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Mahmoud E, Abanamy R, Binawad E, Alhatmi H, Alzammam A, Habib A, Alturaifi D, Alharbi A, Alqahtani H, Aldohayan M. Infections and patterns of antibiotic utilization in support and comfort care patients: A tertiary care center experience. J Infect Public Health 2021; 14:839-844. [PMID: 34118733 DOI: 10.1016/j.jiph.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/07/2021] [Accepted: 05/18/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Little is known regarding the burden of infections and clinical practice towards hospitalized patients with limits on life-sustaining measures. We aim to describe the infectious syndromes, clinical care, the emergence of multi-drug resistant organisms and outcomes in this population. PATIENTS AND METHODS Retrospective cohort of patients labeled as support or comfort care in a tertiary care center between 2016-2019. RESULTS A total of 347 patients were included with a mean age of 68.5 years, who were predominantly males (59.94%), bedbound (69.74%), on tube feeding (66.86%), and required indwelling urinary catheters (61.96%). The total number of admissions during the first year was 498, with the mean length of stay being 30 days. The number of infectious syndromes identified during that period was 821episodes, with a mean of 2 infectious syndromes per admission. The most common infection identified was pneumonia (41.66%) followed by urinary tract infections (27.16%). A total of 3891 microbiological cultures were taken with a mean of 5 cultures per infectious syndrome. The most commonly identified pathogens were Gram-negative bacteria (61.03%), with a high rate of multidrug-resistant organisms (MDROs) (48.53%). The one-year mortality was 86.4%. Using carbapenem antibiotic and pneumonia were the independent predictors used for the MDROs. CONCLUSION Our study reflects the high burden of infections, antimicrobial resistance, and hospital admissions among a population with limited life expectancy. A consensus regarding investigating and managing of infectious syndromes, and antimicrobial prescription is needed to reduce the harms associated with overuse of antimicrobials.
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Affiliation(s)
- Ebrahim Mahmoud
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.
| | - Reem Abanamy
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Eman Binawad
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hind Alhatmi
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Ali Alzammam
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman Habib
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Dana Alturaifi
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Alharbi
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hajar Alqahtani
- Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed Aldohayan
- Department of Health Informatics, CPHHI, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Data and Business Intelligence Management Department, ISID, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Tan LF, Seetharaman S. Preventing the Spread of COVID-19 to Nursing Homes: Experience from a Singapore Geriatric Centre. J Am Geriatr Soc 2020; 68:942. [PMID: 32216132 PMCID: PMC7228324 DOI: 10.1111/jgs.16447] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 03/24/2020] [Indexed: 12/03/2022]
Affiliation(s)
- Li Feng Tan
- Healthy Ageing Programme, Alexandra HospitalSingapore
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Hase T, Miura Y, Nakagami G, Okamoto S, Sanada H, Sugama J. Food bolus‐forming ability predicts incidence of aspiration pneumonia in nursing home older adults: A prospective observational study. J Oral Rehabil 2019; 47:53-60. [DOI: 10.1111/joor.12861] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 06/22/2019] [Accepted: 07/04/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Takashi Hase
- Department of Oral and Maxillofacial Surgery Noto General Hospital Ishikawa Japan
| | - Yuka Miura
- Department of Imaging Nursing Science, Graduate School of Medicine The University of Tokyo Tokyo Japan
| | - Gojiro Nakagami
- Department of Gerontological Nursing/ Wound Care Management, Graduate School of Medicine The University of Tokyo Tokyo Japan
- Global Nursing Research Center, Graduate School of Medicine The University of Tokyo Tokyo Japan
| | - Shigefumi Okamoto
- Department of Laboratory Science, School of Health Sciences, College of Medical, Pharmaceutical, and Health Sciences Kanazawa University Ishikawa Japan
| | - Hiromi Sanada
- Department of Gerontological Nursing/ Wound Care Management, Graduate School of Medicine The University of Tokyo Tokyo Japan
- Global Nursing Research Center, Graduate School of Medicine The University of Tokyo Tokyo Japan
| | - Junko Sugama
- Institute for Frontier Science Initiative Kanazawa University Ishikawa Japan
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Liu C, Cao Y, Lin J, Ng L, Needleman I, Walsh T, Li C. Oral care measures for preventing nursing home-acquired pneumonia. Cochrane Database Syst Rev 2018; 9:CD012416. [PMID: 30264525 PMCID: PMC6513285 DOI: 10.1002/14651858.cd012416.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pneumonia occurring in residents of long-term care facilities and nursing homes can be termed 'nursing home-acquired pneumonia' (NHAP). NHAP is the leading cause of mortality among residents. NHAP may be caused by aspiration of oropharyngeal flora into the lung, and by failure of the individual's defence mechanisms to eliminate the aspirated bacteria. Oral care measures to remove or disrupt oral plaque might be effective in reducing the risk of NHAP. OBJECTIVES To assess effects of oral care measures for preventing nursing home-acquired pneumonia in residents of nursing homes and other long-term care facilities. SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 November 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 10), MEDLINE Ovid (1946 to 15 November 2017), and Embase Ovid (1980 to 15 November 2017) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1937 to 15 November 2017). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the Chinese Biomedical Literature Database, the China National Knowledge Infrastructure, and the Sciencepaper Online to 20 November 2017. SELECTION CRITERIA 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. DATA COLLECTION AND ANALYSIS 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 ratio (RR) for dichotomous outcomes, mean difference (MD) for continuous outcomes, and hazard ratio (HR) for time-to-event outcomes, using random-effects models. MAIN RESULTS We included four RCTs (3905 participants), all of which were at high risk of bias. The studies all evaluated one comparison: professional oral care versus usual oral care. We did not pool the results from one study (N = 834 participants), which was stopped at interim analysis due to lack of a clear difference between groups.We were unable to determine whether professional oral care resulted in a lower incidence rate of NHAP compared with usual oral care over an 18-month period (hazard ratio 0.65, 95% CI 0.29 to 1.46; one study, 2513 participants analysed; low-quality evidence).We were also unable to determine whether professional oral care resulted in a lower number of first episodes of pneumonia compared with usual care over a 24-month period (RR 0.61, 95% CI 0.37 to 1.01; one study, 366 participants analysed; low-quality evidence).There was low-quality evidence from two studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24-month follow-up (RR 0.41, 95% CI 0.24 to 0.72, 507 participants analysed).We were uncertain whether or not professional oral care may reduce all-cause mortality compared to usual care, when measured at 24-month follow-up (RR 0.55, 95% CI 0.27 to 1.15; one study, 141 participants analysed; very low-quality evidence).Only one study (834 participants randomised) measured 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. AUTHORS' CONCLUSIONS Although low-quality evidence suggests that professional oral care could reduce mortality due to pneumonia in nursing home residents when compared to usual care, this finding must be considered with caution. Evidence for other outcomes is inconclusive. We found no high-quality evidence to determine which oral care measures are most effective for reducing nursing home-acquired pneumonia. Further trials are needed to draw reliable conclusions.
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Affiliation(s)
- Chang Liu
- West China Hospital of Stomatology, Sichuan UniversityDepartment of Oral and Maxillofacial Surgery, State Key Laboratory of Oral DiseasesNO.14, 3rd Section of Ren Min Nan RoadChengduSichuanChina610041
| | - Yubin Cao
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Jie Lin
- West China Hospital of Stomatology, Sichuan UniversityDepartment of Oral Anaesthesiology and Intensive Care UnitNo 14, Section 3, South Renmin RoadChengduSichuanChina610041
| | - Linda Ng
- The University of QueenslandSchool of Nursing and MidwiferyMater Campus: JP Kelly BuildingSouth BrisbaneQueenslandAustralia4101
| | - Ian Needleman
- UCL Eastman Dental InstituteUnit of Periodontology and International Centre for Evidence‐Based Oral Health256 Gray's Inn RoadLondonUKWC1X 8LD
| | - Tanya Walsh
- The University of ManchesterDivision of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Chunjie Li
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
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Affiliation(s)
- David G Smithard
- Consultant in Elderly and Stroke Medicine. King's College Hospital NHS Foundation Trust
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McClester Brown M, Sloane PD, Kistler CE, Reed D, Ward K, Weber D, Zimmerman S. Evaluation and Management of the Nursing Home Resident With Respiratory Symptoms and an Equivocal Chest X-Ray Report. J Am Med Dir Assoc 2016; 17:1164.e1-1164.e5. [PMID: 27815108 DOI: 10.1016/j.jamda.2016.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 09/18/2016] [Accepted: 09/19/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Pneumonia is a leading cause of morbidity and mortality in nursing home (NH) residents. Chest x-ray evidence is considered a key diagnostic criterion for pneumonia by the Infectious Disease Society of America (IDSA) diagnostic guidelines, the modified McGeer diagnostic criteria, and the Loeb criteria for initiating antibiotics; however, x-ray interpretation is often equivocal. We conducted chart audits of patients in NHs who had chest x-rays for new respiratory symptoms to determine the degree of ambiguity in the radiology reports and their relationship to antibiotic prescription decisions. DESIGN Cross-sectional study. SETTING Thirty-one NHs in North Carolina. PARTICIPANTS Two hundred twenty-six NH residents who had a chest x-ray. METHODS Medical charts were abstracted to record (1) the patient's clinical presentation when a chest x-ray was ordered, (2) the verbatim report of the chest x-ray, and (3) the patient's course during the subsequent 7 days. To standardize the radiologist reports, a seven-category coding system was developed, which was further aggregated into three groups based on the radiologist's description of the likelihood of pneumonia. RESULTS Of the 226 chest x-rays, 118 (52%) identified a very low likelihood of pneumonia, 67 (30%) indicated that pneumonia was present or highly likely, and the remaining 41 (18%) used a variety of terms to describe uncertainty regarding the presence of pneumonia. NH medical providers tended to treat ambiguous chest x-ray reports similarly to positive x-ray reports, prescribing antibiotic therapy to 71% of patients with ambiguous reports and 78% of positive reports. Also notable is that 40 (34%) of the 118 patients with a very low likelihood of pneumonia based on chest x-ray results were prescribed antibiotics, the majority of whom failed to meet criteria for a clinical diagnosis of pneumonia or chronic obstructive pulmonary disease exacerbation. CONCLUSION The moderate rate of ambiguous x-ray interpretations in NH residents is likely a combination of the poor quality of portable x-rays, a high prevalence of chronic lung conditions, and conservative (ie, cautious) decision making by radiologists whose interpretation is based on little clinical information and a suboptimal quality film. As a result, data suggest that chest x-rays obtained in NHs may unnecessarily encourage antibiotic prescribing because a majority of readings are ambiguous or show a low likelihood of pneumonia, yet more than half of the patients are still treated. From an antibiotic stewardship standpoint, the apparent solution is to more closely rely on clinical signs and symptoms for diagnosis of pneumonia and to place less emphasis on the role of the chest x-ray given the high number of unclear readings.
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Affiliation(s)
- Mallory McClester Brown
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Philip D Sloane
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christine E Kistler
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David Reed
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kimberly Ward
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - David Weber
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Medicine and Pediatrics, Division of Infectious Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Li C, Zhang Q, Ng L, Needleman I, Jie L, Walsh T. Oral care measures for preventing nursing home-acquired pneumonia. Cochrane Database Syst Rev 2016. [DOI: 10.1002/14651858.cd012416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Chunjie Li
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University; Department of Head and Neck Oncology; No. 14, Section Three, Ren Min Nan Road Chengdu Sichuan China 610041
| | - Qi Zhang
- State Key Laboratory of Oral Diseases, West China College of Stomatology, Sichuan University; Department of Oral Implantology; No. 14, Section Three, Ren Min Nan Road Chengdu Sichuan China 610041
| | - Linda Ng
- University of Queensland; School of Nursing and Midwifery; Mater Campus: JP Kelly Building South Brisbane Queensland Australia 4101
| | - Ian Needleman
- UCL Eastman Dental Institute; Unit of Periodontology and International Centre for Evidence-Based Oral Health; 256 Gray's Inn Road London UK WC1X 8LD
| | - Lin Jie
- West China Hospital of Stomatology, Sichuan University; Department of Oral Anaesthesiology and Intensive Care Unit; No 14, Section 3, South Renmin Road Chengdu China 610041
| | - Tanya Walsh
- The University of Manchester; Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health; JR Moore Building Oxford Road Manchester UK M13 9PL
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Jablonski RA, Munro CL, Grap MJ, Elswick RK. The Role of Biobehavioral, Environmental, and Social Forces on Oral Health Disparities in Frail and Functionally Dependent Nursing Home Elders. Biol Res Nurs 2016; 7:75-82. [PMID: 15920005 DOI: 10.1177/1099800405275726] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this article is to review the literature on and discuss how interactions between bio-behavioral aging, nursing home environments, and social forces shaping current health care policies have contributed to oral health disparities in frail and functionally dependent elders who reside in nursing homes. Emerging empirical evidence suggests links between poor oral health with dental plaque deposition and systemic disease, such as nursing home-acquired pneumonia. The majority of nursing home residents lack either the functional ability or the mental capacity to perform their own mouth care and therefore must rely on others to perform mouth care for them. Certified nursing assistants (CNAs), who provide the majority of care activities, were unsure how to provide care to residents who engaged in care-resistive behaviors. The nurses who supervise the CNAs have limited knowledge regarding the provision of mouth care in general, and they specifically lack knowledge regarding the provision of mouth care to elders exhibiting care-resistant behavior. Elders in nursing homes have limited options when paying for dental care; Medicare does not generally cover routine dental care. Medicaid coverage varies widely between individual states; even when coverage exists, low Medicaid reimbursements discourage dentists from accepting Medicaid patients. The strategies needed to reduce these oral health disparities are complicated but not unrealistic. Investigators willing to embrace this cause will have no shortage of opportunities to test methods to improve the delivery of oral care as well as to monitor and reassess these methods.
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Affiliation(s)
- Rita A Jablonski
- School of Nursing, Virginia Commonwealth University, Richmond 23298, USA.
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Scannapieco FA, Shay K. Oral health disparities in older adults: oral bacteria, inflammation, and aspiration pneumonia. Dent Clin North Am 2014; 58:771-82. [PMID: 25201541 DOI: 10.1016/j.cden.2014.06.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Poor oral hygiene has been suggested to be a risk factor for aspiration pneumonia in the institutionalized and disabled elderly. Control of oral biofilm formation in these populations reduces the numbers of potential respiratory pathogens in the oral secretions, which in turn reduces the risk for pneumonia. Together with other preventive measures, improved oral hygiene helps to control lower respiratory infections in frail elderly hospital and nursing home patients.
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Affiliation(s)
- Frank A Scannapieco
- Department of Oral Biology, School of Dental Medicine, University at Buffalo - The State University of New York, Foster Hall, Buffalo, NY 14214, USA.
| | - Kenneth Shay
- Geriatrics and Extended Care Services (10P4G), US Department of Veterans Affairs, PO Box 134002, Ann Arbor, MI 48113-4002, USA
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Age and other risk factors of pneumonia among residents of Polish long-term care facilities. Int J Infect Dis 2013; 17:e37-43. [DOI: 10.1016/j.ijid.2012.07.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 05/24/2012] [Accepted: 07/04/2012] [Indexed: 11/20/2022] Open
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Arinzon Z, Peisakh A, Schrire S, Berner Y. C-reactive protein (CRP): An important diagnostic and prognostic tool in nursing-home-associated pneumonia. Arch Gerontol Geriatr 2011; 53:364-9. [DOI: 10.1016/j.archger.2011.01.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 01/17/2011] [Accepted: 01/19/2011] [Indexed: 11/17/2022]
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El-Solh AA, Niederman MS, Drinka P. Nursing home-acquired pneumonia: a review of risk factors and therapeutic approaches. Curr Med Res Opin 2010; 26:2707-14. [PMID: 20973617 DOI: 10.1185/03007995.2010.530154] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Ali A El-Solh
- Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Western New York Healthcare System, Buffalo, NY 14215-1199, USA.
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Cagatay AA, Tufan F, Hindilerden F, Aydin S, Elcioglu OC, Karadeniz A, Alpay N, Gokturk S, Taranoglu O. The causes of acute Fever requiring hospitalization in geriatric patients: comparison of infectious and noninfectious etiology. J Aging Res 2010; 2010:380892. [PMID: 21151521 PMCID: PMC2989655 DOI: 10.4061/2010/380892] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2009] [Revised: 04/09/2010] [Accepted: 07/06/2010] [Indexed: 01/25/2023] Open
Abstract
Introduction. Infectious diseases may present with atypical presentations in the geriatric patients. While fever is an important finding of infections, it may also be a sign of noninfectious etiology. Methods. Geriatric patients who were hospitalized for acute fever in our infectious diseases unit were included. Acute fever was defined as presentation within the first week of fever above 37.3°C. Results. 185 patients were included (82 males and 103 females). Mean age was 69.7 ± 7.5 years. The cause of fever was an infectious disease in 135 and noninfectious disease in 32 and unknown in 18 of the patients. The most common infectious etiologies were respiratory tract infections (n = 46), urinary tract infections (n = 26), and skin and soft tissue infections (n = 23). Noninfectious causes of fever were rheumatic diseases (n = 8), solid tumors (n = 7), hematological diseases (n = 10), and vasculitis (n = 7). A noninfectious cause of fever was present in one patient with no underlying diseases and in 31 of 130 patients with underlying diseases. Conclusion. Geriatric patients with no underlying diseases generally had infectious causes of fever while noninfectious causes were responsible from fever in an important proportion of patients with underlying diseases.
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Affiliation(s)
- A Atahan Cagatay
- Istanbul University, Istanbul Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, PB 34390, Fatih, Istanbul, Turkey
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Simoni-Wastila L, Blanchette CM, Qian J, Yang HWK, Zhao L, Zuckerman IH, Pak GH, Silver H, Dalal AA. Burden of chronic obstructive pulmonary disease in Medicare beneficiaries residing in long-term care facilities. ACTA ACUST UNITED AC 2010; 7:262-70. [PMID: 19948302 DOI: 10.1016/j.amjopharm.2009.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD increases health care resource utilization and spending and adversely affects quality of life. Data from the clinical and economic outcomes in Medicare beneficiaries with COPD who reside in long-term care (LTC) facilities are limited. OBJECTIVE The purpose of this study was to investigate the clinical and economic outcomes associated with COPD in Medicare beneficiaries residing in LTC facilities. METHODS This retrospective cohort study analyzed data from MarketScan Medicaid, a large US administrative claims database containing data on Medicaid programs in 8 states. The study cohort comprised LTC facility residents aged > or =60 years who had a diagnosis of COPD. Eligible patients also had a prescription filled between January 1, 2003, and June 30, 2005, for one of the following COPD treatments: fluticasone propionate + salmeterol xinafoate, tiotropium bromide, ipratropium bromide, or ipratropium bromide + albuterol sulfate. The date of the first prescription fill was considered the index date. Measures of health care resource utilization included COPD-related and all-cause hospitalizations and emergency department (ED) visits. Cost analysis outcomes included COPD-related and all-cause inpatient, outpatient, pharmacy, LTC, and total costs during the 12-month postindex period. RESULTS Data from 3037 patients were included (63.0% women; 82.2% white; mean [SD] age, 78.1 [10.0] years). A total of 43.3% of patients had > or =1 hospitalization; 90.0%, > or =1 ED visit. With the exception of age <70 years, age was associated with all-cause hospitalization (age 70-<75 years, hazard ratio [HR] = 1.31 [95% CI, 1.03-1.68]; age 75-<80 years, HR = 1.40 [95% CI, 1.11-1.78]; age > or =80 years, HR = 1.48 [95% CI, 1.19-1.85]). Age was not associated with COPD-related hospitalization, all-cause ED visits, or COPD-related ED visits. The risk for all-cause hospitalization in white patients was significantly lower compared with that in nonwhite patients (HR = 0.79 [95% CI, 0.69-0.91]). Patients with comorbid asthma had a higher risk for a COPD-related ED visit (HR = 1.34 [95% CI, 1.08-1.66]) than did patients without asthma. Preindex all-cause hospitalization was associated with COPD-related hospitalization (HR = 1.78 [95% CI, 1.49-2.14]) and all-cause hospitalization (HR = 2.05 [95% CI, 1.932.19]). Twelve-month COPD-related and all-cause direct expenditures per beneficiary were US $7391 and $48,183. In COPD-related and all-cause estimates, mean (SD) LTC costs were the largest cost components ($5629 [$12,562] and $32,966 [$14,871], respectively), followed by pharmacy costs ($956 [$957] and $5565 [$3873]), inpatient costs ($466 [$3393] and $6436 [$22,603]), and outpatient costs ($341 [$1793] and $3216 [$6458]). CONCLUSION This study found that the utilization of health care resources and economic burden of LTC residents with COPD were primarily due to LTC, pharmacy, and inpatient costs.
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Affiliation(s)
- Linda Simoni-Wastila
- Peter Lamy Center on Drug Therapy and Aging, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland 21201, USA.
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[Repeated prevalence investigations of nursing home-associated infections as a tool to assess the hygienic quality of care]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2009; 52:936-44. [PMID: 19756338 DOI: 10.1007/s00103-009-0938-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The rate of healthcare-associated infections can be regarded as an important outcome parameter of the hygienic quality of care in nursing homes. Our study aimed to evaluate the applicability of repeated prevalence investigations as a tool for surveillance of healthcare-associated infections in nursing homes. From December 2006 to September 2007 a total of five prevalence investigations were conducted in four nursing homes each (n=2,369 residents). Initially, defined structural and procedural parameters of the hygienic quality of the four nursing homes were evaluated based on a detailed inspection and a checklist including 40 parameters. The results showed a uniformly high level of the hygienic quality with only minor variation (mean 84%, range 75%-93% of parameters fulfilled). In total, the prevalence of healthcare-associated infections was 6.8%, with a marked increase with higher categories of dependency (3.5%, 4.0%, 8.5%, and 12.3%, respectively, in the categories 0, I, II, and III of the German grading of skilled nursing care). Respiratory tract (4.1%), skin/soft tissue (1.5%), and urinary tract infections were the most prevalent healthcare-associated infections. Respiratory tract infections showed a marked seasonal pattern. During the second prevalence investigation (February 2007), an outbreak of upper respiratory tract infections occurred in one of the nursing homes (attack rate, 17%). The crude prevalence rates showed considerable differences between the four nursing homes; however, after adjusting for the different categories of dependency, the standardized infection rates (SIR) were largely comparable (excluding the outbreak). After inclusion of the outbreak, the SIR of the specific nursing home was significantly higher compared to all other nursing homes. In conclusion, our study shows that repeated prevalence investigations can be an easy to use tool for surveillance of healthcare-associated infections as a surrogate parameter of the hygienic quality in nursing homes. This implies a knowledge of the seasonality of specific infections and a risk adjustment according to the categories of dependency. The primary intention of surveillance should be the identification of hygienic problems. However, the resources should preferentially be focused on hygienic structures and processes.
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High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. J Am Geriatr Soc 2009; 57:375-94. [PMID: 19278394 PMCID: PMC7166905 DOI: 10.1111/j.1532-5415.2009.02175.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Residents of long‐term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one‐half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on‐site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.
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Affiliation(s)
- Kevin P High
- Section on Infectious Diseases, Wake Forest University Health Sciences, Winston Salem, North Carolina 27157-1042, USA.
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High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. J Am Geriatr Soc 2009. [PMID: 19278394 DOI: 10.1111/j.1532‐5415.2009.02175.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.
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Affiliation(s)
- Kevin P High
- Section on Infectious Diseases, Wake Forest University Health Sciences, Winston Salem, North Carolina 27157-1042, USA.
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High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, Yoshikawa TT. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 48:149-71. [PMID: 19072244 DOI: 10.1086/595683] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided.
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Affiliation(s)
- Kevin P High
- Section on Infectious Diseases, Wake Forest University Health Sciences, Winston Salem, 100 Medical Center Blvd., Winston Salem, NC 27157-1042, USA.
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Pneumonia in the elderly: a review of the epidemiology, pathogenesis, microbiology, and clinical features. South Med J 2009; 101:1141-5; quiz 1132, 1179. [PMID: 19088525 DOI: 10.1097/smj.0b013e318181d5b5] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pneumonia is a common and important disease in the elderly. The incidence is expected to rise as the population ages, and, therefore, it will become an increasingly significant problem in hospitals and the community. A comprehensive literature review was performed in order to look at the characteristics of pneumonia in the elderly population. In particular, the epidemiology, etiology and pathogenesis--including risk factors, microbiology, and clinical features--were evaluated. While aging causes physiological changes which make elderly patients more susceptible to pneumonia, it was found that comorbidities, rather than age, are also an important risk factor. The most common micro-organism responsible for pneumonia is Streptococcus pneumoniae, but other organisms need to be considered, depending on the environment of presentation. Elderly patients are more likely than younger adults to present with an absence of fever and an altered mental state. Nursing home residents tend to present with more atypical and less characteristic symptoms.
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Hutt E, Radcliff TA, Liebrecht D, Fish R, McNulty M, Kramer AM. Associations Among Nurse and Certified Nursing Assistant Hours per Resident per Day and Adherence to Guidelines for Treating Nursing Home-Acquired Pneumonia. J Gerontol A Biol Sci Med Sci 2008; 63:1105-11. [DOI: 10.1093/gerona/63.10.1105] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
INTRODUCTION Pneumonia is the leading cause of mortality, morbidity, and transfers to acute care facilities among residents of nursing homes. With the expected growth of the nursing home population over the next 30 years, the annual incidence of nursing home-acquired pneumonia (NHAP) is expected to reach 1.9 million cases. Yet there is growing evidence to suggest that the transfer of nursing home residents to hospitals with NHAP results in little to no improvement in overall mortality or morbidity when compared with residents treated in the nursing home. Furthermore, recent evidence suggests that nursing home residents admitted to hospitals may be at greater risk for functional decline, delirium, and pressure ulcer formation following hospitalization. The author therefore performed a comprehensive review of the literature to consider the salient issues confronting a clinician faced with the question of whether to transfer a nursing home resident diagnosed with pneumonia to an acute care facility. METHODOLOGY A structured literature search was performed relating to the diagnosis, treatment, and triage of residents with nursing home pneumonia. Relevant key words used to conduct this search included: pneumonia, long-term care facility, nursing home, nursing home-acquired pneumonia, triage, treatment, and hospitalization. References in English dated from 1966 to the present day were considered. RESULTS One prospective observational study and 2 retrospective, case control studies have directly compared the 30-day mortality rates of residents with NHAP who are hospitalized versus those who are treated in the nursing home. A second, prospective, observational study evaluated the mortality rate in residents with any form of infection who were transferred to acute care hospitals. These studies all suggest that mortality rates are similar or reduced when residents are treated in the nursing home. Studies also suggest that considerable cost savings can be incurred when residents are treated in the nursing home. Additional literature reviews were conducted to evaluate important factors that need to be considered before making triage decisions on nursing home residents diagnosed with pneumonia. These factors include the ease of making the diagnosis of NHAP, the availability and use of antibiotics, relevant cost issues, and barriers to providing adequate care in the nursing home environment. CONCLUSION There is growing evidence to suggest that hospitalization for residents with NHAP is not required and may result in increased cost, morbidity, and mortality. To date, studies show that residents may benefit from hospitalization if their respiratory rate is over 40. Otherwise, if appropriate treatment can be initiated expeditiously in the nursing home, resident mortality and morbidity may decrease. Numerous barriers to treating acutely ill residents in the nursing home exist, including a difficulty in obtaining antibiotics quickly, inadequate staffing, and poor documentation of a resident's wishes for hospitalization. More studies need to be conducted to further identify these barriers to nursing home care.
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Affiliation(s)
- David Dosa
- Division of Geriatrics and Department of Medicine and Community Health, Brown University, Providence, RI, USA.
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Paladino JA, Eubanks DA, Adelman MH, Schentag JJ. Once-Daily Cefepime Versus Ceftriaxone for Nursing HomeâAcquired Pneumonia. J Am Geriatr Soc 2007; 55:651-7. [PMID: 17493183 DOI: 10.1111/j.1532-5415.2007.01152.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To compare once-daily intramuscular cefepime with ceftriaxone controls. DESIGN Double-blind study. SETTING Six skilled nursing facilities. PARTICIPANTS Residents aged 60 and older with nursing home-acquired pneumonia. INTERVENTION Cultures were obtained, and patients were randomized to cefepime or ceftriaxone 1 g intramuscularly every 24 hours. MEASUREMENTS Clinical success: cure or improvement. Cure was defined as complete resolution of all symptoms and signs of pneumonia or a return to the patient's baseline state. Improvement was defined as clear improvement but incomplete resolution of all pretherapy symptoms or signs or incomplete return to the patient's usual baseline status. Safety and pharmacoeconomics were also assessed. RESULTS Sixty-nine patients were randomized; 61 were evaluable: (32 to cefepime, 29 ceftriaxone). Patients were predominately female (76%). They had a mean age+/-standard deviation of 85+/-6, with a mean 5.8+/-1.9 comorbidities; they had age-appropriate renal dysfunction, with a mean estimated creatinine clearance of 35+/-7 mL/min. Clinical success occurred in 78% of cefepime- and 66% of ceftriaxone-treated patients (P=.39). Fifty-seven patients (93%) were switched to oral antibiotics after 3 days. Antibiotic-related adverse events occurred in 5% of patients. Seven patients (11.5%) were hospitalized. The overall mortality rate was 8%. Mean antibiotic costs were 117+/-40 dollars for cefepime- and 215+/-68 dollars for ceftriaxone-treated patients (P<.001). Cost-effectiveness analysis of total costs showed that cefepime would cost 597 dollars and ceftriaxone 1,709 dollars per expected successfully treated patient. One- and two-way sensitivity analyses using a generic price for ceftriaxone and improving its comparative efficacy revealed that the results were robust. CONCLUSIONS Once-daily cefepime was a cost-effective alternative to ceftriaxone for the treatment of elderly nursing home residents who developed pneumonia and did not require hospitalization.
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Hutt E, Ruscin JM, Corbett K, Radcliff TA, Kramer AM, Williams EM, Liebrecht D, Klenke W, Hartmann S. A Multifaceted Intervention to Implement Guidelines Improved Treatment of Nursing HomeâAcquired Pneumonia in a State Veterans Home. J Am Geriatr Soc 2006; 54:1694-700. [PMID: 17087696 DOI: 10.1111/j.1532-5415.2006.00937.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To assess the feasibility of a multifaceted strategy to translate evidence-based guidelines for treating nursing home-acquired pneumonia (NHAP) into practice using a small intervention trial. DESIGN Pre-posttest with untreated control group. SETTING Two Colorado State Veterans Homes (SVHs) during two influenza seasons. PARTICIPANTS Eighty-six residents with two or more signs of lower respiratory tract infection. INTERVENTION Multifaceted, including a formative phase to modify the intervention, institutional-level change emphasizing immunization, and availability of appropriate antibiotics; interactive educational sessions for nurses; and academic detailing. MEASUREMENTS Subjects' SVH medical records were reviewed for guideline compliance retrospectively for the influenza season before the intervention and prospectively during the intervention. Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test. RESULTS At the intervention facility, compliance with five of the guidelines improved: influenza vaccination, timely physician response to illness onset, x-ray for patients not being hospitalized, use of appropriate antibiotics, and timely antibiotic initiation for unstable patients. Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year. CONCLUSION Multifaceted, evidence-based, NHAP guideline implementation improved care processes in a SVH. Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents.
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Affiliation(s)
- Evelyn Hutt
- Department of Medicine, Denver Veterans Affairs Medical Center, Denver, Colorado 80220, USA.
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Abstract
INTRODUCTION Pneumonia is the leading cause of mortality, morbidity, and transfers to acute care facilities among residents of nursing homes. With the expected growth of the nursing home population over the next 30 years, the annual incidence of nursing home-acquired pneumonia (NHAP) is expected to reach 1.9 million cases. Yet there is growing evidence to suggest that the transfer of nursing home residents to hospitals with NHAP results in little to no improvement in overall mortality or morbidity when compared with residents treated in the nursing home. Furthermore, recent evidence suggests that nursing home residents admitted to hospitals may be at greater risk for functional decline, delirium, and pressure ulcer formation following hospitalization. The author therefore performed a comprehensive review of the literature to consider the salient issues confronting a clinician faced with the question of whether to transfer a nursing home resident diagnosed with pneumonia to an acute care facility. METHODOLOGY A structured literature search was performed relating to the diagnosis, treatment, and triage of residents with nursing home pneumonia. Relevant key words used to conduct this search included: pneumonia, long-term care facility, nursing home, nursing home-acquired pneumonia, triage, treatment, and hospitalization. References in English dated from 1966 to the present day were considered. RESULTS One prospective observational study and 2 retrospective, case control studies have directly compared the 30-day mortality rates of residents with NHAP who are hospitalized versus those who are treated in the nursing home. A second, prospective, observational study evaluated the mortality rate in residents with any form of infection who were transferred to acute care hospitals. These studies all suggest that mortality rates are similar or reduced when residents are treated in the nursing home. Studies also suggest that considerable cost savings can be incurred when residents are treated in the nursing home. Additional literature reviews were conducted to evaluate important factors that need to be considered before making triage decisions on nursing home residents diagnosed with pneumonia. These factors include the ease of making the diagnosis of NHAP, the availability and use of antibiotics, relevant cost issues, and barriers to providing adequate care in the nursing home environment. CONCLUSION There is growing evidence to suggest that hospitalization for residents with NHAP is not required and may result in increased cost, morbidity, and mortality. To date, studies show that residents may benefit from hospitalization if their respiratory rate is over 40. Otherwise, if appropriate treatment can be initiated expeditiously in the nursing home, resident mortality and morbidity may decrease. Numerous barriers to treating acutely ill residents in the nursing home exist, including a difficulty in obtaining antibiotics quickly, inadequate staffing, and poor documentation of a resident's wishes for hospitalization. More studies need to be conducted to further identify these barriers to nursing home care.
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Affiliation(s)
- David Dosa
- Division of Geriatrics and Department of Medicine and Community Health, Brown University, Providence, RI, USA.
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van der Steen JT, Mehr DR, Kruse RL, Sherman AK, Madsen RW, D'Agostino RB, Ooms ME, van der Wal G, Ribbe MW. Predictors of mortality for lower respiratory infections in nursing home residents with dementia were validated transnationally. J Clin Epidemiol 2006; 59:970-9. [PMID: 16895821 DOI: 10.1016/j.jclinepi.2005.12.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2005] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Jenny T van der Steen
- EMGO Institute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
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Abstract
As life expectancy continues to rise, the number of geriatric patients will increase and the percentages of geriatric patients seen in the emergency department will reflect those numbers. Emergency physicians are responsible for making immediate diagnoses and initiating expeditious treatment. Infectious diseases in the elderly are more prevalent, challenging to diagnose, and are associated with greater morbidity and mortality than with the younger patient population.
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Affiliation(s)
- Adeyinka Adedipe
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Dowling 1 South, Boston, MA 02188, USA
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Abstract
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.
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Affiliation(s)
- Joseph M Mylotte
- Department of Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA.
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Shay K, Scannapieco FA, Terpenning MS, Smith BJ, Taylor GW. Nosocomial pneumonia and oral health. SPECIAL CARE IN DENTISTRY 2005; 25:179-87. [PMID: 16295222 DOI: 10.1111/j.1754-4505.2005.tb01647.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This article will critically review the evidence linking pneumonia to the aspiration of microbe-laden oropharyngeal secretions and tie that to the predisposition for these processes to affect dependent, medically compromised individuals. The goal of this review is to alert the reader to the role that oral disease and oral health play in fostering and preventing, respectively, widespread and potentially fatal pulmonary disease among high-risk individuals.
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Affiliation(s)
- Kenneth Shay
- Veterans Integrated Service Network #11, Dept. of Veterans Affairs, Ann Arbor, MI, USA.
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Ebihara T, Takahashi H, Ebihara S, Okazaki T, Sasaki T, Watando A, Nemoto M, Sasaki H. Capsaicin Troche for Swallowing Dysfunction in Older People. J Am Geriatr Soc 2005; 53:824-8. [PMID: 15877558 DOI: 10.1111/j.1532-5415.2005.53261.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Takae Ebihara
- Department of Geriatric and Respiratory Medicine, Tohoku University School of Medicine, Sendai, Japan.
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Mohammad AR, Preshaw PM, Bradshaw MH, Hefti AF, Powala CV, Romanowicz M. Adjunctive subantimicrobial dose doxycycline in the management of institutionalised geriatric patients with chronic periodontitis*. Gerodontology 2005; 22:37-43. [PMID: 15747897 DOI: 10.1111/j.1741-2358.2004.00044.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the efficacy of subantimicrobial dose doxycycline (SDD; 20 mg doxycycline twice daily) as an adjunct to scaling and root planing (SRP) in the treatment of moderate-severe chronic periodontitis (CP) in institutionalised elderly patients aged 65 years or older. BACKGROUND Previous studies have shown that SDD is of clinical benefit in the treatment of CP. However, the benefits of SDD in geriatric populations (65+ years) have not been determined. MATERIAL AND METHODS A 9-month, double-blind, randomised, placebo-controlled pilot study was conducted. 24 institutionalised geriatric patients (65 years or older) with evidence of CP manifested by baseline clinical attachment levels (CAL) 5-9 mm, probing depths (PD) 4-9 mm and bleeding on probing (BOP) were recruited. At baseline, patients were treated by a standardised episode of SRP, and randomised to receive either adjunctive SDD or placebo. Full mouth PD and CAL were measured using the manual UNC-15 periodontal probe at 3, 6, and 9 months post-baseline to assess the response to treatment. Periodontal sites were stratified by baseline PD value: sites with PD 4-5 mm were considered moderately diseased and sites with PD > or = 6 mm severely diseased. RESULTS The SRP + placebo resulted in PD reductions similar to those reported previously in the literature. At all time-points and in both moderate and deep sites, SRP + SDD resulted in significantly greater PD reductions relative to baseline than SRP + placebo. At month 9, in moderate sites, mean PD reductions of 1.57 +/- 0.11 mm were reported in the adjunctive SDD group, compared with 0.63 +/- 0.11 mm in the adjunctive placebo group (p < 0.001). In deep sites at month 9, mean PD reductions of 3.22 +/- 0.29 mm were reported in the adjunctive SDD group, compared with 0.98 +/- 0.31 mm in the adjunctive placebo group (p < 0.05). Similar improvements were observed for CAL in the SDD group compared with the placebo group. Significantly lower BOP scores were also recorded at month 9 in the SDD group (7.5%) compared with the placebo group (71.2%) (p < 0.01). CONCLUSION SDD used as an adjunct to SRP provides significant benefit for elderly patients with CP compared with SRP alone.
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Affiliation(s)
- Abdel R Mohammad
- College of Dentistry, Ohio State University, Columbus, OH 43210, USA.
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Quagliarello V, Ginter S, Han L, Van Ness P, Allore H, Tinetti M. Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis 2004; 40:1-6. [PMID: 15614684 DOI: 10.1086/426023] [Citation(s) in RCA: 133] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2004] [Accepted: 08/02/2004] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND This study sought to identify modifiable risk factors for pneumonia in elderly nursing home residents. METHODS A cohort of 613 elderly residents (age, >65 years) of 5 nursing homes in the New Haven, Connecticut, area was followed-up prospectively from February 2001 through March 2003. The primary outcome was radiographically documented pneumonia within a 12-month surveillance period. Baseline modifiable risk factors were evaluated for their independent association with pneumonia. RESULTS Of 613 elderly nursing home residents, 131 (21%) died, and an additional 112 (18%) developed a radiographically documented case of pneumonia during the 12-month surveillance period. Among the 9 candidate modifiable risk factors that were evaluated individually in Cox proportional hazards models adjusting for covariates (i.e., nursing home facility, age, race, coexisting conditions, and immobility), inadequate oral care (hazard ratio [HR], 1.60; 95% confidence interval [CI], 1.06-2.35; P=.024) and swallowing difficulty (HR, 1.65; 95% CI, 1.04-2.62; P=.033) were associated with pneumonia. When modifiable risk factors were evaluated simultaneously in the same Cox proportional hazards model, inadequate oral care (HR, 1.55; 95% CI, 1.04-2.30; P=.030) and swallowing difficulty (HR, 1.61; 95% CI, 1.02-2.55; P=.043) remained independently associated with pneumonia, adjusting for the same covariates. Calculation of population-based attributable fractions showed that 21% of all cases of pneumonia in our cohort could have been avoided if inadequate oral care and swallowing difficulty were not present. CONCLUSIONS Two biologically plausible and modifiable risk factors increased the risk of pneumonia in elderly nursing home residents. These results provide a framework for the development and testing of a targeted pneumonia prevention strategy.
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Affiliation(s)
- Vincent Quagliarello
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520-8022, USA.
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Abstract
The seriousness of community-acquired pneumonia (CAP), despite being a reasonably common and potentially lethal disease, often is under estimated by physicians and patients alike. CAP results in more than 10 million visits to physicians, 64 million days of restricted activity, and 600,000 hospitalizations. This article discusses the epidemiology and bacterial causes of CAP in immunocompetent adults and the severe acute respiratory syndrome coronavirus.
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Affiliation(s)
- Lionel A Mandell
- Division of Infectious Diseases, Department of Medicine, McMaster University, Henderson Site, 711 Concession Street, 40 Wing, 5th Floor, Room 503, Hamilton, ON Canada L8V 1C3.
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Durand-Gasselin B, Gisselbrecht M. Infections pulmonaires aiguës chez les patients âgés en institution. Rev Mal Respir 2004. [DOI: 10.1016/s0761-8425(04)71568-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Paley GA, Slack-Smith LM, O'Grady MJ. Aged care staff perspectives on oral care for residents: Western Australia. Gerodontology 2004; 21:146-54. [PMID: 15369017 DOI: 10.1111/j.1741-2358.2004.00020.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine manager and staff perceptions of oral health and dental service issues for residents in aged care facilities in the Perth Metropolitan Area, Western Australia. DESIGN Focus groups and face-to-face semi-structured interviews with aged care facility managers and staff. SETTING AND SUBJECTS Personnel at 12 facilities (high-level and low-level care) located in the Perth Metropolitan Area participated in the study. Interviews were conducted with 14 facility managers. Focus groups and face-to-face interviews were conducted with 40 facility staff. RESULTS Managers and staff had similar views regarding most issues. While resident oral health was considered important, regular oral care programmes were limited or lacking. In general, high care facility residents did not have regular dental checkups, while those in low-level care facilities usually visited their own dentist for checkups or treatment. Barriers to maintaining regular oral care included: resident noncompliance; financial concerns; lack of co-operation from family; mobility issues; and lack of interest from dental professionals. Suggested improvements to current services included regular on-site visits, staff education and specialised dental professionals. CONCLUSION Residents face many barriers to maintenance of adequate oral health care, particularly those who are functionally dependent and cognitively impaired. There is an urgent need for appropriate oral care programmes for aged care residents, which include dentists with aged care experience and continuing education for facility staff. Any major programmes should be evaluated carefully.
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Affiliation(s)
- Glenys A Paley
- School of Population Health, The University of Western Australia, Nedlands, WA, Australia
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35
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van der Steen JT, Kruse RL, Ooms ME, Ribbe MW, van der Wal G, Heintz LL, Mehr DR. Treatment of Nursing Home Residents with Dementia and Lower Respiratory Tract Infection in the United States and the Netherlands: An Ocean Apart. J Am Geriatr Soc 2004; 52:691-9. [PMID: 15086647 DOI: 10.1111/j.1532-5415.2004.52204.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To compare treatment of nursing home residents with dementia and lower respiratory tract infection (LRI) in Missouri and the Netherlands. DESIGN Two separate but simultaneous prospective cohort studies. SETTING Nursing homes in Missouri (n=36) and the Netherlands (n=61). PARTICIPANTS Selected residents (701 from Missouri and 551 from the Netherlands) diagnosed with LRI and dementia. MEASUREMENTS Treatment, dementia severity, symptoms and signs of LRI, and general health condition were recorded at the time of diagnosis of LRI. Death was monitored at follow-up. Treatment and mortality, stratified for dementia severity, are reported. RESULTS Treatment of nursing home-acquired LRI in Missouri residents involved a larger number of antibiotics, more frequent hospitalization, and greater use of intravenous antibiotics and rehydration therapy than in Dutch residents of equal dementia severity. Furthermore, for Missouri residents, intensive interventions were more often provided irrespective of severe dementia. By contrast, in both countries, treatments to relieve symptoms of LRI were provided for only a minority of residents. Dutch mortality rates were higher overall. CONCLUSION Care for U.S. nursing home residents with LRI and dementia is more aggressive than care for Dutch residents, particularly in residents with severe dementia. These results are relevant to the debate on optimal care in relation to curative or palliative treatment goals.
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Affiliation(s)
- Jenny T van der Steen
- Institute for Research in Extramural Medicine (EMGO Institute), VU University Medical Center, Amsterdam, The Netherlands.
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36
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Coleman PR. Pneumonia in the Long-Term Care Setting: Etiology, Management, and Prevention. J Gerontol Nurs 2004; 30:14-23; quiz 54-5. [PMID: 15109043 DOI: 10.3928/0098-9134-20040401-06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
1.Nursing-home acquired pneumonia (NHAP) is a major cause of death and disability among elderly nursing home residents, despite the availability of new antimicrobials and diagnostic techniques. 2. Elderly individuals with NHAP have vague clinical presentations and unique institutional limitations can lead to delays in diagnosis, treatment, and poor resident outcomes. 3. Successful management of the resident with pneumonia includes choice of antibiotic therapy, excellent nursing care, and thoughtful consideration of treatment setting. 4. Preventive strategies to reduce the risk of NHAP include attention to vaccination status and oral hygiene care to reduce bacterial colonization of potential respiratory pathogens.
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37
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Abstract
Pneumonia is a major medical problem in the very old. The increased frequency and severity of pneumonia in the elderly is largely explained by the ageing of organ systems (in particular the respiratory tract, immune system, and digestive tract) and the presence of comorbidities due to age-associated diseases. The most striking characteristic of pneumonia in the very old is its clinical presentation: falls and confusion are frequently encountered, while classic symptoms of pneumonia are often absent. Community-acquired pneumonia (CAP) and nursing-home acquired pneumonia (NHAP) have to be distinguished. Although there are no fundamental differences in pathophysiology and microbiology of the two entities, NHAP tends to be much more severe, because milder cases are not referred to the hospital, and residents of nursing homes often suffer from dementia, multiple comorbidities, and decreased functional status. The immune response decays with age, yet pneumococcal and influenza vaccines have their place for the prevention of pneumonia in the very old. Pneumonia in older individuals without terminal disease has to be distinguished from end-of-life pneumonia. In the latter setting, the attributable mortality of pneumonia is low and antibiotics have little effect on life expectancy and should be used only if they provide the best means to alleviate suffering. In this review, we focus on recent publications relative to CAP and NHAP in the very old, and discuss predisposing factors, microorganisms, diagnostic procedures, specific aspects of treatment, prevention, and ethical issues concerning end-of-life pneumonia.
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Affiliation(s)
- Jean-Paul Janssens
- Division of Lung Diseases and Department of Geriatrics, Geneva University Hospitals, Geneva, Switzerland.
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38
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Kruse RL, Boles KE, Mehr DR, Spalding D, Lave JR. The Cost of Treating Pneumonia in the Nursing Home Setting. J Am Med Dir Assoc 2003. [DOI: 10.1016/s1525-8610(04)70280-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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39
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Bonomo RA, Salata RA. Managing infections in the elderly: The challenge of long-term care facilities. ACTA ACUST UNITED AC 2002. [DOI: 10.1016/s0196-4399(02)80044-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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40
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Mylotte JM. Nursing home-acquired pneumonia. Clin Infect Dis 2002; 35:1205-11. [PMID: 12410480 DOI: 10.1086/344281] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2002] [Accepted: 08/06/2002] [Indexed: 11/03/2022] Open
Abstract
Pneumonia is the most serious of the common infections that occur in nursing homes, with a high case-fatality rate and considerable mortality among survivors. Risk factors for nursing home-acquired pneumonia (NHAP) have been defined, and prediction models for death due to NHAP have been developed. The bacterial etiology of NHAP has been debated, but "typical" bacterial pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) are most important. Clinical presentation of NHAP is said to be "atypical," but this may be confounded by dementia in the nursing home resident. A recent guideline has made recommendations regarding the minimal diagnostic workup when a resident has a suspected case of pneumonia. Until recently, most guidelines for the treatment of pneumonia did not specifically address NHAP; there is some evidence that use of a quinolone alone may be an acceptable first choice of therapy for most cases. Pneumococcal and influenza vaccination have been the primary prevention measures. However, additional methods to prevent NHAP should be evaluated, including improving the oral hygiene of residents and instituting pharmacological interventions.
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Affiliation(s)
- Joseph M Mylotte
- Department of Medicine, Division of Infectious Diseases, School of Medicine and Biomedical Sciences, University at Buffalo, Erie County Medical Center, Buffalo, New York 14215, USA.
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41
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42
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Shay K. Infectious complications of dental and periodontal diseases in the elderly population. Clin Infect Dis 2002; 34:1215-23. [PMID: 11941548 DOI: 10.1086/339865] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2001] [Revised: 12/18/2001] [Indexed: 11/03/2022] Open
Abstract
Retention of teeth into advanced age makes caries and periodontitis lifelong concerns. Dental caries occurs when acidic metabolites of oral streptococci dissolve enamel and dentin. Dissolution progresses to cavitation and, if untreated, to bacterial invasion of dental pulp, whereby oral bacteria access the bloodstream. Oral organisms have been linked to infections of the endocardium, meninges, mediastinum, vertebrae, hepatobiliary system, and prosthetic joints. Periodontitis is a pathogen-specific, lytic inflammatory reaction to dental plaque that degrades the tooth attachment. Periodontal disease is more severe and less readily controlled in people with diabetes; impaired glycemic control may exacerbate host response. Aspiration of oropharyngeal (including periodontal) pathogens is the dominant cause of nursing home-acquired pneumonia; factors reflecting poor oral health strongly correlate with increased risk of developing aspiration pneumonia. Bloodborne periodontopathic organisms may play a role in atherosclerosis. Daily oral hygiene practice and receipt of regular dental care are cost-effective means for minimizing morbidity of oral infections and their nonoral sequelae.
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Affiliation(s)
- Kenneth Shay
- Geriatrics and Extended Care Service Line, Ann Arbor Veterans Affairs Healthcare System, and University of Michigan School of Dentistry, Ann Arbor, MI, USA.
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43
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44
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Abstract
Pneumonia is a common infection among residents of long-term-care facilities (LTCFs), with an incidence of 1.2 episodes per 1,000 patient-days. This rate is believed to be six- to tenfold higher than the rate of pneumonia among elderly individuals living in the community. The risk factors for pneumonia among residents of LTCFs are profound disability, bedridden state, urinary incontinence, difficulty swallowing, malnutrition, tube feedings, contractures, and use of benzodiazepines and anticholinergic medications. An elevated respiratory rate is often an early clue to pneumonia in this group of patients. Staphylococcus aureus (including methicillin-resistant S. aureus) and aerobic gram-negative bacilli (including multidrug-resistant isolates) are more frequent causes of pneumonia in this setting than in the community. Criteria have been developed that help identify patients for treatment in their LTCFs.
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Affiliation(s)
- Thomas J Marrie
- Walter C. Mackenzie Health Sciences Center, Edmonton, Alberta, Canada
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45
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46
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van der Steen JT, Ooms ME, Ribbe MW, van der Wal G. Decisions to treat or not to treat pneumonia in demented psychogeriatric nursing home patients: evaluation of a guideline. Alzheimer Dis Assoc Disord 2001; 15:119-28. [PMID: 11522929 DOI: 10.1097/00002093-200107000-00003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We evaluated a new guideline, in the form of a "checklist of considerations," to support end-of-life decision making in the treatment of demented patients with pneumonia. Questionnaires were sent to nursing home physicians (NHPs) in The Netherlands at three times: before implementation of the checklist (concerning 91 individual patients), during use of the checklist (concerning another 107 individual patients), and after data collection (concerning the targeted patient category of demented nursing home patients with pneumonia as a whole). In the last questionnaire, one NHP from each nursing home (n = 55 NHPs) gave his or her general opinion about the checklist. We measured the usefulness of the checklist in supporting decision making and its frequency of actual use. The NHPs accepted the contents of the checklist for use in the targeted patient category. It was used in 46% of the incident cases of pneumonia. The checklist was considered more useful in supporting decision making for the targeted patient category (85% of the NHPs) than for the individual patient (47%). Possible explanations for this discrepancy in "usefulness" include the difference in the nature of the outcome measures and the fact that the checklist was used more frequently for the "easier cases." Information on individual patient level, patient category level, and nursing home and NHP characteristics is used to suggest checklist improvements.
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Affiliation(s)
- J T van der Steen
- Institute for Research in Extramural Medicine (EMGO), Department of Nursing Home Medicine, Vrije Universiteit Medical Center Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
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47
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Abstract
We reviewed literature published from 1995 through 2000 on developments in ventilator-associated pneumonia. There is no gold standard with which to compare the accuracy of various invasive procedures performed for diagnosis. Moreover, leaders in the field are calling for an outcomes-based analysis to assess the utility of invasive procedures. Two things are clear: 1) adequate empiric therapy is beneficial, and 2) changes in therapy based on recovery of pathogens by invasive means do not affect outcome. Clinicians are urged to review local antimicrobial resistance patterns and to initiate empiric therapy on the basis of those data.
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Affiliation(s)
- Joseph R. Lentino
- Section of Infectious Diseases, Edward Hines, Jr. Veterans Affairs Hospital, Fifth Avenue at Roosevelt Road, Hines, IL 60141-5000, USA.
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48
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Bentley DW, Bradley S, High K, Schoenbaum S, Taler G, Yoshikawa TT. Practice guideline for evaluation of fever and infection in long-term care facilities. J Am Geriatr Soc 2001; 49:210-22. [PMID: 11207876 DOI: 10.1046/j.1532-5415.2001.49999.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The elderly population (i.e., persons aged > or = 65 years) in the United States is rapidly expanding and will nearly double in number over the next 30 years. It is estimated that >40% of persons aged > or = 65 years will require care in a long-term care facility (LTCF), such as a skilled nursing facility (SNF), at some point during their lifetime. For the most part, residents of LTCFs are very old and have age-related immunologic changes, chronic cognitive and/or physical impairments, and diseases that alter host resistance; therefore, they are highly susceptible to infections and their complications. The diagnosis of infections in residents of LTCFs is often difficult because LTCFs differ from acute-care facilities in their goals of care, staffing ratios, types of primary care providers, availability of laboratory tests, and criteria for infections. Consequently, guidelines and standards of practice used for diagnosis of infections in patients in acute-care facilities may not be applicable nor appropriate for residents in LTCFs. Moreover, the clinical manifestations of diseases and infections are often subtle, atypical, or nonexistent in the very old. Fever may be low or absent in LTCF residents with infection. The initial evaluation of an LTCF resident suspected of an infection may not be done by a physician. Although nurses commonly perform initial assessments for infection in residents of LTCFs, further studies are needed to determine the appropriateness and validity of this practice. Provided there are no directives (advance or current by resident or caregiver) limiting diagnostic or therapeutic interventions, all residents of LTCFs with suspected symptomatic infection should have appropriate diagnostic laboratory studies done promptly, and the findings should be discussed with the primary care clinician (see Recommendations). The most common infections among LTCF residents are urinary tract infections, respiratory infections, skin or soft tissue infections, and gastroenteritis. Decisions concerning possible transfer of an LTCF resident to an acute-care facility are best expressed through an advance directive or, when not available, through transfer policies developed by the LTCF. In general, LTCF residents have been transferred to an acute-care facility when any of the following conditions exist: (1) the resident is clinically unstable and the resident or family goals indicate aggressive interventions should be initiated, (2) critical diagnostic tests are not available in the LTCF, (3) necessary therapy or the mode of administration of therapy (frequency or monitoring) are beyond the capacity of the LTCF, (4) comfort measures cannot be assured in the LTCF, and (5) specific infection-control measures are not available in the LTCF.
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Affiliation(s)
- D W Bentley
- Division of Geriatric Medicine, St Louis University School of Medicine, St Louis Veterans Affairs Medical Center, Missouri, USA
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49
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Andersen BM, Rasch M. Hospital-acquired infections in Norwegian long-term-care institutions. A three-year survey of hospital-acquired infections and antibiotic treatment in nursing/residential homes, including 4500 residents in Oslo. J Hosp Infect 2000; 46:288-96. [PMID: 11170760 DOI: 10.1053/jhin.2000.0840] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Point prevalence studies of hospital-acquired infections among the elderly in 65-70 long-term care facilities (LTCF) were carried out once a year over a three-year period in Oslo city, Norway. They showed an overall rate of 6.5% of hospital-acquired infections among 13 762 residents. The infection rate was approximately the same as in hospitals and twice as high as among hospitalized long-term psychiatric patients. Residents who had received surgical treatment within the previous three months had a high rate of postoperative infections, especially wound infections (14.8%). During the study period, the LTCFs were found to be understaffed and overcrowded. They had few private rooms, a lack of bathrooms and toilets, no isolation facilities and deficient ventilation systems. The economic consequences of hospital-acquired infections in these LTCFs were extra costs in medical and nursing care and antibacterial treatment of 157 500 Nkr/day (22500 USD). There would be a substantial cost-benefit in effective preventive measures against hospital-acquired infections in long-term care institutions.
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Affiliation(s)
- B M Andersen
- Department of Hospital Infection, Ullevål University Hospital, 0407, Oslo, Norway
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50
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Naughton BJ, Mylotte JM, Tayara A. Outcome of nursing home-acquired pneumonia: derivation and application of a practical model to predict 30 day mortality. J Am Geriatr Soc 2000; 48:1292-9. [PMID: 11037018 DOI: 10.1111/j.1532-5415.2000.tb02604.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To derive a prediction model of 30 day mortality for nursing home-acquired pneumonia (NHAP) based on factors that can be readily identified by nursing home staff at the time of diagnosis and to apply the model to management issues related to NHAP including clarifying the importance of prepneumonia functional status as a predictor of outcome of NHAP. DESIGN This was a retrospective chart review of 378 episodes of NHAP treated in the nursing home or hospital during two periods: November 1997 to April 1998 and November 1998 to April 1999. SETTING Eleven nursing homes in the greater Buffalo, NY region. PARTICIPANTS Nursing home residents with radiographically proven pneumonia who had at least one of the following signs/symptoms: cough, fever, purulent sputum, respiratory rate > or =25 breaths/minute, localized auscultatory findings, or pleuritic pain. MEASUREMENTS Status (alive or dead) of each resident at 30 days (30 day mortality) after diagnosis of NHAP was the dependent variable. Factors predicting 30 day mortality were identified by logistic regression analysis. A scoring system was developed based on the results of the logistic model. Each episode of NHAP in the derivation cohort was scored using the model and the cohort was stratified by the model score into six categories or risk for mortality (0-5). The predictability of the model in the derivation cohort was measured using receiver operator characteristics curve analysis. RESULTS Of 378 episodes of NHAP, 74% were treated initially in the nursing home and 26% were hospitalized initially for treatment. The overall 30 day mortality was 21.4%; however, the mortality rate was significantly higher for those treated initially in the hospital (29.6% vs 16.6%; P = .012). Logistic regression analysis identified four predictors of 30 day mortality: (1) respiratory rate >30 breaths/minute (2 points), (2) pulse > 125 beats/minute (1 point), (3) altered mental status (1 point), and (4) a history of dementia (1 point). Applying the scoring system to each episode in the derivation cohort demonstrated increasing mortality with increasing score. The c statistic for the model in the derivation cohort was .74. Based on the severity of NHAP, model episodes treated initially in the hospital were more acutely ill than those who were treated initially in the nursing home, and episodes treated with a parenteral antibiotic in the nursing home were more acutely ill than those who were treated with an oral agent. Functional status was not a predictor of 30 day mortality although there was a trend of higher mortality in the most dependent group (P = .065). The severity of NHAP model was able to define low and high risk mortality groups within a functional status category. CONCLUSIONS A severity of NHAP model was derived from a large cohort of episodes in multiple facilities. The model had reasonable discriminatory power in the derivation cohort. The model may aid clinicians in making treatment decisions in the nursing home setting and in making hospitalization decisions. Although prepneumonia functional status provides a reasonable estimate of NHAP severity and prognosis, the severity of NHAP model permitted further refinement of these estimates. The severity of NHAP model requires validation before it can be recommended for general use.
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Affiliation(s)
- B J Naughton
- Department of Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, USA
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