A comparison of nursing home-acquired pneumonia patients with patients with community-acquired pneumonia and nursing home patients without pneumonia

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

Introduction

Despite 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).

Methods

This 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.

Results

Participants 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).

Conclusions

PC 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.

[Pneumonia in old age]

Die Pneumonie ist eine bei alten Menschen häufige und schwere Erkrankung. Sie steht in dieser Patientengruppe an vierter Stelle der zum Tode führenden Erkrankungen. Die Diagnose kann oft aufgrund einer atypischen klinischen Präsentation schwierig sein. Daher sollte bei jeder Verschlechterung eines alten Menschen ursächlich auch an eine Pneumonie gedacht werden. Geriatrische Probleme wie Gebrechlichkeit und physische und psychische Einschränkungen sollten ebenso erfasst werden wie die soziale Situation, da alle diese Faktoren prognoserelevant sind. Prognostisch ungünstiger verlaufen Pneumonien, die im Pflegeheim oder von Pflegebedürftigen erworben wurden. Sie gelten zwar als ambulant erworben, sollten dennoch besonders beachtet werden. Die Behandlung unterscheidet sich nicht grundsätzlich von der Behandlung jüngerer Patient, sollte aber besondere Situationen wie den in einer Patientenverfügung festgelegten Patientenwunsch bei der Therapieplanung berücksichtigen. Gerade ältere Menschen zeigen unter einer COVID(coronavirus disease)-19-Infektion oft atypische klinische Bilder, sodass bei akuten Veränderungen im Alter auch daran zu denken ist.

Development of tissue conditioner containing cetylpyridinium chloride montmorillonite as new antimicrobial agent: Pilot study on antimicrobial activity and biocompatibility

PURPOSE

The mechanical properties, antimicrobial activity, and biocompatibility of a novel antimicrobial tissue conditioner containing cetylpyridinium chloride with montmorillonite (CPC-Mont) were evaluated.

METHODS

To examine the mechanical properties of the novel material, hardness, consistency, and penetration tests were conducted. Antimicrobial activity against Candida albicans (C. albicans) and Staphylococcus aureus (S. aureus) was evaluated. Cell viabilities of fibroblasts and epithelial cells using eluates from materials were measured to evaluate cytotoxicity. In addition, to assess tissue response, animal experiments were conducted.

RESULTS

The hardness test results were similar to those of other commercially available materials. The novel tissue conditioner showed good antimicrobial activity against C. albicans and S. aureus compared with other materials. This effect was sustained for a week for C. albicans. In the case of S. aureus, microbial growth was suppressed for up to 3 weeks. Cell viability of the novel material for the eluate at 1 day was significantly less than those of other material for both cells. However, the cell viability at 7 days showed no significant difference. Animal experiments demonstrated that inflammatory responses around materials were not observed on the oral mucosa as other material.

CONCLUSION

Within the limitations of this in vitro and in vivo study, the results suggest that the newly developed tissue conditioner containing CPC-Mont has not only excellent antimicrobial properties, but also the same mechanical properties and biocompatibility as tissue conditioners on the market.

Nursing Home-Associated Pneumonia, Part I: Diagnosis

Pneumonia is 1 of the 3 most common infections identified in nursing home residents and is associated with the highest mortality of any infection in this setting. In regard to pneumonia in the nursing home setting, practitioners are focused primarily on identifying residents with this infection and choosing a treatment regimen. In this article, the diagnosis of this infection is addressed. Based on published studies and clinical experience, "bedside criteria" for the diagnosis of nursing home-associated pneumonia (NHAP) are proposed that are based primarily on objective respiratory signs and symptoms that can be readily identified by staff. It is also stressed that factors predisposing to aspiration should be identified because there is a risk for aspiration pneumonitis. A previously published decision tool to distinguish between aspiration pneumonia and aspiration pneumonitis is discussed. Because providers are often not present when there is a change in status of a resident, nursing staff are crucial to the diagnosis of NHAP. However, there is variability in staff experience and the ability to obtain and communicate clinical findings to assist providers in making decisions about diagnosis. To deal with this issue, templates have been developed to help staff collect the appropriate information before contacting the provider. The most important diagnostic test in a resident with suspected pneumonia is a chest radiograph. However, studies done more than a decade ago demonstrated considerable variability in radiologists' interpretation of chest radiographs of residents performed in the nursing home. Radiologic techniques have improved considerably with utilization of digital technology, but there have been no recent studies to determine if interpretation of these radiographs is more consistent. An alternative to radiographs is lung ultrasonography, which has been found to be more accurate than chest radiographs in identifying pneumonia in adults; however, this method has not been studied in the nursing home setting. Host biomarkers such as serum C-reactive protein and procalcitonin levels have been studied in adults with pneumonia to distinguish between bacterial and nonbacterial infection, but there has been limited study in NHAP and the findings are conflicting. Lastly, it is stressed that the provider should carefully document the clinical findings and testing that result in a diagnosis of pneumonia to enhance surveillance for infection as well as antimicrobial stewardship activities.

Predictive and prognostic factors in patients with blood-culture-positive community-acquired pneumococcal pneumonia

In patients with pneumococcal community-acquired pneumonia (CAP), the risk factors for bacteraemia and its impact on outcomes are not fully elucidated. We aimed to compare characteristics of patients with blood-culture-positive versus blood-culture-negative pneumococcal CAP, and to characterise bacteraemic serotypes.We describe a prospective, observational study on nonimmunocompromised patients with pneumococcal CAP, from 1996 to 2013. We define severe pneumonia according to American Thoracic Society/Infectious Diseases Society of America guidelines.Of a total of 917 patients with pneumococcal CAP, 362 had blood-culture-positive pneumococcal pneumonia (BCPPP; 39%). High C-reactive protein (CRP) (≥20 mg·dL(-1)) (odds ratio (OR) 2.36, 95% CI 1.45-3.85), pleural effusion (OR 2.03, 95% CI 1.13-3.65) and multilobar involvement (OR 1.69, 95% CI 1.02-2.79) were independently associated with bacteraemic CAP, while nursing home resident (OR 0.12, 95% CI 0.01-1.00) was found as a protective factor. Despite the clinical differences, BCPPP showed similar outcomes to blood-culture-negative pneumococcal pneumonia (BCNPP). 14% of the serotypes (period 2006-2013) causing bacteraemia are included in pneumococcal conjugate vaccine PVC7, 74% in pneumococcal conjugate vaccine PVC13 and 83% in pneumococcal polysaccharide vaccine PPSV23.Pleural effusion, a high level of CRP and multilobar involvement predicted an increased risk of BCPPP. Although BCPPP patients were more severely ill at admission, mortality was not significantly greater than in BCNPP 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.

Microbiology of healthcare-associated infections and the definition accuracy to predict infection by potentially drug resistant pathogens: a systematic review

Background

Healthcare-associated infections (HCAI) represent up to 50 % of all infections among patients admitted from the community. The current review intends to provide a systematic review on the microbiological profile involved in HCAI, to compare it with community-acquired (CAI) and hospital-acquired infections (HAI) and to evaluate the definition accuracy to predict infection by potentially drug resistant pathogens.

Methods

We search for HCAI in MEDLINE, SCOPUS and ISI Web of Knowledge with no limitations in regards to publication language, date of publication, study design or study quality. Only studies using the definition by Friedman et al. were included. This review was registered at PROSPERO Systematic Review Registration with the Number CRD42014013648.

Results

A total of 21 eligible studies with 12,096 infected patients were reviewed; of these 3497 had HCAI, 2723 were microbiologically documented. Twelve studies were on pneumonia involving 1051 patients with microbiological documented HCAI, the application of the current guidelines for this group of patients would result in an appropriate antibiotic therapy in 95 % of cases at the expense of overtreatment in 73 %; the application of community-acquired pneumonia guidelines would be adequate in only 73–76 % of the cases; an alternative regimen with piperacillin-tazobactam or aztreonam plus azithromycin would increase antibiotic adequacy rate to 90 %. Few studies were found on additional focus of infection: endocarditis, urinary, intra-abdominal and bloodstream infections. All studies included in this review showed an association of the HCAI definition with infection by PDR pathogens when compared to CAI [odds ratio (OR) 4.05, 95 % confidence interval (95 % CI) 2.60–6.31)]. The sensitivity of HCAI to predict infection by a PDR pathogen was 0.69 (0.65–0.72), specificity was 0.67 (0.66–0.68), positive likelihood ratio was 1.9 and the area under the summary ROC curve was 0.71.

Conclusions

This systematic review provides evidence that HCAI represents a separate group of infections in terms of the microbiology profile, including a significant association with infection by PDR pathogens, for the main focus of infection. The results provided can help clinician in the selection of empiric antibiotic therapy and international societies in the development of specific treatment recommendations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1304-2) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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.

AIM

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.

METHODS

We used combined data from two prospective observational cohorts of adult patients with pneumonia. Older patients aged ≥ 65 years were analysed.

RESULTS

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.

CONCLUSIONS

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.

Oral care may reduce pneumonia in the tube-fed elderly: a preliminary study

Pneumonia is one of the most important diseases in terms of mortality in the elderly. In particular, bedridden patients who are forbidden oral ingestion during enteral nutrition may have a poor outcome resulting from a respiratory infection. Oral hygiene can play a positive role in preventing aspiration pneumonia in the elderly. The aim of this study was to investigate the effectiveness of oral hygiene for bedridden and tube-fed patients at an increased risk of pneumonia. This retrospective study was conducted from July 2011 to June 2013 on a long-term-care hospital unit. The oral care protocol (OCP) intervention commenced in July 2012, during the study period. The subjects of this study were 63 elderly patients with a mean age of 81.7 years. Thirty-one patients were enrolled in the OCP intervention group, and the mean observation length was 130.4 days; the mean observation length for the 32 patients in the control group was 128.4 days. The incidence of pneumonia and the numbers of days with a recorded fever, antibiotics administration, blood tests, and radiological examinations were reduced from 1.20 to 0.45, 24.57 to 17.48, 25.52 to 10.12, 10.91 to 6.54, and 6.33 to 3.09 %, respectively. These reductions were significantly less in the OCP intervention group. In conclusion, the results of the present study suggest that daily oral care for tube-fed patients who do not receive nutrition by mouth reduced the incidence of pneumonia. In addition to patients consuming food by mouth, all tube-fed patients require dedicated oral care to maintain healthy oral conditions.

Carboxy-terminal provasopressin may predict prognosis in nursing home acquired pneumonia

BACKGROUND

This study compares biomarker (including procalcitonin, pro-ANP, and copeptin) levels to pneumonia severity scores to predict 30-day mortality in NHAP (nursing home acquired pneumonia) patients.

METHODS

Seventy three patients aged ≥ 65 y, admitted to general hospitals and who fulfilled the definition of NHAP were included in the study. Data collected at admission included age, gender, nursing home admission, coexisting illness, symptoms and clinical parameters (blood pressure, pulse rate, respiratory rate and status). Additional data collected included laboratory results, radiographic findings and outcome variables. Severity of pneumonia was evaluated using a prediction rule calculated by CURB-65 criteria (confusion, urea nitrogen, respiratory rate, blood pressure, age>65 y).

RESULTS

After adjustment for age, sex and CURB-65, copeptin (OR=5.60, 95% confidence interval (CI)=1.20-26.24) was associated with 30-day mortality in NHAP patients, while procalcitonin and pro-ANP were not. The areas under the receiver operating characteristic curves (AUCs) for CURB-65, in predicting mortality were 0.685 [95% CI 0.559-0.811], whereas copeptin showed slightly superior accuracy with an AUC of 0.698 (95% CI 0.568-0.827).

CONCLUSIONS

Among 3 biomakers, copeptin was the strongest predictor of 30-day mortality from NHAP. The pathophysiologic and clinical implications of this finding require further investigation.

Pulmonary emergencies: pneumonia, acute respiratory distress syndrome, lung abscess, and empyema

This article describes the clinical presentation of pneumonia, acute respiratory distress syndrome, lung abscess, and empyema: life-threatening infections of the pulmonary system. The etiology and risk factors for each of these conditions are described, diagnostic approaches are discussed, and evidence-based management options are reviewed.

Presentation, etiology and outcome of pneumonia in younger nursing home residents

OBJECTIVE

Nursing home-acquired pneumonia characteristically affects elderly patients with multiple comorbidities; it is associated with multidrug-resistant (MDR) pathogens and a high mortality. We studied the specific impact of age on the presentation, etiology and outcome of patients with NHAP.

METHODS

Data from the prospective multicenter CAPNETZ database were used for a comparison of the hospitalized younger nursing home residents with pneumonia to those aged ≥ 65 years as regards clinical presentation, comorbidity, severity at presentation, etiology, and outcome.

RESULTS

Amongst 618 patients with NHAP, 16% of patients (n = 100) were aged; 65 years. Comorbidity was present in most patients with NHAP but the pattern of comorbidity differed significantly. The rate of potential MDR pathogens was low among both age groups (together around 5%). According to the CRB-65 score, NHAP presentation was less severe in the younger patients. Short- and long-term mortality was twice as low in the younger patients with rates of 12.9% vs 26.6%, and 24.3% vs 43.8%, p = 0.014 and 0.002), respectively. In contrast, the usage of mechanical ventilation was more than two-fold higher (12% vs 5%) (p = 0.008) in younger patients. Antimicrobial treatment strategies did not account for different outcomes.

CONCLUSIONS

A considerable proportion of patients with NHAP are: 65 years of age. They differ from older patients in terms of clinical presentation, frequency and type of comorbidity, as well as outcome. NHAP is a heterogeneous entity, with age and comorbidity as the main determinant of NHAP characteristics.

Guidelines for the management of adult lower respiratory tract infections--summary

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Effect of saliva viscosity on the co-aggregation between oral streptococci and Actinomyces naeslundii

BACKGROUND

The co-aggregation of oral bacteria leads to their clearance from the oral cavity. Poor oral hygiene and high saliva viscosity are common amongst the elderly; thus, they frequently suffer from pneumonia caused by the aspiration of oral microorganisms.

OBJECTIVES

To examine the direct effect of saliva viscosity on the co-aggregation of oral streptococci with actinomyces.

MATERIALS AND METHODS

Fifteen oral streptococcal and a single actinomyces strain were used. Co-aggregation was assessed by a visual assay in phosphate buffer and a spectrophotometric assay in the same buffer containing 0-60% glycerol or whole saliva.

RESULTS

Nine oral streptococci co-aggregated with Actinomyces naeslundii ATCC12104 in the visual assay and were subsequently used for the spectrophotometric analysis. All tested strains displayed a decrease in co-aggregation with increasing amounts of glycerol in the buffer. The co-aggregation of Streptococcus oralis with A. naeslundii recovered to baseline level following the removal of glycerol. The per cent co-aggregation of S. oralis with A. naeslundii was significantly correlated with the viscosity in unstimulated and stimulated whole saliva samples (correlation coefficients: -0.52 and -0.48, respectively).

CONCLUSION

This study suggests that saliva viscosity affects the co-aggregation of oral streptococci with actinomyces and that bacterial co-aggregation decreases with increasing saliva viscosity.

Guidelines for the management of adult lower respiratory tract infections--full version

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Pneumonia in the long-term resident

Pneumonia in the long-term resident is common. It is associated with high morbidity and mortality. However, diagnosis and management of pneumonia in long-term care residents is challenging. This article provides an overview of the epidemiology, pathophysiology, diagnostic challenges, and management recommendations for pneumonia in this setting.

Review Series: Old age: Pneumonia in old age

At the end of the 19th century William Osler noted key differences in the presentation of pneumonia in the elderly. His observational perspicuity has withstood the passage of time. The following article pays deference to this Canadian physician, summarizing not only differences in clinical presentation but also including an update on epidemiology, aetiology and management.

Nursing home-acquired pneumonia: a review of risk factors and therapeutic approaches

OBJECTIVE

To review the risk factors, etiologic profile, treatment approaches, and guidelines for the management of nursing home-acquired pneumonia (NHAP).

RESEARCH DESIGN AND METHODS

A search of the current literature was conducted using the MEDLINE and Embase databases. This search, limited to studies performed in humans and published in English between January 1, 1990 and October 31, 2009, included the terms 'acquired pneumonia', 'associated pneumonia', 'nursing home', 'long-term care', 'institution', and 'healthcare'.

RESULTS

Older age, male gender, swallowing difficulty, and inability to take oral medications are all significant risk factors for pneumonia. Medications such as antipsychotics and anticholinergics, histamine receptor blockers and proton pump inhibitors have also been linked to higher risk of pneumonia. The etiology of NHAP overlaps with that of community-acquired pneumonia (CAP), with Streptococcus pneumoniae and Haemophilus influenzae as predominant pathogens in long-term care facilities. In patients who require hospitalization, Chlamydophila pneumoniae, Staphylococcus aureus, and influenza virus have also been identified. In contrast, the etiology of severe NHAP overlaps with that of hospital-acquired pneumonia (HAP), with S. aureus, including methicillin-resistant S. aureus (MRSA), Pseudomonas aeruginosa, and enteric Gram-negative bacilli as important causative pathogens. Therapy is dependent on disease severity and, on the treatment setting. Respiratory fluoroquinolones or β-lactams plus a macrolide are recommended in patients with NHAP. Patients hospitalized with severe NHAP may require triple combination therapy that covers both MRSA and P. aeruginosa. However, there is little evidence of the clinical superiority of one regimen over another, making it challenging to establish guidelines for the treatment of NHAP in the nursing home setting.

CONCLUSION

There is a pressing need for clinical trials of antibiotic therapy in nursing home patients that would help establish uniform guidelines to standardize therapy in the nursing home setting.

Rethinking the concepts of community-acquired and health-care-associated pneumonia

The increasing numbers of patients who are elderly and severely disabled has led to the introduction of a new category of pneumonia management: health-care-associated pneumonia (HCAP). An analysis of the available evidence in support of this category, however, reveals heterogeneous and misleading definitions of HCAP, reliance on microbiological data of questionable validity, failure to recognise the contribution of aspiration pneumonia, failure to control microbial patterns for functional status, and failure to recognise frequently applied restrictions of treatment escalation as bias in assessing outcomes. As a result, the concept of HCAP contributes to confusion more than it provides a guide to pneumonia management, and it potentially leads to overtreatment. We suggest a reassignment of the criteria for HCAP to reconstruct the triad of community-acquired pneumonia (with a recognised core group of elderly and disabled patients and a subgroup of younger patients), hospital-acquired pneumonia, and pneumonia in immunosuppressed patients.

Oral environmental factors affecting number of microbes in saliva of complete denture wearers

The purpose of this study was to clarify which oral environmental factors affected number of microbes in saliva in an edentulous environment. We enrolled 68 edentulous subjects in the study. Numbers of total anaerobic bacteria and Candida species in saliva were determined. Age, sex, un-stimulated salivary flow rate, pH and viscosity of saliva, histatin level in saliva, tongue coating status, tongue pressure, denture plaque status, material of denture base, duration of edentulism, frequency of self oral health care and number of cigarettes per day were also investigated as oral environmental factors. Correlation between number of total anaerobic bacteria or Candida species and each oral environmental factor was determined with the Spearman rank correlation coefficient. Stepwise logistic regression analysis was used to identify which factors were significantly associated with level of total anaerobic bacteria and Candida species. Correlation and stepwise logistic regression analyses revealed associations between un-stimulated salivary flow rate, tongue coating status, denture plaque status or frequency of self oral health care and number of total anaerobic bacteria. The correlation analysis showed a significant correlation between age and number of total anaerobic bacteria. Stepwise logistic analysis revealed associations between pH of saliva or viscosity of saliva and level of anaerobic bacteria; it also revealed associations between histatin level in saliva or un-stimulated salivary flow rate and level of Candida species. We conclude that salivary flow rate, in particular, affects number of salivary microbes in an edentulous environment.

Role of pathogenic oral flora in postoperative pneumonia following brain surgery

BACKGROUND

Post-operative pulmonary infection often appears to result from aspiration of pathogens colonizing the oral cavity. It was hypothesized that impaired periodontal status and pathogenic oral bacteria significantly contribute to development of aspiration pneumonia following neurosurgical operations. Further, the prophylactic effects of a single dose preoperative cefazolin on the oral bacteria were investigated.

METHODS

A matched cohort of 18 patients without postoperative lung complications was compared to 5 patients who developed pneumonia within 48 hours after brain surgery. Patients waiting for elective operation of a single brain tumor underwent dental examination and saliva collection before surgery. Bacteria from saliva cultures were isolated and periodontal disease was scored according to type and severity. Patients received 15 mg/kg cefazolin intravenously at the beginning of surgery. Serum, saliva and bronchial secretion were collected promptly after the operation. The minimal inhibitory concentrations of cefazolin regarding the isolated bacteria were determined. The actual antibiotic concentrations in serum, saliva and bronchial secretion were measured by capillary electrophoresis upon completion of surgery. Bacteria were isolated again from the sputum of postoperative pneumonia patients.

RESULTS

The number and severity of coexisting periodontal diseases were significantly greater in patients with postoperative pneumonia in comparison to the control group (p = 0.031 and p = 0.002, respectively). The relative risk of developing postoperative pneumonia in high periodontal score patients was 3.5 greater than in patients who had low periodontal score (p < 0.0001). Cefazolin concentration in saliva and bronchial secretion remained below detectable levels in every patient.

CONCLUSION

Presence of multiple periodontal diseases and pathogenic bacteria in the saliva are important predisposing factors of postoperative aspiration pneumonia in patients after brain surgery. The low penetration rate of cefazolin into the saliva indicates that its prophylactic administration may not be sufficient to prevent postoperative aspiration pneumonia. Our study suggests that dental examination may be warranted in order to identify patients at high risk of developing postoperative respiratory infections.

Pneumonia in the older patient

This article examines the bacteriology, clinical features, therapy for, and prevention of pneumonia in older patients. The discussion focuses on patients who develop pneumonia out of the hospital, including individuals with community-acquired pneumonia and health care-associated pneumonia. Health care-associated pneumonia incorporates patients who live in nursing homes when they develop pneumonia and in many instances requires management similar to nosocomial pneumonia. We have chosen not to discuss nosocomial pneumonia in older patients because it does not have distinctive features or a different management approach than when this illness arises in younger patients.

Tongue-coating as risk indicator for aspiration pneumonia in edentate elderly

Silent aspiration of oral microorganisms is a major cause of aspiration pneumonia. To establish oral hygiene criteria for the prevention of aspiration pneumonia in edentulous elderly persons, we investigated the relationship between presence of tongue-coating and number of oral bacteria in saliva and episodes of pneumonia. A total of 71 edentulous Japanese people aged 65 years or older living in nursing homes were enrolled in the study. A tongue plaque index (TPI) was used to evaluate quantity of tongue-coating, with TPI0 signifying no tongue-coating and TPI1 signifying presence of tongue-coating. Edentate elderly with TPI1 demonstrated significantly higher salivary bacterial counts than those with TPI0 (p<0.05). The number of elderly patients developing aspiration pneumonia was larger (p<0.005) in patients with TPI-based poor scores (average TPI>0.5) than in those with TPI-based good scores. The relative risk of developing pneumonia in the good tongue hygiene group compared with in the poor tongue hygiene group was 0.12, 95% confidence interval (CI): 0.02-0.9. The results demonstrate that tongue-coating is associated with number of viable salivary bacterial cells and development of aspiration pneumonia, suggesting that tongue-coating is a risk indicator of aspiration pneumonia in edentate subjects.

Professional oral health care by dental hygienists reduced respiratory infections in elderly persons requiring nursing care

OBJECTIVES

Respiratory infection is a major cause of death in the elderly. We have evaluated the role of professional oral health care (POHC) by dental hygienists in reducing respiratory infections in elderly persons requiring nursing care.

METHODS

Two populations of elderly persons, one receiving POHC and one not, were examined to determine numbers of microorganisms, potent pathogens of respiratory infection, enzymatic activity in saliva, fevers, prevalence of fatal aspiration pneumonia and prevalence of influenza.

RESULTS

In the first population, we found a high prevalence of potent respiratory pathogens such as Staphylococcus species, Pseudomonas aeruginosa and Candida albicans. Patients who received POHC showed a lower prevalence for these pathogens than those who did not. The ratio of fatal aspiration pneumonia in POHC patients was significantly lower than that in patients without POHC (non-POHC) over a 24-month period (P < 0.05). The prevalence of a fever of 37.8 degrees C or more in POHC patients was significantly lower than that in the non-POHC group (P < 0.05). In the second study population, we investigated the effects of POHC on infection with influenza over a 6-month period. In the POHC group, neuraminidase and trypsin-like protease activities decreased, and one of 98 patients was diagnosed with influenza; whereas, in the non-POHC group, nine of 92 patients were diagnosed with influenza. The relative risk of developing influenza while under POHC was 0.1 (95% CI 0.01-0.81, P = 0.008).

CONCLUSION

These results suggest that POHC by dental hygienists is effective in preventing respiratory infections in elderly persons requiring nursing care.

Assessment of pneumonia in older adults: effect of functional status

OBJECTIVES

Evaluate the effect of preadmission functional status on severity of pneumonia, length of hospital stay (LOS), and all-cause 30-day and 1-year mortality of adults aged 60 and older and to understand the effect of pneumonia on short-term functional impairment.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PARTICIPANTS

One hundred twelve patients with radiograph-proven pneumonia (mean age 74.6) were enrolled.

MEASUREMENTS

Functional status and comorbidities were assessed using the Functional Autonomy Measurement System (SMAF) and Charlson Comorbidity Index. Clinical information was used to calculate the Pneumonia Prognostic Index (PPI).

RESULTS

Eighty-four (75%) patients were functionally independent (FI) before admission, with a SMAF score of 40 or lower. Dementia and aspiration history were higher in the group that was functionally dependent (FD) before admission (P<.001). The FI group had less-severe pneumonia per the PPI and shorter mean LOS+/-standard deviation (5.62+/-0.51 days) than the FD group (11.42+/-2.58, P<.004). The FI group had lower 1-year mortality (19/65, 23%) than the FD group (14/28, 50%), and the difference remained significant after adjusting for Charlson Index and severity of illness (P=.009). All patients lost function after admission, with loss being more pronounced in the FI group (mean change 19.24+/-12.9 vs 4.72+/-6.55, P<.001).

CONCLUSION

Older adults who were FI before admission were more likely to present with less-severe pneumonia and have a shorter LOS. In addition, further loss of function was common in these patients. Assessment of function before and during hospitalization should be an integral part of clinical evaluation in all older adults with pneumonia.

Oral hygiene evaluation for effective oral care in preventing pneumonia in dentate elderly

The purpose of this study was to establish criteria for the visual evaluation of oral hygiene by analyzing the relationship between status of oral hygiene and number of oral bacteria in saliva for use in predicting the development of pneumonia. A total of 145 Japanese people of advanced age living in nursing homes were enrolled in the study. We evaluated the Dental Plaque Index (DPI) and Tongue Plaque Index (TPI) as simple measures of status of oral hygiene. We also determined the number of viable microorganisms in the saliva of each subject. The relationship between the status of oral hygiene and episodes of pneumonia was investigated over a period of one year. Dentate patients with poor oral hygiene as indicated by their DPI and TPI scores demonstrated significantly higher salivary bacterial counts than those with a good score for oral hygiene (p<0.01 and p<0.05, respectively). Both the number of febrile days was significantly higher (p=0.0012), and number of patients developing pneumonia larger (p<0.01) in dentate patients with DPI-based poor scores than those with DPI-based good scores. These results demonstrate a significant positive correlation between salivary bacteria and visual evaluation of oral hygiene in dentate patients according to number of febrile days and development of pneumonia.

Predictors of mortality for lower respiratory infections in nursing home residents with dementia were validated transnationally

BACKGROUND AND OBJECTIVE

Generalizability of clinical predictors for mortality from lower respiratory infection (LRI) in nursing home residents has not been assessed for residents with dementia.

STUDY DESIGN AND SETTING

In prospective cohort studies of LRI in 61 nursing homes in the Netherlands (n = 541) and 36 nursing homes in Missouri, USA (n = 564), we examined 14-day and 1- and 3-month mortality in residents with dementia who were treated with antibiotics.

RESULTS

A logistic model predicting 14-day mortality derived from Dutch data included eating dependency, elevated pulse, decreased alertness, respiratory difficulty, insufficient fluid intake, high respiratory rate, male gender, and pressure sores. After adjusting coefficients with the heuristic shrinkage factor, the 14-day model showed good discrimination and calibration in both datasets. The apparent c-statistic for the original Dutch model was 0.80 (after correction for optimism, it was 0.75); the c-statistic was 0.74 in the U.S. validation population. The models predicting 1- and 3-month mortality showed moderate performance. A scoring system for estimating 14-day mortality performed equally well as the original model.

CONCLUSION

We identified a set of credible clinical predictors that are easily assessed and demonstrated validity in identifying residents at low risk of dying from LRI across different nursing home populations. This tool should inform decision-making for families and doctors.

Epidemiology of community- and nursing home-acquired pneumonia in older adults

Pneumococcus remains the most important cause of community-acquired pneumonia in older adults. Alcoholism, bronchial asthma, immunosuppression, lung disease, heart disease, institutionalization and increasing age are important risk factors. There is a reduced prevalence of nonrespiratory symptoms in this age group. Advanced age and comorbidity are important prognostic factors. Influenza and pneumococcal vaccination remain the key factors for prevention.

Nursing Home-Acquired Pneumonia

The management of nursing home-acquired pneumonia (NHAP) continues to be debatable because of the lack of clinical trials and controversy regarding its aetiology. The controversy regarding aetiology stems, in part, from studies that utilised sputum cultures for the diagnosis of NHAP without assessing the quality of the samples. These studies found a high proportion of Gram-negative aerobic bacilli in cultures as well as Staphylococcus aureus. However, in studies that have assessed the reliability of sputum samples, Gram-negative bacilli and S. aureus were isolated infrequently and Streptococcus pneumoniae and Haemophilus influenzae isolated most commonly. Since Gram-negative aerobic bacilli and S. aureus frequently cause hospital-acquired pneumonia, some authors have considered NHAP to be a variant of this group. Many other studies, however, have considered NHAP as part of the community-acquired pneumonia category. Depending on which categorisation is used for NHAP, the treatment recommendations have varied. There are several factors to consider in the management of NHAP in addition to choice of antibacterial: hospitalisation decision, initial route of administration of antibacterials for treatment in the nursing home, timing of switch from a parenteral to an oral agent and the duration of therapy. These factors, which have not been addressed in published guidelines, are discussed in this review. Recent guidelines recommend a fluoroquinolone (gatifloxacin, levofloxacin or moxifloxacin) or amoxicillin/clavulanic acid plus a macrolide for initial treatment of NHAP in the nursing home. For treatment in the hospital, a parenteral fluoroquinolone (as listed above) or a second- or third-generation cephalosporin plus a macrolide is recommended. A recent guideline for the treatment of healthcare-associated pneumonia (that includes NHAP) recommended an antipseudomonal cephalosporin or a carbapenem or an antipseudomonal penicillin/beta-lactamase inhibitor plus ciprofloxacin plus vancomycin or linezolid for treatment of NHAP based on findings in residents with severe pneumonia who required mechanical ventilation. However, this recommendation does not apply to the majority of residents who are hospitalised with pneumonia and not intubated. Other factors to consider when choosing an empiric regimen include recent antibacterial therapy and prior colonisation with a resistant organism, e.g. methicillin-resistant S. aureus. Recently, a group of studies by investigators in The Netherlands have focused on the concept of withholding antibacterial therapy in nursing home residents with pneumonia who have advanced dementia. These studies are reviewed in some detail because this is an approach to the management of NHAP that is uncommon but deserves more consideration given the terminal status of these people. Future studies of NHAP should focus on development of rapid (molecular) methods to identify aetiological agents, determination of the optimum antimicrobial regimen and duration of therapy, and identification of criteria that can assist physicians and families in making the decision to withhold antimicrobial therapy in residents with advanced dementia and pneumonia.

Community-Acquired Pneumonia in Patients Receiving Home Care

OBJECTIVES

To describe the features of community-acquired pneumonia (CAP) requiring hospitalization in subjects receiving home care.

DESIGN

Prospective study from November 15, 2000, to November 14, 2002.

SETTING

Six hospitals in the Edmonton, Canada, area.

PARTICIPANTS

Two thousand four hundred sixty-four subjects aged 17 years and older with CAP, 21.9% of whom were receiving home care.

MEASUREMENTS

Pneumonia attack rates, demographic features, severity of illness, medication, length of stay, mortality, in hospital complications, and time to achieve physiological stability.

RESULTS

The overall rate of CAP requiring a visit to an emergency department in home care recipients was 25 per 1,000 person years, 90.8% of whom were admitted to the hospital for treatment. Patients who were receiving home care at the time of admission were older and less likely to be current tobacco smokers, had higher in-hospital mortality (11%) and a longer length of stay, were receiving more medications, and had more comorbidity and fewer symptoms except for shortness of breath and altered mental state than those who were not receiving home care. Home care patients had four times as many myocardial infarctions and recurrent aspiration as the non-home care patients. Falls occurred five times more often, and urinary catheters were inserted twice as often. Except for oxygen saturation, time to achieve physiological stability was the same for the two groups of patients. Half (51.2%) of the home care patients passed the get-up-and-go test, compared with 75% (P<.001) of the non-home care patients.

CONCLUSION

Home care patients with CAP had an 11% mortality rate and a higher rate of complications than those who did not receive home care.

Can We Prevent Aspiration Pneumonia in the Nursing Home?

Aspiration pneumonia is a significant cause of morbidity, hospitalization, and mortality in the nursing home population. Patients who aspirate have three times higher mortality than patients who do not aspirate. We discuss the factors known to increase the risk of aspiration and its consequences, and recognize some of the preventive measures for aspiration pneumonia. We suggest approaches to decrease the risk of this very prevalent syndrome.

Capsaicin Troche for Swallowing Dysfunction in Older People

OBJECTIVES

To determine whether oral capsaicin troche supplementation with every meal upregulates the impairment of upper respiratory protective reflexes such as the swallowing reflex and the cough reflex.

DESIGN

Randomized, controlled study with recruitment through nursing homes.

SETTING

Sendai, Japan, from September 2002 through December 2003.

PARTICIPANTS

Sixty-four participants in nursing homes with a mean age+/-standard deviation of 81.9+/-1.0 with stable physical status.

INTERVENTION

Participants were randomly assigned to the program for the supplementation of capsaicin trochisci or placebo trochisci before every meal for 4 weeks.

MEASUREMENTS

Assessment of individual latency time of the swallowing reflex (LTSR) and cough reflex sensitivity.

RESULTS

Before the commencement of this study, there were no significant baseline differences in multiple parameters between the intervention group and control group. LTSR in participants in the intervention group was significantly shorter than in the control group (P<.05). The odds ratio (OR) of the shortening of the LTSR of more than 1 minute in the intervention group was 3.4 (95% confidence interval (CI)=1.1-10.4), compared with the control group (P=.03). In particular, daily capsaicin supplementation significantly increased the ratio of LTSR reduction at 4 weeks after the study to baseline LTSR in the high-risk group (baseline LTSR >6.0 seconds) compared with the low-risk group (baseline LTSR <3.0 seconds) and the intermediate group (3.0 seconds <baseline LTSR <6.0 seconds) (P<.005). Seventeen (52.1%) participants in the intervention group and seven (21.9%) in the control group showed improvement in cough reflex sensitivity (OR=4.1, 95% CI=1.4-12.2; P<.01).

CONCLUSION

Daily capsaicin supplementation resulted in a significant improvement in upper protective respiratory reflexes, particularly in older people with a high risk for aspiration.

[Community-acquired pneumonia among the elderly: differences between patients living at home and in nursing homes]

OBJECTIVE

The etiology, presentation, and prognosis of community-acquired pneumonia (CAP) among nursing home residents are believed to differ from those of other groups. However, few Spanish studies have confirmed those assumptions or studied regional differences in CAP etiology.

PATIENTS AND METHODS

A prospective study which included all patients over 65 years of age admitted to our hospital with CAP was carried out over a period of 18 months (2002-2003). We examined clinical, analytical, and radiographic characteristics paying particular attention to functional status--using the Eastern Cooperative Oncology Group (ECOG) scale and Barthel and Karnofsky indices--and comorbidity. Two blood cultures, a Legionella antigen test in urine, and serology for atypical bacteria were used for the etiologic diagnosis; bacterial cultures of respiratory samples were also used in certain cases.

RESULTS

Ninety-one patients, 25 of whom were nursing home residents, were enrolled. The nursing home residents were older than the other patients (mean [SD] age of 82 [4] compared with 73 [5]; P=.0001) and had greater comorbidity (P=.0001)--with a significantly greater presence of diabetes mellitus, cerebrovascular disease, congestive heart failure, and dementia. They also had a poorer functional status (ECOG, 2.09 [0.9] compared with 0.93 [1.1], P=.001; Barthel Index, 19 [33] compared with 77 [35], P=.001; Karnofsky In-dex, 51 [17] compared with 78 [23], P=.001). Regarding clinical characteristics, significant differences were found for respiratory rate (39 [11] compared with 27 [7] breaths/min; P=.001), blood pressure (69.5 [20] compared with 79.2 [18] mm Hg; P=.029), and temperature (36.6 [1.2] compared with 37.7 [1.1] degrees C; P=.001). CAP patients from nursing homes presented a greater number of affected lobules in chest x-rays (P=.004), more hypoxemia, acidosis, anemia, hypoalbuminemia, and greater scores of urea and creatinine. Fine Scale scores were also greater (134 [26] compared with 95 [28]; P=.001) as was mortality (7/25 compared with 3/66; P=.005). Few patients had an etiologic diagnosis and no significant differences were observed between the groups. The variable that predicted mortality in elderly patients in this series, according to stepwise logistic regression, was urea (adjusted R2=0.452).

CONCLUSIONS

In our sample population, nursing home residents were older, had greater comorbidity, and severe functional impairment. Under these circumstances the severity of CAP increases and becomes an important cause of mortality despite the fact that the etiologic agents do not appear to differ from those of the other patients.

Management of respiratory infections in the elderly

Respiratory infections are common at all ages but are particularly sinister among the elderly because of the fragility and chronic comorbidity associated with this age group. The three types of respiratory infection in the elderly are community-acquired pneumonia, acute exacerbation of chronic obstructive pulmonary disease and nonpneumonic respiratory tract infection. The etiology of these three types of infection includes classic bacteria, atypical pathogens and respiratory viruses. The relative frequency of each of the etiological groups as the causative agent of the infection varies significantly among these types of infection, but in all three types a significant proportion of infections involves more than one pathogen. The causative agent of respiratory infection in the elderly cannot be determined on the basis of clinical manifestation or the results of routine imaging procedures or laboratory tests. Thus, initial antibiotic therapy in these patients should be empiric, based on accepted guidelines. In recent years, the antipneumococcal fluoroquinolones have gained in stature as one of the best options to treat these infections. Pneumococcal and influenza vaccinations can reduce morbidity and mortality from respiratory infections in the elderly, so it is important that all elderly individuals are vaccinated through a structured program in the framework of primary care. The economic impact of respiratory infections in the elderly is primarily associated with the requirement for hospitalization in many of the cases. Any action that can reduce hospitalization rates has important economic ramifications. In light of the difficulty in reaching an early etiologic diagnosis in respiratory infections, it is essential to invest in the development of a compact diagnostic kit for the early stages of the disease, which could change reality in this important area of medicine.

Étude descriptive des bactériémies dans un hôpital gériatrique universitaire

OBJECTIVES

To describe clinical features, microbiologic characteristics and outcome of bacteremia in the elderly patients hospitalized in a geriatric hospital.

PATIENTS AND METHODS

All episodes of bacteremia diagnosed from January 1(st) to December 31(st) 1998 were analysed, excluding false-positive cases due to skin contamination. The hospital comprises 1084 geriatric beds distributed as 111 in acute care (ACF), 333 in rehabilitation and intermediate-care (RICF), and 516 in long-term-care facilities (LTCF).

RESULTS

Sixty-six episodes of bacteremia were observed in 65 patients. Among them 59 (89%) were nosocomial bacteremia distributed as 20 in ACF, 29 in RICF and 10 in LTCF (rates of 0.6, 0.35, and 0.05 episodes per 1000 patient-days, respectively.). Escherichia coli and Staphylococcus aureus were the main bacterial species involved in 31% and 28% of the cases, respectively. E. coli strains were 50% resistant to amoxicillin and 41% resistant to co-amoxiclav, and 68% of S. aureus strains were resistant to methicillin. Portals of entry were urinary tract (44%), respiratory tract (14%), digestive tract (11%), and soft tissue (8%). The same bacterial strain as in bacteremia was isolated from a peripheric site in 30 cases (47%), most of them being urines. For 15% cases, portal of entry cannot be determined. Mortality associated to nosocomial bacteremia was 25%, and death was significantly associated to MRSA, urinary or intravascular devices, chronic wounds and inappropriate antibiotic prescription.

CONCLUSION

In geriatric hospitals, bacteremia are mainly nosocomial cases. Prevention should focus on indwelling devices and antibiotic resistance.

Outcome predictors of pneumonia in elderly patients: importance of functional assessment

OBJECTIVES

To evaluate the outcome of elderly patients with community-acquired pneumonia (CAP) seen at an acute-care hospital, analyzing the importance of CAP severity, functional status, comorbidity, and frailty.

DESIGN

Prospective observational study.

SETTING

Emergency department and geriatric medical day hospital of a university teaching hospital.

PARTICIPANTS

Ninety-nine patients aged 65 and older seen for CAP over a 6-month recruitment period.

MEASUREMENTS

Clinical data were used to calculate Pneumonia Severity Index (PSI), Barthel Index (BI), Charlson Comorbidity Index, and Hospital Admission Risk Profile (HARP). Patients were then assessed 15 days later to determine functional decline and 30 days and 18 months later for mortality and readmission. Multiple logistic regression was used to analyze outcomes.

RESULTS

Functional decline was observed in 23% of the 93 survivors. Within the 30-day period, case-fatality rate was 6% and readmission rate 11%; 18-month rates were 24% and 59%, respectively. Higher BI was a protective factor for 30-day and 18-month mortality (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.94-0.98 and OR=0.97, 95% CI=0.95-0.99, respectively; P<.01), and PSI was the only predictor for functional decline (OR=1.03, 95% CI=1.01-1.05; P=.01). Indices did not predict readmission. Analyses were repeated for the 74 inpatients and indicated similar results except for 18-month mortality, which HARP predicted (OR=1.73; 95% CI=1.16-2.57; P<.01).

CONCLUSION

Functional status was an independent predictor for short- and long-term mortality in hospitalized patients whereas CAP severity predicted functional decline. Severity indices for CAP should possibly thus be adjusted in the elderly population, taking functional status assessment into account.