NURSING HOME ACQUIRED PNEUMONIA (NHAP) CLINICAL PRACTICE GUIDELINE

NURSING HOME ACQUIRED PNEUMONIA (NHAP)
CLINICAL PRACTICE GUIDELINE

DISEASE RECOGNITION

New/exacerbated cough with or without sputum
Change in vital signs - increased or decreased T, increased R, increased AP
Pleuritic chest pain
Mental and/or functional status change

CONTEXT / / COMMUNICATION

If the resident is moribund and/or receiving comfort care measures or refuses work-up and treatment and develops pneumonia the health care agent should be contacted by the MD or NP or facility nurse before the diagnostic work-up is started to discuss treatment options and comfort care measures. If no antibiotics are to be given Option C should be implemented and “comfort” assured.

ASSOCIATED RISKS

Aspiration risks (PEG, oropharyngeal dysphagia, feeding dependence
COPD
Cardiac disease
Smoker
Diabetes Mellitus
Tracheostomy
Neurological disorder, especially new CVA
Malignancy

PHYSICAL EXAMINATION

Rapid, labored breathing
Grunting on expiration
Intercostal/subcostal retractions
Minimal or absent lung sounds or abnormal lung sounds
Dullness on percussion

DIAGNOSTIC WORK-UP

Chest x-ray
Sputum Gram’s stain and culture (optional and difficult to obtain)
CBC with differential
BUN, creatinine, electrolytes (BMP)
Pulse oximetry
Vital signs (include accucheck if diabetic)
Consider swallowing evaluation for change in swallowing ability and pneumonia

TREATMENT OPTIONS A	TREATMENT OPTIONS B
Clinically judged or CXR confirmed pneumonia and one (1) of the following: --has not responded to oral antibiotics -- body temperature <95 or >104 degrees fahrenheit -- oxygen saturation < 90% on room air -- respiratory rate > 30/min -- SBP < 90 mm Hg -- AP > 120/min -- acutely altered mental status -- no alternative route (PEG)/can’t take P.O.	Does not meet criteria “A” Clinical appearance of pneumonia With or without associated risk(s)

START IM ANTIBIOTICS Rocephin 500-1000 mg QD or Claforan 1000 mg Q 12 hours IF PCN ANAPHYLAXIS CONSIDER HOSPITALIZATION OR NG TUBE WITH ORAL MEDICATION Switch to oral antibiotic when clinically stable: Cough and SOB decrease Temperature < 100.5 for at least 16 hours WBC (if done) < 12,000 if initially elevated or > 4,000 if initially low No evidence of cardiac or other life threatening event in 1^st 3 days of treatment Now able to take meds P.O. Re-evaluate for clinical stability by Day 3 to switch to oral agents as listed in “B” - Day 5 at latest.	START ORAL ANTIBIOTIC Amoxicillin 250-500 mg Q 8 hrs or Augmentin 250 mg Q 8 hrs or Ceftin 500 mg Q 12 hrs IF PCN ALLERGIC: Levofloxacin 500 mg QD
DURATION OF TREATMENT (IM AND/OR P.O.) 7-10 DAYS
OPTION C (COMFORT CARE) Oxygen as needed to maintain pulse oximetry > 90% Oral care, ice chips, vaseline to lips, Atropine eye drops, SL, to dry oral secretions and prevent suctioning Morphine or Nubain to relieve pain and excessive respiratory distress Anxiolytics as needed Gentle bowel management Foley catheter for urinary retention or primarily to improve comfort

References for NHAP

Hutt, E & Kramer, AM: Evidence-based guideline for management of nursing home-acquired pneumonia in The Journal of Family Practice, Vol. 51, No. 8, August 2002, 709-716.
Medina-Walpole, AM: Provider Practice Patterns in Nursing Home-Acquired Pneumonia in JAGS 46:187-192, 1998.
Muder, RR: Pneumonia in Residents of Long-Term Care Facilities: Epidemiology, Etiology, Management, and Prevention in Excerpta Medica, Inc., 319-330, 1998 from Infectious Disease Section, VA Pittsburgh Healthcare System and the Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
Naughton, BJ, Mylotte, JM: Treatment for nursing home-acquired pneumonia based on community practice in J Amer Geriatr Soc. 2000;48:62-66.
Reichmuth, KJ, Meyer, KC: Management of Community-Acquired Pneumonia in the Elderly in Annals of Long-Term Care, Vol. 11, No. 7, July 2003, 27-31.
Reuben, DB, Grossberg, GT et al: Infectious Diseases in Geriatrics At Your Fingertips, 1998/99 Edition, 78-80.

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