Nursing Home-Associated Pneumonia, Part II: Etiology and Treatment.
Joseph M Mylotte
PMID 32061505WHAT IT FOUND
Nursing home pneumonia is most often caused by S pneumoniae; resistant organisms were infrequently identified overall.
If swallowing is safe, oral treatment is reasonable, with close monitoring and a day 2 to 3 review.
Key findings
01Across seven post-2005 etiology studies in hospitalized residents, S pneumoniae was the most consistent identified cause, while S aureus, Enterobacteriaceae, and P aeruginosa were infrequently identified.
02The HCAP category was abandoned in the 2019 ATS/IDSA CAP guideline; current care focuses on specific risk factors for resistant organisms, such as prior respiratory colonization with MRSA or P aeruginosa or recent antibiotic therapy.
03In a retrospective study of 239 NHAP episodes, 171 were treated in the nursing home; of those, 66 were initially parenteral, median 2 days, with no difference in hospital transfers or 30-day mortality compared with oral treatment, and a day 2 to 3 time-out can guide switching and duration.
STILL TO COME
How it was doneWhat they foundWhat it means for SLPsWhat it means for RNs
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What it does not show
This is a narrative review, not an original study, and it does not report a single methods section or new participant outcomes. Etiology data mostly come from hospitalized nursing home residents, not residents treated in the nursing home, and none of the post-2005 studies were in the United States or Canada. The etiology studies were small except for two, and the proportion with an identified cause varied widely. There are no studies defining the best initial route, switch timing, or short-course duration for nursing home pneumonia. The clinical pathway trial reduced hospitalizations but the pathway was not validated, and clinical pathways do not replace clinician judgment. Recommendations for resistant organisms are explicitly the author's best guess because no studies guide that situation.
The easy way to misread this
Do not assume all nursing home residents with pneumonia need broad-spectrum antibiotics for MRSA or Pseudomonas. The etiology studies found these organisms were infrequently identified overall, and the paper says to consider resistant organisms when specific risk factors are present.