Nursing home-acquired pneumonia: update on treatment options

The management of nursing home-acquired pneumonia (NHAP) continues to be debatable because of the lack of clinical trials and controversy regarding its aetiology. The controversy regarding aetiology stems, in part, from studies that utilised sputum cultures for the diagnosis of NHAP without assessing the quality of the samples. These studies found a high proportion of Gram-negative aerobic bacilli in cultures as well as Staphylococcus aureus. However, in studies that have assessed the reliability of sputum samples, Gram-negative bacilli and S. aureus were isolated infrequently and Streptococcus pneumoniae and Haemophilus influenzae isolated most commonly. Since Gram-negative aerobic bacilli and S. aureus frequently cause hospital-acquired pneumonia, some authors have considered NHAP to be a variant of this group. Many other studies, however, have considered NHAP as part of the community-acquired pneumonia category. Depending on which categorisation is used for NHAP, the treatment recommendations have varied. There are several factors to consider in the management of NHAP in addition to choice of antibacterial: hospitalisation decision, initial route of administration of antibacterials for treatment in the nursing home, timing of switch from a parenteral to an oral agent and the duration of therapy. These factors, which have not been addressed in published guidelines, are discussed in this review. Recent guidelines recommend a fluoroquinolone (gatifloxacin, levofloxacin or moxifloxacin) or amoxicillin/clavulanic acid plus a macrolide for initial treatment of NHAP in the nursing home. For treatment in the hospital, a parenteral fluoroquinolone (as listed above) or a second- or third-generation cephalosporin plus a macrolide is recommended. A recent guideline for the treatment of healthcare-associated pneumonia (that includes NHAP) recommended an antipseudomonal cephalosporin or a carbapenem or an antipseudomonal penicillin/beta-lactamase inhibitor plus ciprofloxacin plus vancomycin or linezolid for treatment of NHAP based on findings in residents with severe pneumonia who required mechanical ventilation. However, this recommendation does not apply to the majority of residents who are hospitalised with pneumonia and not intubated. Other factors to consider when choosing an empiric regimen include recent antibacterial therapy and prior colonisation with a resistant organism, e.g. methicillin-resistant S. aureus. Recently, a group of studies by investigators in The Netherlands have focused on the concept of withholding antibacterial therapy in nursing home residents with pneumonia who have advanced dementia. These studies are reviewed in some detail because this is an approach to the management of NHAP that is uncommon but deserves more consideration given the terminal status of these people. Future studies of NHAP should focus on development of rapid (molecular) methods to identify aetiological agents, determination of the optimum antimicrobial regimen and duration of therapy, and identification of criteria that can assist physicians and families in making the decision to withhold antimicrobial therapy in residents with advanced dementia and pneumonia.