Treatment of Nursing Home-Acquired Pneumonia
For nursing home-acquired pneumonia (NHAP), most residents can be successfully treated with oral fluoroquinolone monotherapy (such as levofloxacin 750 mg daily) or amoxicillin-clavulanate, without requiring broad-spectrum multidrug regimens, unless specific risk factors for multidrug-resistant organisms are present.
Risk Stratification Determines Antibiotic Selection
The critical first step is identifying whether the patient has risk factors for multidrug-resistant (MDR) pathogens, as NHAP is a heterogeneous disease and not all residents require the same aggressive therapy 1, 2.
High-risk patients requiring broad-spectrum therapy include those with:
- Hospitalization within the past 90 days 1
- Antibiotic therapy within the past 6 months 1
- Severe illness requiring ICU-level care 1
- Poor functional status (low activities of daily living score) 1
- Immune suppression 1
Standard-risk patients without these factors can be treated similarly to community-acquired pneumonia with narrower-spectrum agents 1, 2.
Recommended Antibiotic Regimens
For Standard-Risk Patients:
- Oral fluoroquinolone (levofloxacin 750 mg daily for 5-7 days) is highly effective, as levofloxacin covers the typical NHAP pathogens including Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and atypical organisms 3, 2
- Amoxicillin-clavulanate is an alternative that may help preserve broader-spectrum antibiotics for resistant cases 4
For High-Risk Patients:
- Combination therapy targeting methicillin-resistant Staphylococcus aureus (MRSA) and resistant gram-negative organisms 1
- Consider vancomycin or linezolid PLUS an anti-pseudomonal beta-lactam (piperacillin-tazobactam or cefepime) 3, 1
Treatment Location and Route
Most residents should be treated in the nursing home rather than hospitalized 2, 5. The decision to hospitalize should be reserved for those with severe respiratory distress, hemodynamic instability, or inability to maintain oral intake 5.
Initial Route of Administration:
- Oral therapy is preferred for residents who can swallow and absorb medications 2
- If parenteral therapy is initiated, switch to oral within 2-3 days once clinical stability is achieved (stable vital signs, ability to take oral medications, improving clinical status) 6, 2
Duration of Therapy
Shorter courses (5-7 days) are as effective as traditional 10-14 day regimens for most cases 3, 2. Levofloxacin can be used for 5-day regimens in uncomplicated cases 3.
Microbiological Considerations
Obtain sputum cultures when quality specimens are available to guide focused therapy and monitor for resistant organisms within the facility 4. However, empiric therapy should not be delayed while awaiting cultures 3, 4.
The microbiology of NHAP resembles community-acquired pneumonia more than hospital-acquired pneumonia, with limited evidence of MDR organisms in most cases 2. Studies using sophisticated diagnostic testing found that resistant organisms like MRSA or resistant gram-negatives are uncommon in standard-risk residents 2.
Common Pitfalls to Avoid
- Over-prescribing broad-spectrum antibiotics: The 2005 healthcare-associated pneumonia (HCAP) designation led to overuse of broad-spectrum regimens; subsequent evidence shows this approach is unnecessary for most nursing home residents 1, 2
- Automatic hospitalization: Many residents can be safely and effectively treated on-site 2, 5
- Prolonged antibiotic courses: Extending therapy beyond 7 days without clear indication promotes resistance 2
- Ignoring functional status: The ability to produce sputum correlates with better outcomes and lower mortality 4
Adjunctive Measures
Annual influenza vaccination is approximately 50% effective in preventing hospitalization and pneumonia, and 80% effective in preventing death 6. Pneumococcal vaccination should be administered on admission and every 6 years thereafter 6.