=30 (53.3%); and five; n=22 (68.2%); and sepsis n=50 (34.0%), severe sepsis n=43 (48.8%) and septic shock n=22 (72.7%). Significant risk factors for in-hospital mortality in multivariate analysis were polypnea (p=0.001), age≥75years (p=0.02), and severe sepsis or shock (p=0.03) at the ED. Microbiological testing in 78.4% of cases was positive in 15.4% (n=15): methicillin-resistant Staphylococcus aureus (26.7%), Pseudomonas aeruginosa (20.0%), S. pneumoniae (13.3%), Escherichia coli (13.3%), others (26.7%); the rate of MDR bacteria was 53.3%. This study reveals high rates of mortality and MDR bacteria among NHAP hospital admissions supporting the use of empirical broad-spectrum antibiotic therapy in these patients.

Impact of microbiological samples in the hospital management of community-acquired, nursing home-acquired and hospital-acquired pneumonia in older patients.

We investigated the positivity rate, the detection rates for non-covered pathogens and the therapeutic impact of microbiological samples (MS) in community-acquired pneumonia (CAP), nursing home-acquired pneumonia (NHAP) and hospital-acquired pneumonia (HAP) in elderly hospitalised patients. Patients aged 75 years and over with pneumonia and hospitalised between 1/1/2013 and 30/6/2013 in the departments of medicine (5) and intensive care (1) of our university hospital were included. Microbiological findings, intra-hospital mortality and one-year mortality were recorded. Among the 217 patients included, there were 138 CAP, 56 NHAP and 23 HAP. MS were performed in 89.9, 91.1 and 95.6% of CAP, NHAP and HAP, respectively. Microbiological diagnosis was made for 29, 11.8 and 27.3% of patients for CAP, NHAP and HAP, respectively (p = 0.05). Non-covered pathogens were detected for 8% of CAP, 2% of NHAP and 13.6% of HAP (p = 0.1). The antimicrobial spectrum was significantly more frequently reduced when the MS were positive (46.7% vs. 10.8% when MS were negative, p = 10(-7)). The MS positivity rate was significantly lower in NHAP than in CAP and HAP. MS revealed non-covered pathogens in only 2% of NHAP. These results show the poor efficiency and weak clinical impact of MS in the management of pneumonia in hospitalised older patients and suggest that their use should be rationalised.

Anthropometric measurements may be informative for nursing home-acquired pneumonia.

Objective:To evaluate the relationship between anthropometric measurements and Nursing Home-Acquired Pneumonia (NHAP) risk.Methods:Consecutive patients of 65 years or elderly who were living in the Balikli Rum Hospital Nursing Homes were included in this prospective study. At the beginning of this study, the patients’ anthropometrics values were measured. The patients were followed for one year, and any incidences of pneumonia attacks were recorded. The relationship between the anthropometric measurements and pneumonia occurrences was analyzed.Results:There were 133 inmates at the initial assessments. Of 108 patients who were eligible for the study, 77 (72.2%) were female and 37 (27.8%) were male. The mean age of the group was 79.8±10.5. Patients were assigned to a group according to the presence of pneumonia during the one -year follow-up. There were 74 (55.6%) patients who had suffered from at least one attack of pneumonia during the follow-up period. The mean triceps skinfold was significantly thinner in the pneumonia group, and the mean handgrip measurements in both the dominant and non-dominant hands were significantly weaker in the pneumonia group. Furthermore, the frequency of Chronic Obstructive Pulmonary Diseases (COPD) was significantly higher in this group (p < 0.001).Conclusions:The risk of pneumonia was high in the elderly population who live in nursing homes. Simple anthropometric values may be predictive of the potential for Nursing Home-Acquired Pneumonia.

The treatment of nursing home-acquired pneumonia using a medically intensive Hospital in the Home service.

To compare the outcomes for patients with nursing home-acquired pneumonia (NHAP) treated completely in a Hospital in the Home (HITH) setting with those of patients treated in a traditional hospital ward. Case-control study. All patients admitted by the Royal Melbourne Hospital for treatment of NHAP from 1 July 2013 to 31 January 2014. Admission to the Royal Melbourne Hospital HITH Unit within 48 hours of presentation. Length of stay, in-hospital and 30-day mortality, hospital readmissions (30-day), complications and unplanned returns to hospital. Sixty HITH patients and 54 hospital (control) patients were identified. Thirty-two patients (53%) were admitted directly to HITH without any hospital or emergency stay, 25 (42%) were referred directly from the emergency department. HITH patients were more likely to be male, older and dehydrated, and less likely to have an advanced care directive or to have had non-invasive ventilation. There were no significant differences in CURB-65 or CORB scores between the two patient groups; similar proportions were given intravenous fluids or supplemental oxygen. There were no adjusted differences in median length of stay between HITH and control patients (-1.00 days; 95% CI, -2.72 to 0.72; P = 0.252) or in overall mortality at 30 days (HITH v control patients: adjusted odds ratio [aOR], 1.97; 95% CI, 0.67-5.73). Inpatient mortality was lower for HITH patients (aOR, 0.19; 95% CI, 0.05-0.75) but unadjusted postdischarge 30-day mortality was higher (OR, 13.25; 95% CI 1.67-105.75). There were no differences between the two groups with regard to complications (falls and pressure wounds) and 30-day readmission rates (aOR, 1.59; 95% CI, 0.30-8.53). This study suggests that HITH may be an effective and safe alternative to hospital treatment for residents of aged care facilities presenting with NHAP.

Effect of age and residential status on the predictive performance of CURB-65 score.

The CURB-65 score was designed to predict 30-day mortality and decide the site of care of pneumonia. It is uncertain how age and residential status affect the accuracy of CURB-65 score in older patients. This study aimed to evaluate the effect of age and residential status on the performance of CURB-65 score in predicting 30-day all-cause mortality of pneumonia in older patients. We used combined data from two prospective observational cohorts of adult patients with pneumonia. Older patients aged ≥ 65 years were analysed. Of 1644 patients, 1200 were living in the community and 464 residing in nursing homes. The 30-day mortality rates of community-acquired pneumonia (CAP) and nursing home-acquired pneumonia (NHAP) were 10.7% and 14.2% respectively. In each age group of CAP and NHAP, mortality increased with pneumonia severity. Mortality decreased with advancing age in NHAP, and the reverse was true for CAP. In NHAP but not CAP, the proportion of highly severe pneumonia (CURB-65 score ≥ 3) was lower in older patients. The overall predictive performance of CURB-65 score was comparable in CAP and NHAP. The accuracy deteriorated with advancing age in NHAP but not CAP. Using the cut-off score of ≥3 (highly severe pneumonia), the CURB-65 score achieved high negative predictive values (>90%) in CAP and NHAP. Advancing age adversely affected the predictive performance of CURB-65 score in NHAP but not CAP. The score was not helpful in guiding the site of care at admission in older patients with pneumonia.

Predictors of mortality for nursing home-acquired pneumonia: a systematic review.

Background. Current risk stratification tools, primarily used for CAP, are suboptimal in predicting nursing home acquired pneumonia (NHAP) outcome and mortality. We conducted a systematic review to evaluate current evidence on the usefulness of proposed predictors of NHAP mortality. Methods. PubMed (MEDLINE), EMBASE, and CINAHL databases were searched for articles published in English between January 1978 and January 2014. The literature search elicited a total of 666 references; 580 were excluded and 20 articles met the inclusion criteria for the final analysis. Results. More studies supported the Pneumonia Severity Index (PSI) as a superior predictor of NHAP severity. Fewer studies suggested CURB-65 and SOAR (especially for the need of ICU care) as useful predictors for NHAP mortality. There is weak evidence for biomarkers like C-reactive protein and copeptin as prognostic tools. Conclusion. The evidence supports the use of PSI as the best available indicator while CURB-65 may be an alternative prognostic indicator for NHAP mortality. Overall, due to the paucity of information, biomarkers may not be as effective in this role. Larger prospective studies are needed to establish the most effective predictor(s) or combination scheme to help clinicians in decision-making related to NHAP mortality.

Nursing home-acquired pneumonia: course and management in the emergency department.

BackgroundPneumonia is among the foremost causes of hospitalization and mortality in patients residing in extended care facilities. Despite its prevalence, there is currently little literature focusing on the course and management of nursing home-acquired pneumonia (NHAP) in the emergency department (ED). Our objective was to investigate the ED presentation, course, management and outcomes in patients admitted through the ED with NHAP.MethodsA retrospective chart review of nursing home patients with a presumptive or final diagnosis of pneumonia admitted through the ED was performed at two large hospitals in Detroit, Michigan.ResultsA total of 296 patients were included in the study from 2002 to 2007 with a mean age of 81.1 years (SD ± 10.95) and 55.4% females. Blood cultures were performed on 90.8% of patients in the ED; 17.8% of these revealed growths, but half of these were considered contaminants. Initial chest x-ray in the ED was read as possible pneumonia in 18.2% of patients; 73.9% were started on antibiotics (ABX) in the ED. Mean hospital length of stay (LOS) was 10.75 days (SD ± 9.35) and in-hospital mortality was 16.2%. Time until first ABX in univariate analysis was nearly significant (p = 0.053) for mortality prediction, and the appropriate versus inappropriate ABX (per the Infectious Diseases Society of America and American Thoracic Society guidelines) did not affect mortality. Patients treated with a single ABX had significantly increased LOS (p = 0.0089). There was poor correlation between LOS and time until first ABX as well as LOS and time until appropriate ABX with a correlation coefficient of -0.048 (p = 0.42) and -0.08 (p = 0.43), respectively.ConclusionsIn this data set of NHAP patients admitted through the ED, we found a surprisingly low prevalence of true-positive blood cultures, high incidence of antibiotic pre-treatment at nursing homes prior to admission, high hospital mortality and low immunization rates. There was a wide spectrum of pathogens grown in blood culture. Only two thirds of the patients had dyspnea at presentation, and less than half had either cough or fever. On physical examination, about one fourth had no clinical findings consistent with pneumonia. Further, less than one fifth of chest x-rays were interpreted as possible pneumonia.

Prognostic value of severity indicators of nursing-home-acquired pneumonia versus community-acquired pneumonia in elderly patients

BackgroundThe credibility of prognostic indicators in nursing-home-acquired pneumonia (NHAP) is not clear. We previously reported a simple prognostic indicator in community-acquired pneumonia (CAP): blood urea nitrogen to serum albumin (B/A) ratio. This retrospective study investigated the prognostic value of severity indicators in NHAP versus CAP in elderly patients.MethodsPatients aged ≥65 years and hospitalized because of NHAP or CAP within the previous 3 years were enrolled. Demographics, coexisting illnesses, laboratory and microbiological findings, and severity scores (confusion, urea, respiratory rate, blood pressure, and age ≥65 [CURB-65] scale; age, dehydration, respiratory failure, orientation disturbance, and pressure [A-DROP] scale; and pneumonia severity index [PSI]) were retrieved from medical records. The primary outcome was mortality within 28 days of admission.ResultsIn total, 138 NHAP and 307 CAP patients were enrolled. Mortality was higher in NHAP (18.1%) than in CAP (4.6%) (P<0.001). Patients with NHAP were older and had lower functional status and a higher rate of do-not-resuscitate orders, heart failure, and cerebrovascular diseases. The NHAP patients more frequently had typical bacterial pathogens. Using the receiver-operating characteristics curve for predicting mortality, the area under the curve in NHAP was 0.70 for the A-DROP scale, 0.69 for the CURB-65 scale, 0.67 for the PSI class, and 0.65 for the B/A ratio. The area under the curve in CAP was 0.73 for the A-DROP scale, 0.76 for the CURB-65 scale, 0.81 for the PSI class, and 0.83 for the B/A ratio.ConclusionPatient mortality was greater in NHAP than in CAP. Patient characteristics, coexisting illnesses, and detected pathogens differed greatly between NHAP and CAP. The existing severity indicators had less prognostic value for NHAP than for CAP.

The Value of Neutrophil-Lymphocyte Count Ratio for Disease Severity in Nursing Home Acquired Pneumonia Patients

,Background: We evaluated the value of neutrophil-lymphocyte count ratio (NLCR) in patients admitted to the Emergency Department (ED) with suspected nursing home acquired pneumonia (NHAP) Methods: From May 2011 to January 2013, 116 patients admitted to the ED with suspected NHAP were retrospectively studied. The clinical characteristics, C-reactive protein (CRP), white blood cell count, neutrophil count, lymphocyte count, and NLCR were assessed. CURB-65 score was used to calculate disease severity. General ward or intensive care unit (ICU) admissions, and 72-hour and 30-day mortality for each infection marker was assessed. Results: The 116 patients had a median age of 77 years. As the CURB-65 score increased from 0-1 (low risk), to 2-3 (moderate risk), and to 4-5 (high risk), the NLCR consistently increased (mean, 6.9, 8.89, and 16.22, respectively). The difference between the moderate and high risk groups was significant (p=0.008). The NLCR (mean±standard deviation) was high in patients with NHAP (10.28±8.81) and increased even more for patients admitted to the ICU (15.69 ±14.81) or who died within 72-hour (15.63±9.57). NLCR showed the trend of higher value in ICU admission (p=0.072), and CRP was significantly different between ICU and general ward admission (p=0.007). Conclusion: NLCR at ED admission correlated with NHAP severity and was comparable to the traditional infection marker. NLCR can be assessed simply and added to the assessment tools to determine the severity of pneumonia during ED admission.