Evidence-based guidelines for management of nursing home-acquired pneumonia

We convened a multidisciplinary, multispecialty panel to develop comprehensive evidence and consensus-based guidelines for managing nursing home-acquired pneumonia. The panel began with explicit criteria for process of care quality measures, performed a comprehensive review of the English-language literature, evaluated the quality of the evidence, and drafted a set of proposed guidelines. The panel reviewed the draft, an annotated bibliography, and data from a study of 30-day survival from nursing home-acquired pneumonia, and then participated in an all-day meeting in January 2001. Using a modified Delphi process, the panel refined the guidelines and developed a care pathway. The guidelines recommend a comprehensive approach, including immunization of staff and residents, and communication between nursing staff and the attending physician within 2 hours of symptom 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 antibiotic 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.

Mortality from nursing home-acquired pneumonia is as high as 44%,¹and nearly a third of those who survive 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 elderly patients, to be colonized with gram-negative rods and pathogens with multiple antibiotic resistance.^3-8Inappropriate use of antibiotics in long-term care facilities contributes significantly to the growing problem of antibiotic resistance generally.⁹ In addition, most nursing home residents are cognitively impaired, immunocompromised, have multiple functional deficits, or have dysphagia, which further contributes to their vulnerability.¹⁰

In recent work¹¹ with a national nursing home sample, we showed that high quality care, including appropriate antibiotic use, hospitalization when indicated, 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 adequate care; for example, only 31% of residents received antibiotics within one 8-hour shift of symptom 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 diagnosis and treatment of infections in nursing homes have been published in the last 2 years,^15-17but these guidelines are not specific to pneumonia. The only guideline specific to nursing home-acquired pneumonia used current community practice in 1 metropolitan 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, pharmacology, pulmonology, geriatrics, and nursing to develop comprehensive evidence-based guidelines for management of nursing home-acquired pneumonia. The guidelines address immunization, infection control, timing and thoroughness of nurse and physician evaluation of lower respiratory tract infections, criteria for hospitalization, and criteria for antibiotic spectrum, timing, route, and duration.

Guideline development

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 mulidisciplinary 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 criteria 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 literature 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 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).¹⁹ Published Canadian and American guidelines for treatment of community-acquired and nosocomial pneumonia formed a template for the antibiotic recommendations.^20,21