From the Guidelines
Pneumonia in a skilled nursing facility should be treated as healthcare-associated pneumonia (HCAP), which requires different antibiotic coverage than hospital-acquired pneumonia (HAP). The treatment approach for pneumonia in skilled nursing facilities, also known as nursing home-acquired pneumonia (NHAP) or HCAP, differs from that of HAP due to distinct microbial ecology and resistance patterns 1. For NHAP, initial empiric therapy often includes coverage for both typical community pathogens and some drug-resistant organisms, with a common regimen being a respiratory fluoroquinolone like levofloxacin (750 mg daily) or a combination of a beta-lactam (such as ceftriaxone 1-2g daily) plus a macrolide (like azithromycin 500 mg daily) 1. In contrast, HAP typically requires broader coverage for multidrug-resistant organisms, often involving combination therapy with antipseudomonal agents like piperacillin-tazobactam (4.5g every 6 hours) or cefepime (2g every 8 hours) plus vancomycin or linezolid for MRSA coverage 1. Clinical assessment, including severity of illness and risk factors for resistant organisms, should guide the final treatment decision, as emphasized in guidelines for managing adults with HAP, VAP, and HCAP 1. Additionally, the high burden of infection in long-term care facilities, including UTI and pneumonia, underscores the need for appropriate antibiotic therapy and infection control measures to prevent the spread of antibiotic-resistant pathogens 1. Overall, the treatment of pneumonia in skilled nursing facilities should prioritize the unique needs and risks of this population, balancing effective antibiotic coverage with the need to minimize antibiotic resistance and promote optimal patient outcomes.
From the Research
Treatment of Pneumonia in Skilled Nursing Facilities
Pneumonia in skilled nursing facilities is not always treated the same as hospital-acquired pneumonia (HAP). The treatment approach depends on various factors, including the severity of the disease, the patient's overall prognosis, and the setting of care.
- The diagnosis of pneumonia in nursing home residents can be challenging, and suspicion of pneumonia is heightened if pulse oximetry measurements are low 2.
- The treatment of pneumonia in skilled nursing facilities may involve oral antibiotics, such as respiratory fluoroquinolones or beta-lactam antibiotics with a macrolide, whereas hospitalized patients may initially receive intravenous antibiotics and transition to oral antibiotics after clinical improvement 2, 3.
- The choice of antibiotic regimen depends on the severity of the disease and the presence of underlying medical conditions, such as aspiration pneumonia or pneumonitis 3, 4.
- In patients with severe nursing home-acquired pneumonia (NHAP), the etiology may overlap with that of HAP, and treatment may require coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa 3.
Comparison with Hospital-Acquired Pneumonia
While NHAP and HAP share some similarities, there are also some differences in their treatment approaches.
- NHAP may be treated with oral antibiotics in the nursing home setting, whereas HAP typically requires intravenous antibiotics in the hospital setting 2, 3.
- The antibiotic regimens used to treat NHAP and HAP may differ, with NHAP often requiring coverage for community-acquired pathogens, such as Streptococcus pneumoniae and Haemophilus influenzae, and HAP requiring coverage for hospital-acquired pathogens, such as MRSA and Pseudomonas aeruginosa 3.
- The duration of treatment for NHAP and HAP may also vary, with NHAP typically requiring a shorter course of treatment (5-8 days) compared to HAP 2, 5.
Diagnostic Approaches
The diagnosis of pneumonia in skilled nursing facilities is crucial for guiding treatment decisions.
- Bedside criteria, such as objective respiratory signs and symptoms, can be used to diagnose NHAP 4.
- Chest radiographs are the most important diagnostic test for pneumonia in nursing home residents, but lung ultrasonography may also be a useful alternative 4.
- Host biomarkers, such as serum C-reactive protein and procalcitonin levels, may be used to distinguish between bacterial and nonbacterial infection, but their use in NHAP is limited and requires further study 4.