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 1st 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

  1. 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.
  2. Medina-Walpole, AM: Provider Practice Patterns in Nursing Home-Acquired Pneumonia in JAGS 46:187-192, 1998.
  3. 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.
  4. Naughton, BJ, Mylotte, JM: Treatment for nursing home-acquired pneumonia based on community practice in J Amer Geriatr Soc. 2000;48:62-66.
  5. 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.
  6. Reuben, DB, Grossberg, GT et al: Infectious Diseases in Geriatrics At Your Fingertips, 1998/99 Edition, 78-80.

MS/7.99
©EMS
Revised 8.03

 

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