Outcome of nursing home-acquired pneumonia: derivation and application of a practical model to predict 30 day mortality

Prediction models of all-cause mortality among older adults in nursing home setting: A systematic review and meta-analysis

Background and Aims

Few studies have meta-analyzed different prognostic models developed for older adults, especially nursing home residents. We aimed to systematically review and meta-analyze the performance of all published models that predicted all-cause mortality among older nursing home residents.

Methods

We systematically searched PubMed and EMBASE from the databases' inception to January 1, 2020 to capture studies developing and/or validating a prognostic/prediction model for all-cause mortality among nursing home residents. We then carried out both qualitative and quantitative analyses evaluating these models' risks of bias and applicability.

Results

The systematic search yielded 23,975 articles. We identified 28 indices that predicted the risk of all-cause mortality from 14 days to 39 months among older adults in nursing homes. The most used predictors were age, sex, body weight, swallowing problem, congestive heart failure, shortness of breath, body mass index, and activities of daily living. Of the 28 indices, 8 (29%) and 3 (11%) were internally and externally validated, respectively. None of the indices was validated in more than one cohort. Of the 28 indices, 22 (79%) reported the C-statistic, while only 6 (6%) reported the 95% confidence interval for the C statistic in the development cohorts. In the validation cohorts, 11 (39%) reported the C-statistic and 8 (29%) reported the 95% confidence interval. The meta-analyzed C statistic for all indices is 0.733 (95% prediction interval: 0.669-0.797). All studies/indices had high risks of bias and high concern for applicability according to PROBAST.

Conclusion

We identified 28 indices for predicting all-cause mortality among older nursing home residents. The overall quality of evidence was low due to a high degree of bias and poor reporting of model performance statistics. Before any prediction model could be recommended in routine care, future research is needed to rigorously validate existing prediction models and evaluate their applicability and develop new prediction models.

Antibiotic use for respiratory tract infections among older adults living in long-term care facilities: a systematic review and meta-analysis

BACKGROUND

Antibiotics are commonly prescribed for respiratory tract infections (RTIs) among older adults in long-term care facilities (LTCFs), and this contributes to the emergence of antimicrobial resistance. The objective of this study was to determine the antibiotic prescribing rate for RTIs among LTCF residents, and to analyse the antibiotic consumption patterns with the AwaRe monitoring tool, developed by the World Health Organization.

METHODS

MEDLINE, EMBASE and CINAHL were searched from inception to March 2022. Original articles reporting antibiotic use for RTIs in LTCFs were included in this review. Study quality was assessed using the Joanna Briggs Institute's Critical Appraisal Checklist for Prevalence Data. A random-effects meta-analysis was employed to calculate the pooled estimates. Subgroup analysis was conducted by type of RTI, country, and study start year.

RESULTS

In total, 47 articles consisting of 50 studies were included. The antibiotic prescribing rate ranged from 21.5% to 100% (pooled estimate 69.8%, 95% confidence interval 55.2-82.6%). The antibiotic prescribing rate for lower respiratory tract infections (LRTIs) was higher than the rates for viral and general RTIs. Compared with Italy, France and the USA, the Netherlands had lower antibiotic use for LRTIs. A proportion of viral RTIs were treated with antibiotics, and all the antibiotics were from the Watch group. Use of antibiotics in the Access group was higher in the Netherlands, Norway, Switzerland and Slovenia compared with the USA and Australia.

CONCLUSION

The antibiotic prescribing rate for RTIs in LTCFs was high, and AWaRe antibiotic use patterns varied by type of RTI and country. Improving antibiotic use may require coordination efforts.

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

Introduction

Despite the poor prognosis for nursing home acquired pneumonia (NHAP), a useful prognostic factor is lacking. We evaluated protein C (PC) activity as a predictor of in-hospital death in patients with NHAP and community-acquired pneumonia (CAP).

Methods

This prospective, observational study included all patients hospitalized with pneumonia between July 2007 and December 2012 in a single hospital. We measured PC activity at admission and investigated whether it was different between survivors and non-survivors. We also examined whether PC activity < 55% was a predictor for in-hospital death of pneumonia by logistic regression analysis with CURB-65 items (confusion, blood urea >20 mg/dL, respiratory rate >30/min, and blood pressure <90/60 mmHg, age >65). When it was a useful prognostic factor for pneumonia, we combined PC activity with the existing prognostic scores, the pneumonia severity index (PSI) and CURB-65, and analyzed its additional effect by comparing the areas under the receiver operating characteristic curves (AUCs) of the modified and original scores.

Results

Participants comprised 75 NHAP and 315 CAP patients. PC activity was lower among non-survivors than among survivors in NHAP and all-pneumonia (CAP+NHAP). PC activity <55% was a useful prognostic predictor for NHAP (Odds ratio 7.39 (95% CI; 1.59–34.38), and when PSI or CURB-65 was combined with PC activity, the AUC improved (from 0.712 to 0.820 for PSI, and 0.657 to 0.734 for CURB-65).

Conclusions

PC activity was useful for predicting in-hospital death of pneumonia, especially in NHAP, and became more useful when combined with the PSI or CURB-65.

Modeling of nursing care-associated airborne transmission of SARS-CoV-2 in a real-world hospital setting

Respiratory transmission of SARS-CoV-2 from one older patient to another by airborne mechanisms in hospital and nursing home settings represents an important health challenge during the COVID-19 pandemic. However, the factors that influence the concentration of respiratory droplets and aerosols that potentially contribute to hospital- and nursing care-associated transmission of SARS-CoV-2 are not well understood. To assess the effect of health care professional (HCP) and patient activity on size and concentration of airborne particles, an optical particle counter was placed (for 24 h) in the head position of an empty bed in the hospital room of a patient admitted from the nursing home with confirmed COVID-19. The type and duration of the activity, as well as the number of HCPs providing patient care, were recorded. Concentration changes associated with specific activities were determined, and airway deposition modeling was performed using these data. Thirty-one activities were recorded, and six representative ones were selected for deposition modeling, including patient's activities (coughing, movements, etc.), diagnostic and therapeutic interventions (e.g., diagnostic tests and drug administration), as well as nursing patient care (e.g., bedding and hygiene). The increase in particle concentration of all sizes was sensitive to the type of activity. Increases in supermicron particle concentration were associated with the number of HCPs (r = 0.66; p < 0.05) and the duration of activity (r = 0.82; p < 0.05), while submicron particles increased with all activities, mainly during the daytime. Based on simulations, the number of particles deposited in unit time was the highest in the acinar region, while deposition density rate (number/cm2/min) was the highest in the upper airways. In conclusion, even short periods of HCP-patient interaction and minimal patient activity in a hospital room or nursing home bedroom may significantly increase the concentration of submicron particles mainly depositing in the acinar regions, while mainly nursing activities increase the concentration of supermicron particles depositing in larger airways of the adjacent bed patient. Our data emphasize the need for effective interventions to limit hospital- and nursing care-associated transmission of SARS-CoV-2 and other respiratory pathogens (including viral pathogens, such as rhinoviruses, respiratory syncytial virus, influenza virus, parainfluenza virus and adenoviruses, and bacterial and fungal pathogens).

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

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

Which Nursing Home Residents With Pneumonia Are Managed On-Site and Which Are Hospitalized? Results from 2 Years' Surveillance in 14 US Homes

OBJECTIVES

Pneumonia is a frequent cause of hospitalization among nursing home (NH) residents, but little information is available as to how clinical presentation and other characteristics relate to hospitalization, and the differential use of antimicrobials based on hospitalization status. This study examined how hospitalized and nonhospitalized NH residents with pneumonia differ.

DESIGN

Data from a 2-year prospective study of residents who participated in a randomized controlled trial.

SETTING AND PARTICIPANTS

All residents from 14 NHs in North Carolina followed for pneumonia over a 2-year period.

METHODS

Clinical features, antimicrobial treatment, hospitalization, and demographic data on residents with a pneumonia diagnosis were abstracted from charts; NH information was obtained from NH administrators.

RESULTS

A total of 509 pneumonia episodes were reported for 395 unique residents; the incidence was not higher in the winter months, and 28% were hospitalized. The likelihood of hospitalization did not differ by clinical characteristics except that residents with a respiratory rate >25 breaths per minute were more likely to be hospitalized. Being on hospice [odds ratio (OR) 3.3, 95% confidence interval (CI) 1.5-7.4] and not having dementia (OR 1.9, 95% CI 1.1-3.2) also related to increased likelihood of hospitalization. Fluoroquinolone (usually levofloxacin) monotherapy was the most common treatment (54%) in both settings, and ceftriaxone monotherapy varied by hospitalization status (7% of hospitalized vs 16% treated on-site). Approximately 36% of nonhospitalized residents received antimicrobials for more than 7 days.

CONCLUSIONS/IMPLICATIONS

Respiratory rate is associated with hospitalization but was not documented for more than a quarter of residents, suggesting the clinical benefit of more consistently conducting this assessment. Differential hospitalization rates for persons with dementia and on hospice suggest that care is being tailored to individuals' wishes, but this assumption merits study, as does use of fluoroquinolones (due to side effects) and treatment duration (due to potential contribution to antibiotic resistance).

Antibiotic Stewardship Programs in Nursing Homes: A Systematic Review

INTRODUCTION

Antibiotic stewardship programs (ASPs) are coordinated interventions promoting the appropriate use of antibiotics to improve patient outcomes and reduce microbial resistance. These programs are now mandated in nursing homes (NHs) but it is unclear if these programs improve resident outcomes. This systematic review evaluated the current evidence regarding outcomes of ASPs in the NH.

METHODS

PubMed, CINAHL, EMBASE, and the Cochrane Library were systematically searched for intervention trials of ASPs performed in NHs that evaluated final health outcomes (mortality and Clostridium difficile infections), healthcare utilization outcomes (emergency department visits and hospital admissions) and intermediate health outcomes (number of antibiotics prescribed, adherence to recommended guidelines).

RESULTS

A total of 14 studies rated good or fair quality were included. Eight studies reported a reduction in antibiotic prescriptions. Ten found an increase in adherence to guidelines proposed by the studied ASP. None reported a statistically significant change in NH mortality rates, C. difficile infection rates, or hospitalizations.

DISCUSSION

The limited research to date suggests that NH ASPs can affect intermediate health outcomes, but not key health outcomes or health care utilization.

CONCLUSION

Larger trials evaluating more intensive interventions over longer durations may be needed to determine whether ASPs in NHs improve health outcomes as they have in hospitals.

Predictors of mortality in nursing-home residents with pneumonia: a multicentre study

OBJECTIVES

To evaluate predictors of mortality in patients residing in nursing-homes (NHs) or long-term care facilities (LTCFs) with diagnosis of NH-acquired pneumonia (NHAP).

METHODS

We conducted an observational, prospective study (December 2013-December 2015) of patients residing in nine NHs/LTCFs of Central and Northern Italy with diagnosis of NHAP. Data on demographics, comorbidities, microbiology, and therapies were entered into an electronic database. To identify risk factors associated with 30-day mortality, we performed univariable and multivariable analyses, and predictors were internally validated using a bootstrap resampling procedure. We derived a prediction rule using the coefficients obtained from the multivariable logistic regression. The model obtained was assessed using the area under the receiver operating characteristic curve (AUROC).

RESULTS

Overall, 446 patients with NHAP were included in the final cohort. The median age was 80 (IQR 75-87) years. A definite aetiology was obtained in 120 (26.9%) patients; of these, 66 (55%) had a culture positive for a multidrug-resistant pathogen. The 30-day mortality was 28.7%. On multivariate analysis, malnutrition (OR 7.8; 95% CI 3-20.2, 2 points), bilateral pneumonia (OR 3.7; 95% CI 1.4-9.8, 1 point), acute mental status deterioration (OR 6.2; 95% CI 2.2-17.6, 2 points), hypotension (OR 7.7; 95% CI 2.3-24.9, 2 points), and PaO₂/FiO₂ ratio ≤250 (OR 7.4; 95% CI 2.2-24.2, 2 points) were independently associated with 30-day mortality. The derived prediction rule showed an AUROC of 0.83 (95% CI 0.78-0.87, p <0.001).

CONCLUSIONS

NH residents with pneumonia have specific risk factors associated with 30-day mortality. Malnutrition and acute mental change appear as major determinants of death in this population.

Antimicrobial Use in Patients with Dementia: Current Concerns and Future Recommendations

Infections are common in people with dementia, and antibiotic use is widespread, albeit highly variable, across healthcare settings and countries. The few studies conducted to date that consider the appropriateness of antibiotic prescribing specifically for people with dementia focus on people with advanced dementia and suggest that much of the prescribing of antibiotics for these patients may be potentially inappropriate. We suggest that clinicians must consider a number of factors to determine appropriateness of antimicrobial prescribing for people with dementia, including the risks and benefits of assessing and treating infections, the uncertainty regarding the effects of antibiotics on patient comfort, goals of care and treatment preferences, hydration status, dementia severity and patient prognosis. Future research should examine antibiotic prescribing and its appropriateness across the spectrum of common infections, dementia severities, care settings and countries, and should consider how antibiotic therapy should be considered in discussions regarding treatment preferences, goals of care and/or advance care planning between clinicians, patients and families.

Nursing Home-Acquired Bloodstream Infection

Objectives:

This article reviews published studies of nursing home-acquired BSI in North America to determine whether there have been changes in the epidemiology of this infection in the past 20 years and to define indications for blood cultures in the nursing home setting.

Methods:

A Medline search was conducted for the period from 1980 to August 2003.

Results:

Seven studies of nursing home-acquired BSI were identified. The incidence of nursing home-acquired BSI was low (0.3 episode per 1,000 resident care-days). Sources of BSI changed little during the past two decades, with urinary tract infection representing approximately 50% of the episodes. The bacteriology also did not change substantially during the past 20 years; gram-negative bacilli were isolated in approximately 50% of the episodes and Escherichia coli was the most commonly isolated organism. In the most recent study, covering the period 1997-2000, resistance to fluoroquinolones and broad-spectrum penicillins and cephalosporins was uncommon among gram-negative blood isolates; MRSA was the most common resistant organism causing nursing home-acquired BSI. Case-fatality rates changed little during the past 20 years; urinary tract infection was associated with the lowest mortality and pneumonia had the highest case-fatality rate.

Conclusion:

There has been little change in the epidemiology of nursing home-acquired BSI in the past 20 years. Given the low incidence of BSI and the low overall yield of positive results of blood cultures (probably ≤ 6%), there is currently no support for the routine use of blood cultures in the nursing home setting.

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

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

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

Background

Pneumonia is among the foremost causes of hospitalization and mortality in patients residing in extended care facilities. Despite its prevalence, there is currently little literature focusing on the course and management of nursing home-acquired pneumonia (NHAP) in the emergency department (ED). Our objective was to investigate the ED presentation, course, management and outcomes in patients admitted through the ED with NHAP.

Methods

A retrospective chart review of nursing home patients with a presumptive or final diagnosis of pneumonia admitted through the ED was performed at two large hospitals in Detroit, Michigan.

Results

A total of 296 patients were included in the study from 2002 to 2007 with a mean age of 81.1 years (SD ± 10.95) and 55.4% females. Blood cultures were performed on 90.8% of patients in the ED; 17.8% of these revealed growths, but half of these were considered contaminants. Initial chest x-ray in the ED was read as possible pneumonia in 18.2% of patients; 73.9% were started on antibiotics (ABX) in the ED. Mean hospital length of stay (LOS) was 10.75 days (SD ± 9.35) and in-hospital mortality was 16.2%. Time until first ABX in univariate analysis was nearly significant (p = 0.053) for mortality prediction, and the appropriate versus inappropriate ABX (per the Infectious Diseases Society of America and American Thoracic Society guidelines) did not affect mortality. Patients treated with a single ABX had significantly increased LOS (p = 0.0089). There was poor correlation between LOS and time until first ABX as well as LOS and time until appropriate ABX with a correlation coefficient of -0.048 (p = 0.42) and -0.08 (p = 0.43), respectively.

Conclusions

In this data set of NHAP patients admitted through the ED, we found a surprisingly low prevalence of true-positive blood cultures, high incidence of antibiotic pre-treatment at nursing homes prior to admission, high hospital mortality and low immunization rates. There was a wide spectrum of pathogens grown in blood culture. Only two thirds of the patients had dyspnea at presentation, and less than half had either cough or fever. On physical examination, about one fourth had no clinical findings consistent with pneumonia. Further, less than one fifth of chest x-rays were interpreted as possible pneumonia.

White paper defining optimal palliative care in older people with dementia: a Delphi study and recommendations from the European Association for Palliative Care

BACKGROUND

Dementia is a life-limiting disease without curative treatments. Patients and families may need palliative care specific to dementia.

AIM

To define optimal palliative care in dementia.

METHODS

Five-round Delphi study. Based on literature, a core group of 12 experts from 6 countries drafted a set of core domains with salient recommendations for each domain. We invited 89 experts from 27 countries to evaluate these in a two-round online survey with feedback. Consensus was determined according to predefined criteria. The fourth round involved decisions by the core team, and the fifth involved input from the European Association for Palliative Care.

RESULTS

A total of 64 (72%) experts from 23 countries evaluated a set of 11 domains and 57 recommendations. There was immediate and full consensus on the following eight domains, including the recommendations: person-centred care, communication and shared decision-making; optimal treatment of symptoms and providing comfort (these two identified as central to care and research); setting care goals and advance planning; continuity of care; psychosocial and spiritual support; family care and involvement; education of the health care team; and societal and ethical issues. After revision, full consensus was additionally reached for prognostication and timely recognition of dying. Recommendations on nutrition and dehydration (avoiding overly aggressive, burdensome or futile treatment) and on dementia stages in relation to care goals (applicability of palliative care) achieved moderate consensus.

CONCLUSION

We have provided the first definition of palliative care in dementia based on evidence and consensus, a framework to provide guidance for clinical practice, policy and research.

Comparison of severity predictive rules for hospitalised nursing home-acquired pneumonia in Korea: a retrospective observational study

Background:

Nursing home-acquired pneumonia (NHAP) is the leading cause of death among long-term care residents.

Aims:

To compare current scoring indices (NHAP model score, Pneumonia Severity Index (PSI), CURB-65 (confusion, urea nitrogen, respiratory rate, blood pressure, age >65 years) and SOAR (systolic blood pressure, oxygenation, age, respiratory rate)) in predicting mortality and admission to the intensive care unit (ICU) in patients with NHAP.

Methods:

This retrospective observational study was conducted between July 2008 and June 2011 using data from the Korean Nursing Home Networks. Two hundred and eight nursing home residents were hospitalised with pneumonia in one general hospital. The primary outcome measure was 30-day all-cause mortality. Secondary outcome measures were intensive respiratory or vasopressor support (IRVS), and severe pneumonia (ICU admission or IRVS).

Results:

PSI class V showed the highest Youden index (0.45), specificity (66.7%), positive predictive value (PPV, 40.0%), negative predictive value (NPV, 91.5%), and area under the curve (AUC, 0.73) for 30-day mortality. For severe pneumonia, PSI class V showed the highest Youden index (0.40), specificity (72.8%), PPV (62.2%), NPV (77.1%), and AUC (0.70). Similarly, PSI class V showed the highest Youden index (0.35), specificity (68.3%), PPV (51.1%), NPV (80.5%), and AUC (0.69) for IRVS.

Conclusions:

The PSI has superior discriminatory power in predicting all three clinical outcomes (30-day mortality, severe pneumonia, and IVRS) compared with the NHAP model score, CURB-65 and SOAR.

Mortality following nursing home-acquired lower respiratory infection: LRI severity, antibiotic treatment, and water intake

OBJECTIVE

In some nursing home populations, antibiotic treatment may not reduce mortality following lower respiratory infection (LRI). To better inform treatment decisions, we determined influences on mortality following LRI among antibiotic-treated and non-antibiotic-treated residents in 2 populations.

DESIGN

Observational, prospective, cohort studies.

SETTING

Ninety-seven nursing homes (36 US, 61 Netherlands).

PARTICIPANTS

Residents (1044 US, 513 Netherlands) who met a standardized study definition for LRI.

MEASUREMENTS

Demographics, symptoms and physical findings of LRI, functional status, major illness diagnoses, dementia status, treatments, and date of death within 6 months after diagnosis.

METHODS

We estimated a 2-period (0-14/15-90 days) weighted proportional hazards model of mortality for antibiotic-treated (n = 1280) and non-antibiotic-treated (n = 277) residents; both weights and regressors provide "doubly robust" risk adjustment-for LRI (illness) severity using a prognostic score and for nonrandom receipt of antibiotic treatment using a propensity score.

RESULTS

In both the United States and the Netherlands, 14-day mortality was associated with three factors-LRI severity, water intake at diagnosis, and antibiotic use (not directly by severe dementia)-that accounted for 82% or, sequentially, 39%, 42%, and 1% of the cross-national mortality difference. The LRI Severity Score (based only on at-diagnosis eating dependency, pulse rate, decreased alertness, and breathing difficulty, with adequate discrimination [c ≥ 0.74] and calibration, and cross-indexed to commonly used LRI mortality measures) was related to mortality through 90 days, regardless of treatment. With sufficient water intake at diagnosis, 14-day mortality was unrelated to not receiving antibiotic treatment (adjusted hazard ratio [AHR], 1.20; 95% confidence interval, 0.70-2.04); insufficient water intake was related to increased 14-day mortality with antibiotics (AHR, 1.90; 1.38-2.60) or without (AHR, 7.12; 4.83-10.5). After 14 days, relative mortality worsened for antibiotic-treated residents with insufficient water intake. Inadequate water intake was related to increased eating dependence at onset of the LRI (OR, 4.2; 3.0-5.8).

CONCLUSION

LRI severity, water intake, and antibiotic use explain mortality in both studies and reconcile cross-study Dutch/US 14-day mortality differences. LRI severity, derived at 14 days, is related to mortality through 90 days, regardless of treatment, and is key to risk adjustment. With adequate hydration, the survival benefit from antibiotic use is nonsignificant. Conversely, hydration, even without antibiotic treatment, appears central to curative treatment. In LRI guidelines, treatment, and research, the relative benefits of antibiotics and hydration for curative treatment should be addressed.

Nursing home acquired pneumonia: approach to management

PURPOSE OF REVIEW

Pneumonia is among the leading causes of mortality in nursing home residents and a primary reason for transfer to acute care facilities. Compared with community-dwelling individuals, residents of long-term care facilities have extensive underlying medical illnesses and more functional disabilities and are at increased risk of acquiring drug-resistant pathogens. This review focuses on recent recommendations for diagnostic work up, validity of prognostic models, and current approach to treatment of nursing home acquired pneumonia (NHAP).

RECENT FINDINGS

The inconsistency in defining NHAP is considered a potential hindrance for a uniform approach to the management of pneumonia. Diagnostic evaluation varies between facilities and depends on severity of illness and access to laboratory facilities. The role of prognostic models in stratifying severity of disease remains largely unknown due to paucity of studies and lack of a specific scoring system for hospitalized patients with NHAP. A controversy still exists concerning the best therapeutic option for NHAP, but it is reasonable to believe that each setting is adapting the existing evidence according to the best local practice.

SUMMARY

A unified approach to defining, assessing, and stratifying pneumonia is essential to decrease morbidity and mortality in nursing home residents. High-quality randomized, controlled trials examining empiric antibiotic therapy are needed.

Impact of NHAP guideline implementation intervention on staff and resident vaccination rates

OBJECTIVES

Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home acquired pneumonia (NHAP), including influenza and pneumococcal vaccination, improves resident subject and staff vaccination rates.

METHODS

Quasi-experimental, mixed-methods multifaceted intervention trial conducted at 16 nursing homes (NHs) from 1 corporation (8 in metropolitan Denver, Colorado; 8 in Kansas and Missouri) during 3 influenza seasons, October to April 2004 to 2007. Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI) and NH staff and physicians were eligible. Subjects' NH records were reviewed for vaccination. Each director of nursing (DON) completed a questionnaire assessing staffing and the number of direct care staff vaccinated against influenza. DONs and study liaison nurses were interviewed after the intervention. Bivariate analysis compared vaccination outcomes and covariates between intervention and control homes, and risk-adjusted models were fit. Qualitative interview transcripts were analyzed using content coding.

RESULTS

No statistically significant relationship between the intervention and improved resident vaccination rates was found, so other factors associated with improved rates were explored. Estimated direct patient care staff vaccination rates were better during the baseline and improved more in the intervention NHs. Qualitative results suggested that facility-specific factors and national policy changes impacted vaccination rates.

CONCLUSIONS

External factors influence staff and resident vaccination rates, diluting the potential impact of a comprehensive program to improve care for NHAP on vaccination.

Evaluation of pneumonia severity and acute physiology scores to predict ICU admission and mortality in patients hospitalized for influenza

BACKGROUND

The demand for inpatient medical services increases during influenza season. A scoring system capable of identifying influenza patients at low risk death or ICU admission could help clinicians make hospital admission decisions.

METHODS

Hospitalized patients with laboratory confirmed influenza were identified over 3 influenza seasons at 25 Ontario hospitals. Each patient was assigned a score for 6 pneumonia severity and 2 sepsis scores using the first data available following their registration in the emergency room. In-hospital mortality and ICU admission were the outcomes. Score performance was assessed using the area under the receiver operating characteristic curve (AUC) and the sensitivity and specificity for identifying low risk patients (risk of outcome <5%).

RESULTS

The cohort consisted of 607 adult patients. Mean age was 76 years, 12% of patients died (71/607) and 9% required ICU care (55/607). None of the scores examined demonstrated good discriminatory ability (AUC>or=0.80). The Pneumonia Severity Index (AUC 0.78, 95% CI 0.72-0.83) and the Mortality in Emergency Department Sepsis score (AUC 0.77, 95% 0.71-0.83) demonstrated fair predictive ability (AUC>or=0.70) for in-hospital mortality. The best predictor of ICU admission was SMART-COP (AUC 0.73, 95% CI 0.67-0.79). All other scores were poor predictors (AUC <0.70) of either outcome. If patients classified as low risk for in-hospital mortality using the PSI were discharged, 35% of admissions would have been avoided.

CONCLUSIONS

None of the scores studied were good predictors of in-hospital mortality or ICU admission. The PSI and MEDS score were fair predictors of death and if these results are validated, their use could reduce influenza admission rates significantly.

Short-term prognostic factors in elderly patients seen in emergency departments for acute heart failure

INTRODUCTION AND OBJECTIVES

To investigate factors associated with short-term mortality in elderly patients seen in emergency departments for an episode of acute heart failure.

METHODS

A prospective, non-interventional, multicenter, cohort study was carried out in patients aged 65 years and older who were treated in the emergency department of one of eight tertiary hospitals in Spain. Twenty-eight independent variables that could influence mortality at 30 days were assessed. They covered epidemiological and clinical factors and daily functioning. Data were obtained by reviewing medical records or by interviewing the patient or a relative. Multivariate logistic regression analysis was performed.

RESULTS

The study included 623 patients, 42 of whom (6.7%) died within 30 days of visiting the emergency department. Four variables were significantly associated with higher mortality: functional dependence at baseline (i.e., Barthel index=60; odds ratio [OR]=2.9; 95% confidence interval [CI], 1.2-6.5), New York Heart Association class III-IV (OR=3; 95% CI, 1.3-7), systolic blood pressure <100 mmHg (OR=4.8; 95% CI, 1.6-14.5) and blood sodium <135 mEq/l (OR=4.2; 95% CI, 1.8-9.6).

CONCLUSIONS

Several factors evaluated on initial assessment in the emergency department, including the level of functional dependence, were found to determine a poor short-term prognosis in elderly patients who present with an episode of acute heart failure.

Pneumonia in the elderly: a review of severity assessment, prognosis, mortality, prevention, and treatment

Pneumonia is an increasingly common disease in the elderly due to an aging population. This is a comprehensive literature review outlining the severity assessment, morbidity, mortality, prevention and treatment options. Several models have been postulated to predict severity assessment and prognosis in older patients. Mortality increases with age and functional status is also an independent predictor for short- and long-term mortality. The effectiveness of the pneumococcal vaccine is controversial, whereas the influenza vaccine is universally recommended. Treatment involves antibiotics with the type and method depending on the severity of the pneumonia. However, treatment of nursing home patients is challenging and there are no validated guidelines at present to determine when transfer to the hospital is necessary.

[Pneumonia mortality risk in patients with dementia: nursing home physicians' use and evaluation of a prognostic score]

A validated prognostic score for mortality risk 14 days after antibiotics treatment of nursing home residents with dementia and pneumonia is available. Of the nursing homes contacted, 96% was prepared to participate in a clinical impact analysis to examine usefulness of the score in practice. After randomising nursing homes, physicians of 27 homes in the intervention group were asked to complete a questionnaire and use the score for the next case of pneumonia; the control group comprised physicians of the 27 other homes who only completed the questionnaire. The 38 respondents from the control group who all reported about a single patient did not differ from the respondents of the intervention group (31 physicians enrolled 34 patients). Only in 24 cases did physicians calculate the score. For 79% of those patients, the score was (at least somewhat) useful, but mostly to train prognostication competencies and for better documentation of prognosis; frequently treatment decisions had already been made. Of the total group of respondents, the majority was positive about the use of prognostic scores in general, but no-one in the participating homes had any experience with it. The prognostic score is potentially useful for an important group of patients with pneumonia, but further implementation research and inclusion of prognostic instruments in training curricula is needed.

Variation in mortality rates among long-term care facilities for residents with lower respiratory tract infection

OBJECTIVE

To identify variables contributing to interfacility differences in mortality among residents of long-term care facilities who have lower respiratory tract infection.

DESIGN

Multicenter, prospective, 1-year observational study.

SETTING

Twenty-one long-term care facilities in 4 geographic areas of Canada.

PARTICIPANTS

Residents of long-term care facilities prescribed antimicrobials for treatment of lower respiratory tract infection.

METHODS

Mortality rates were calculated for 3 definitions of lower respiratory tract infection: episodes with a clinical or radiographic diagnosis and treated with antimicrobials (definition 1); episodes with a physician diagnosis of pneumonia (definition 2); and episodes with chest radiography findings consistent with pneumonia (definition 3). Multilevel modeling was used to evaluate variables describing premorbid resident status, clinical presentation, management, and facility characteristics. Multivariable models were developed to identify independent predictors of mortality and determine whether facility-level variables remained independently associated with mortality rate after incorporation of individual-level variables.

RESULTS

Facility mortality rates varied from 0% to 17.8% for definition 1, from 0% to 47.1% for definition 2, and from 0% to 37.5% for definition 3. There were significant differences in mortality rate depending on which definition was used; for definitions 1 and 2, there were significant differences in mortality rate across facilities. Poorer premorbid resident status and a more severe presentation remained independent predictors of mortality in the multivariable analysis. There were also significantly increased mortality rates for episodes in which a fluoroquinolone was prescribed for initial treatment. For definitions 1 and 3, facility-level variables remained independently associated with mortality rate in the final multivariable model.

CONCLUSIONS

Rates of mortality due to lower respiratory tract infection varied among long-term care facilities and differed within a facility, depending on the definition applied. Variables describing premorbid resident status, severity of presentation, and management did not fully explain the variation in mortality rate. Some facility-level variables remained independent predictors of mortality.

Healthcare-associated pneumonia: principles and emerging concepts on management

Healthcare-associated pneumonia (HCAP) is a relatively new entity that includes pneumonia occurring in healthcare settings other than acute-care hospitals. Many patients with HCAP are at greater risk for colonization and infection with multi-drug resistant (MDR) bacteria such as Pseudomonas aeruginosa, Gram-negative bacilli-producing extended-spectrum beta-lactamases and methicillin-resistant Staphylococcus aureus. Infections with these MDR pathogens require different empiric antibiotic therapy. To avoid initiation of inappropriate antibiotic therapy that may result in poorer patient outcomes, new principles for HCAP management were outlined in the 2005 American Thoracic Society and Infectious Diseases Society of America guidelines. These guidelines were suggested for patients assessed in acute-care hospitals and clinics, and may not be applicable for all patients with suspected HCAP in nursing homes and other long-term care settings. This review article addresses HCAP management strategies in both clinical settings.

Translation research in long-term care: improving pain management in nursing homes

BACKGROUND

Pain prevalence in nursing homes remains high, with multiple resident, staff, and physician barriers presenting serious challenges to its improvement.

AIMS

The study aims were to (1) develop and test a multifaceted, culturally competent intervention to improve nursing home pain practices; (2) improve staff, resident, and physician knowledge and attitudes about pain and its management; (3) improve actual pain practices in nursing homes; and (4) improve nursing home policies and procedures related to pain.

METHODS

A multifaceted, culturally competent intervention was developed and tested in six Colorado nursing homes, with another six nursing homes serving as control sites. Both educational and behavioral change strategies were employed.

FINDINGS

The intervention was successful in improving the percentage of residents reporting constant pain in the treatment homes. Contextual factors (implementation of Medicare's Nursing Home Compare report card) appeared to exert a positive influence on pain documentation. There was no reduction in the percentage of residents reporting pain or reporting moderate/severe pain.

DISCUSSION

Multiple challenges to quality improvement exist in nursing homes. Turnover of nursing staff reduced actual exposure to the intervention, and turnover of directors of nursing influenced constancy of message and overall facility stability. Residents often failed to report their pain, and physicians were reluctant to alter their prescribing practices.

IMPLICATIONS

Any intervention to improve pain management in nursing homes must target explicitly the residents, nursing home staff, and primary care physicians. Implementation strategies need to accommodate the high turnover rates among staff, as well as the changes among the nursing home leadership.

CONCLUSIONS

Pain is a complex problem in the nursing home setting. Multiple factors must be considered in both the design and implementation of interventions to improve pain practices and reduce pain prevalence in nursing homes.

Medicare and Medicaid: conflicting incentives for long-term care

The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.

Medicare and Medicaid: conflicting incentives for long-term care

The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.

Nursing Home–Associated Pneumonia

Nursing home-associated pneumonia (NHAP) is associated with considerable morbidity and mortality. The etiology of NHAP continues to be debated and has influenced treatment guideline recommendations. Diagnosis may not be straightforward but at least one respiratory symptom usually is present and the presence of hypoxemia is a key finding. Treatment recommendations vary depending on the organisms believed the predominant cause of NHAP. Pneumococcal and influenza vaccination remain the most important methods for prevention of NHAP at present.

Assessment of pneumonia in older adults: effect of functional status

OBJECTIVES

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

DESIGN

Prospective cohort study.

SETTING

University hospital.

PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND AND OBJECTIVE

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

STUDY DESIGN AND SETTING

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

RESULTS

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

CONCLUSION

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

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

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

Antibiotic treatment and survival of nursing home patients with lower respiratory tract infection: a cross-national analysis

PURPOSE

Although lower respiratory tract infections are a leading cause of death in frail elderly patients, few studies have compared treatments and outcomes. We assessed the effects of different antibiotic treatment strategies on survival of elderly nursing home residents with lower respiratory tract infections in the United States and the Netherlands, where treatment approaches are quite different.

METHODS

We combined data from 2 prospective cohort studies of lower respiratory tract infections conducted in 36 nursing homes in the United States and 61 in the Netherlands. We included residents whose infections were treated with antibiotics: 806 in the United States and 415 in the Netherlands. Outcome measures were 1-month and 3-month mortality. We used logistic regression to adjust for differing illness severity.

RESULTS

Dutch residents had higher mortality than US residents (28.1% vs 15.1% at 1 month, respectively; P <.001). After adjusting for illness severity with logistic regression, the differences between the Dutch and US populations were not significant (odds ratio 1.34; 95% confidence interval, 0.94-1.90). Predicted mortality was overestimated for more severely ill US residents at 1 month but not at 3 months. No antibiotic regimen was consistently associated with increased or decreased mortality.

CONCLUSION

Despite differences in illness severity and treatment, adjusted mortality did not differ between the 2 countries. Although we cannot exclude a short-term survival benefit from more aggressive treatment in the United States, differences in baseline health appear prognostically more important than the type of antibiotic treatment.

Survival of a cohort of elderly patients with advanced dementia: nasogastric tube feeding as a risk factor for mortality

OBJECTIVES

To evaluate and identify factors determining survival in elderly patients with advanced dementia.

METHODS

A prospective, follow-up, observational analysis in a cohort of 67 community-based patients aged 65 years or older with dementia defined by DSM-IV and stage 7A or above on the FAST scale. Data were recorded on socio-demographic variables, FAST, Katz index, language, swallowing ability, diet, nutritional status (from anthropometric and laboratory data), associated diseases and medical complications during the previous 12 months. Survival was analyzed by the Kaplan-Meier method. Prognostic factors for survival were identified by the Cox proportional hazards regression model.

RESULTS

The median follow-up was 832 days. The mean age was 82.2+/-6.7 years and 92.5% were women. A comorbid condition was present in 71.6%, most frequently hypertension (22.4%). A clinical event had occurred in 52 (77.6%) patients during the previous year (pneumonia, urinary infection, stroke, pressure sore, dehydration, sepsis or others). A total of 25 (37.3%) patients died. The mean survival was 676 days (95% confidence interval, 600-752 days). Cox proportional hazards model showed that independent prognostic factors for mortality were having pneumonia within the previous year (RR:3.7; p=0.001), a permanent nasogastric tube (RR:3.5; p=0.003) and serum albumin values below 3.5 g/dL (RR:2.9; p=0.028).

CONCLUSIONS

In patients with advanced dementia, hypoalbuminemia and pneumonia are strongly and positively associated with mortality. Artificial nutrition via a nasogastric tube reduces survival in these patients.

A New Paradigm for Clinical Investigation of Infectious Syndromes in Older Adults: Assessment of Functional Status as a Risk Factor and Outcome Measure

Adults aged >or=65 years comprise the fastest-growing segment of the United States population, and older adults experience greater morbidity and mortality due to infection than do young adults. Although age is well established as a risk factor for infection, most clinical investigations of infectious diseases in older adults focus on microbiology and on crude end points of clinical success, such as cure rates or death; however, they often fail to assess functional status, which is a critical variable in geriatric care. Functional status can be evaluated either as a risk factor for infectious disease or as an outcome of interest after specific interventions using well-validated instruments. This article outlines the currently available data that suggest an association between infection, immunity, and impaired functional status in elderly individuals, summarizes the instruments commonly used to determine specific aspects of functional status, and provides recommendations for a new paradigm in which clinical trials that involve older adults include assessment of functional status.

Short-term outcomes and their predictors for patients hospitalized with community-acquired pneumonia

PURPOSE

This study of patients who were hospitalized with pneumonia describes 4 short-term outcomes and the relative value of 4 variables for predicting the outcomes.

METHOD

We prospectively documented 4 short-term outcomes (hospital length of stay, discharge location, death, 30-day readmission) among 213 adults (mean age = 72.5 years) with pneumonia who were admitted to the hospital. Relationships between the Pneumonia Severity Index (PSI), preadmission walking, malnutrition, grip strength, and outcomes were examined with correlations and multiple logistic regression.

RESULTS

The mean (SD) hospital stay was 8.8 (10.4) days. Many patients (51.6%) were not discharged to their homes; 13.6% died during admission or within 30 days of discharge. Of 205 patients discharged alive, 23.9% were readmitted within 30 days. All predictor variables correlated significantly with length of stay, discharge, and death. Except for grip strength, all predictor variables correlated significantly with readmission. Regression showed that the PSI contributed significantly to the prediction of all outcomes but that other variables also contributed (R(2) =.099 [readmitted] to.484 [discharged to home]).

CONCLUSIONS

Because malnutrition and physical performance measures independently predicted or added to the PSI's prediction of untoward outcomes, the measures merit inclusion when assessing patients with pneumonia.