The number of frail older adults li...

The number of frail older adults living in long-term care (LTC) facilities is reckon uponed to increase dramatically over the nearest 30 years. (1) An estimated 40 percent of adults will pass some time in an LTC facility before dying. (2) Because residents of these facilities have higher evens of functional disability and underlying medical illness than older adults in the community, they are at increased risk of acquiring infectious diseases. (3)

Pneumonia is the leading cause of morbidity and mortality in this population. It also is the leading reason for transfer to acute-care facilities. (4-6) At a median incidence rate of 1 to 12 by 1,000 patient-days, (4,7) residents of LTC facilities cause to grow pneumonia approximately 10 times more repeatedly than older adults in the community. (3) Their hospitalization rate is reported to be nearly 30 times higher. (8)

LTC facilities include a variety of residences that provide care for patients with biologic and psychologic disabilities. Because nursing firesides are the most numerous and best described of the LTC facilities, studies often use the terms "nursing homes" and "LTC facilities" interchangeably. (9) This article will continue that practice.

As the population of older adults swells the LTC facility will become an increasingly important site for medical care. There is little agreement, however, about the evaluation and management of nursing home-acquired pneumonia. (3) This article summarizes modern literature on the diagnosis, treatment, and prevention of pneumonia in older living bodys who live in LTC facilities.

Risk Factors

The diagnosis and prevention of pneumonia in LTC facilities requires the identification and recognition of risk factors. Past retrospective studies have yielded conflicting information. (7) A late prospective cohort study reported that older age, male sex swallowing difficulty, and inability to take oral medications were significant risk factors. (7) A prospective, case-control meditation that focused on modifiable factors reported that unwitnessed aspiration, sedative medication, and the number of comorbidities were associated significantly with pneumonia. (5)

A number of factors may increase the risk of pneumonia and of cross-transmission of pathogens among LTC residents. Individual factors include malnutrition, long-term disease, functional impairment, medications, invasive devices, and lengthened antimicrobial exposure. Institutional factors include larger facilities with a single nursing unit or multiple units with shared nursing staff, form into groups activities, low immunization rates, excessive antimicrobial use, and widespread colonization of residents with antimicrobial-resistant organisms. (1)

Etiology

The etiology of in the greatest degree cases of nursing home-acquired pneumonia is undetermined. (10) Barriers preventing accurate microbial testing include the inability of chiefly patients to produce a sputum specimen suitable for analysis, and the difficulty of distinguishing between colonization and infection in viable specimens. (481011) not seldom patients have received empiric oral antibiotic treatment before specimens for diagnostic testing are obtained. (12)

To date, no multicenter studies have used standardized definitions and comprehensive testing to establish the etiology of nursing home-acquired pneumonia. (12) This inconsistency is throw backed in a wide range of proceeds In a 1998 survey of published studies, Streptococcus pneumoniae was identified in naught to 39 percent of specimens, Staphylococcus aureus in naught to 33 percent, and gram-negative bacteria in nothing to 55 percent. (4) A new study listed agents commonly associated with pneumonia in older adults living in the community or in LTC facilities (Table 1)12 The potential relationship between unrecognized aspiration of oral or gastric contentments and the subsequent development of pneumonia in older adults is receiving more attention. An association has been reported between dysphagia and increased oropharyngeal colonization with bacteria including s aureus and gram-negative bacilli like as Klebsiella pneumoniae and Escherichia coli. similar colonization potentially could lead to aspiration pneumonia. (13) Pseudomonas aeruginosa has been isolated from 34 percent of nasogastric tube-fed older hospitalized patients nevertheless from none of the orally f command group. Other gramnegative organisms were isolated from 64 percent of tube-fed patients and from solely 8 percent of the direct group. Thus, the oropharynx of tube-fed patients could be a potential reservoir for P aeruginosa. (14)

A newly come study examined the relationship between strictly defined aspiration terminations and outcome in patients hospitalized with suspected pneumonia. (15) follows showed that aspiration pneumonitis, succeeding to gastric aspiration, occurred twice as frequently as pneumonia. Although the condition is not infectious in its initial stages, the authors report that physicians attend to to treat aspiration pneumonitis with antibiotics. They report that many episodes of aspiration pneumonitis reduce with supportive care alone, and that the mortality related to this condition may differ from the mortality related to infectious pneumonia. If confirmed, this finding could have important implications for the diagnosis and management of suspected pneumonia. (15)