What is Nursing Home–Acquired Pneumonia?
Pneumonia is an infection that happens in the lower part of your lungs, affecting the lung tissue. Viruses, fungi, and bacteria can all lead to pneumonia. The severity of pneumonia can vary. It can be mild and easy to manage, which is often the case with unusual infections, or it can be severe and life-threatening, especially when it is acquired in a hospital. This article concentrates on pneumonia caused by certain highly infectious organisms that are commonly seen in nursing home residents. The presence of these powerful organisms, along with the patient’s existing health conditions, can lead to increased illness and death risks.
What Causes Nursing Home–Acquired Pneumonia?
Pneumonia happens when a harmful germ bypasses our body’s natural defenses like coughing and enters the lungs. This can occur from breathing in large quantities of germs, being exposed to highly harmful germs, accidentally inhaling food or drink, or if our body’s defenses are weakened.
Pneumonia can be divided into two categories. One is community-acquired, which is caught in everyday environments like homes and schools. The other is hospital-acquired, which is caught in hospital or healthcare settings. The type of pneumonia diagnosed depends on where you likely caught the infection as it helps doctors decide on the best treatment.
Nursing home-acquired pneumonia falls under the category of hospital-acquired group because in these settings, people are more likely to catch infections from germs that are harder to treat. This is due to factors like living closely with others, frequently ill residents, the constant use of antibiotics, and treatments that lower the body’s defenses like chemotherapy.
Even though the nursing home population is more likely to catch harmful germs, the most commonly found germs are similar to those found in the general population. These include Streptococcus pneumoniae, Haemophilus influenzae, and Klebsiella pneumoniae. However, other harmful germs found typically in nursing homes include K. pneumoniae and Pseudomonas aeruginosa, which are often found in patients who have frequent hospital stays. If during these stays, they have tubes inserted into their bodies or need help with breathing using a machine, their risk increases.
Another germ that is commonly found in patients in nursing homes is methicillin-resistant Staphylococcus aureus (MRSA), which is highly resistant to many antibiotics. This germ is also becoming more common in community settings.
Another group of germs often found are anaerobic microbes which normally live in our mouths and throats, including Peptostreptococcus, Bacteroides, and Provotella species. Nursing home patients frequently have conditions that make swallowing difficult, making aspiration (accidental breathing in of food or liquid) more likely. As a result, these mouth and throat germs might be found in their lung samples. Patients with weakened immune systems, such as those undergoing chemotherapy, are at increased risk for fungal organisms like Candida species and harder-to-treat germs like Pneumocystis jiroveci. These are all commonly encountered when treating a nursing home patient with pneumonia.
Risk Factors and Frequency for Nursing Home–Acquired Pneumonia
Nursing home-acquired pneumonia is a condition that happens to 1-2 people for every 1000 days they spend in a nursing home. If a patient with this type of pneumonia needs to be hospitalized, they have a 13 to 41% chance of dying. The risk can vary depending on things like how well the person can move and take care of themselves, if they have any other lung diseases, their age, and other health problems like stroke, issues with muscles and bones, and weakened immune systems.
This type of pneumonia is part of a larger group called healthcare-associated pneumonia. People with healthcare-associated pneumonia are at a higher risk of catching bacteria that are resistant to multiple drugs and having a higher amount of infections caused by gram-negative bacteria. The people who are at the highest risk include:
- People living in nursing or long-term care facilities
- People who’ve had treatments like chemotherapy or wound care in the last 30 days
- People who’ve been in the hospital for more than 2 days in the last 90 days
- People who are receiving hemodialysis, a type of treatment for kidney failure
Signs and Symptoms of Nursing Home–Acquired Pneumonia
Elderly individuals, who are the main concern in cases of pneumonia contracted in nursing homes, often display less noticeable symptoms like feeling confused, tired, or experiencing falls. Despite this, it’s crucial to watch out for more recognizable signs. These can include a persistent cough, difficulty in breathing, production of phlegm, fever, fast breathing, and low oxygen levels.
Usually, health information is collected directly from the patient. But if memory impairment or chronic dementia is a factor, it becomes important to get this information from caregivers or family. This will help in understanding the sequence of events, any noteworthy risk factors, a history of hard-to-treat infections, or any decline in the patient’s typical behavior or physical condition.
Due to the difficulty in getting accurate historical data in such scenarios, a thorough physical check-up is vital. It’s important to check hydration levels, the state of respiratory functions, and any changes in mental status as these can indicate the seriousness of the illness. While listening to the patient’s lungs, it’s important to be alert for abnormal sounds. If these sounds are heard on one side, this could suggest pneumonia in one section (lobe) of the lung, while sounds on both sides could indicate aspiration pneumonia or severe lung condition called acute respiratory distress syndrome.
Testing for Nursing Home–Acquired Pneumonia
Looking after a long-term care facility resident with pneumonia often requires more extensive resources than treating a young and healthy patient. Pneumonia is generally diagnosed based on symptoms and signs, but a chest x-ray or CT scan can confirm the diagnosis. Residents who appear well, show normal vital signs, and whose physical examination doesn’t raise concerns might just be treated based on these observed symptoms. In some cases, chest imaging might be required for further confirmation. Usually, if a patient shows two or more unusual vital signs, they are admitted for treatment.
Because these patients often show symptoms late and their symptoms can be quite general, it’s often necessary to conduct a full medical examination, including lab tests and imaging. It’s really important to check these patients for signs of a body-wide inflammatory response, which could include temperature abnormalities (fever or hypothermia), rapid heartbeat, fast breathing, and abnormalities in white blood cell count.
If a patient shows two of these four signs, along with a suspected case of pneumonia, they meet the criteria for sepsis – a serious condition that increases the risk of illness and death. Additional lab tests might look at kidney and liver function, and lactic acid levels, to check for signs of poor blood flow to the body’s organs. Blood cultures might be needed to check for the presence of bacteria in the blood, and depending on the doctor’s assessment, we might also conduct tests on urine, respiratory samples, and sputum to help guide the use of antibiotic treatments.
Final decisions about the most appropriate treatment will take into consideration the patient’s overall health, vital signs and any lab studies conducted. Two commonly used tools for decision-making include:
The CURB 65 Score:
- (C) Confusion
- (U) Uremia greater than 19
- (R) Respiratory rate greater than 30
- (B) Systolic blood pressure less than 90
- (65) Age older than 65 years
Here, patients get points based on these factors. Patients with 0 or 1 point can usually be treated as outpatients; However, if a patient scores 2 or more points, their probability of death is over 9.2% and they definitely need to be admitted to hospital.
The Pneumonia Severity Index:
This score is multifactorial and not only considers vital signs, imaging, and lab results, but also takes into account other illnesses, age, gender, confusion, and being a nursing home resident. It also checks vital signs like temperature, blood pressure, heart rate, and respiratory rate. Additionally, your doctor will consider any chest x-ray findings and lab values from a complete blood count, basic metabolic profile, and blood pH.
Treatment Options for Nursing Home–Acquired Pneumonia
Acute appendicitis, a condition where the appendix becomes inflamed and potentially bursts, is typically treated with surgery. However, with medical advancements, there’s been growing interest in the use of antibiotics as a primary treatment option. While this approach can successfully manage the condition in the short term for some people, research has shown that about 1 in 4 people treated with antibiotics need surgery to remove their appendix within a year.
So what’s often the go-to treatment? Surgery, or more specifically, an appendectomy wherein the appendix is removed. The surgery can be performed laparoscopically, which involves making small incisions in your abdomen and uses a camera to guide the surgery. This method is preferred over the traditional open surgery as patients tend to recover faster, feel less pain, and are less likely to get infections.
Note that some patients with appendicitis often have other health conditions, which can complicate the surgical procedure. In such cases, the surgical team may decide to first drain out an abscess (a pocket of pus) caused by the inflamed appendix before conducting the surgery. This would typically be performed by a specialist known as an interventional radiologist.
In addition to surgery, doctors also use antibiotics to help control the infection. These medications typically target a variety of bacteria that could be causing the problem. Remember, the selection of these antibiotics can change based on the resistance patterns of the bacteria and the other medicines the patient is taking.
Lastly, the field of surgery is continually evolving, and new techniques are often introduced. Surgeons have been experimenting with newer methods that may lead to less visible scarring and discomfort post-surgery, like using natural orifices to access the abdominal cavity or making a single incision at the belly button. However, these methods also have their limitations and may not be suitable for everyone.
What else can Nursing Home–Acquired Pneumonia be?
Older individuals who come from a nursing home and show signs of pneumonia often display common signs like coughing, producing phlegm, and having difficulty breathing. However, these signs may not always be straightforward. In some cases, they may show more vague symptoms such as falling, confusion, or feeling excessively tired.
As such, doctors need to think about all possible sources of infection when first looking at these patients. This includes both usual causes like urinary tract infections and skin inflammation as well as less typical ones like brain inflammation or problems within the stomach area. Given that many of these patients also suffer from heart disease, it’s wise to consider the possibility of a sudden heart issue.
Many individuals in this group may not be able to move around much, and some may also have a history of severe diseases like cancer or chronic lung disease. Therefore, in patients showing primary signs related to breathing, it’s crucial to consider conditions such as long term lung disease or blood clots in the lungs.
What to expect with Nursing Home–Acquired Pneumonia
The death rate for pneumonia contracted in nursing homes varies from 13% to 41%. Various factors can influence a patient’s chances of recovery and survival. These can include their age, other health conditions they have, how quickly they are able to get medical help, the severity of the infection, the presence of bacteria in their blood, and whether they require care in an intensive care unit (ICU).
Patients who experience severe symptoms, like septic shock or breathing failure, typically have a higher risk. Pneumonia tends to be more deadly in nursing home populations. However, the best chance of recovery comes from getting medical help quickly and aggressively treating the condition.
