eMedicine Specialties > Infectious Diseases > Lower Respiratory Tract Infections
Nursing Home Acquired Pneumonia
Updated: Jun 27, 2008
Introduction
Background
Nursing home–acquired pneumonia (NHAP) is defined as pneumonia occurring in a resident of a chronic care facility or nursing home. NHAP is one of the most common infectious diseases in chronic care facilities and is a significant cause of mortality and morbidity among residents of such facilities. NHAP more closely resembles community-acquired pneumonia (CAP) than nosocomial pneumonia (NP).
NP occurs when the pathogen is distributed in a hospital setting, resulting in a subsequent infection. Aerobic gram-negative bacilli, including Pseudomonas aeruginosa, cause NPs. Staphylococcus aureus (eg, methicillin-susceptible S aureus [MSSA] and methicillin-resistant S aureus [MRSA]) infection is not a significant cause of CAP, NP, or NHAP. The presence of P aeruginosa and other aerobic gram-negative bacilli defines the NP group. Because NHAP is caused by CAP-associated pathogens and not NP-associated pathogens, NHAP is considered diagnostically and therapeutically synonymous to CAP. Patients with NHAP have the same length of hospital stay as patients with CAP. Physicians, therefore, approach the treatment strategy for NHAP and CAP in a similar way and with similar empiric antibiotic coverage.
Table 1. Comparison of Characteristics of Nursing Home–Acquired Pneumonia, Community-Acquired Pneumonia, and Nosocomial Pneumonia
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Table
Type of Pneumonia | Most Common Pathogens | Uncommon Pathogens | Appearance on Chest Radiograph | Length of Stay (Days) |
NHAP | Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis | Legionella Chlamydia pneumoniae 1 | Focal sequential/lobar ± consolidation ± pleural effusion No cavitation | 7-10 |
CAP | S pneumoniae H influenzae M catarrhalis | Legionella Mycoplasma | Focal sequential/lobar ± consolidation ± pleural effusion No cavitation | 7-10 |
NP | P aeruginosa Klebsiella Escherichia coli | Serratia | Necrotizing pneumonia and cavitation with P aeruginosa and Klebsiella Bilateral infiltrates without cavitation or pleural effusion | 10-21 |
Type of Pneumonia | Most Common Pathogens | Uncommon Pathogens | Appearance on Chest Radiograph | Length of Stay (Days) |
NHAP | Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis | Legionella Chlamydia pneumoniae 1 | Focal sequential/lobar ± consolidation ± pleural effusion No cavitation | 7-10 |
CAP | S pneumoniae H influenzae M catarrhalis | Legionella Mycoplasma | Focal sequential/lobar ± consolidation ± pleural effusion No cavitation | 7-10 |
NP | P aeruginosa Klebsiella Escherichia coli | Serratia | Necrotizing pneumonia and cavitation with P aeruginosa and Klebsiella Bilateral infiltrates without cavitation or pleural effusion | 10-21 |
Pathophysiology
The pathophysiology of NHAP is the same as the pathophysiology of CAP. NHAP may result when a patient aspirates oropharyngeal contents into one or more lung segments or lobes. NHAP may also occur if a distant focus of infection hematogenously disseminates to the lungs.
Aspiration pneumonia, whether community-acquired or acquired in a nursing home, results microbiologically from aspirated anaerobic oropharyngeal flora. Hundreds of species of oropharyngeal anaerobes may be cultured from patients with aspiration pneumonia. However, oropharyngeal anaerobes are not like Bacteroides fragilis, which is the primary anaerobe below the diaphragm and is sensitive to nearly all antibiotics. Patients with CAP or NHAP do not require specific anti– B fragilis coverage. In aspiration pneumonia, the location of the lung lesion is related to the position of the patient at the time of aspiration. Because most patients are supine when they aspirate, most lung infiltrates observed on chest radiographs and most aspiration pneumonia occur in segments of the right lung.
If aspiration occurs when patients are lying on their right side, the pulmonary infiltrates most likely involve the right upper lobe. If patients are lying on their left side, the most likely location of the infiltrates is the left upper lobe. If patients are supine and the aspiration is massive, bilateral infiltrates involving multiple lung segments or lobes are possible and may produce a radiologic appearance indistinguishable from left ventricular failure or acute respiratory distress syndrome.
Table 2. Radiographic Patterns in Aspiration Pneumonia
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Table
Patient Position at Aspiration | Chest Radiograph Lobar Involvement |
Supine | Right lower lobe (ie, superior or posterior segment) or bilateral infiltrates (ie, all lobes) |
Right side down | Right upper lobe (ie, axillary segment) |
Left side down | Left upper lobe (ie, axillary segment) |
Prone | Right middle lobe (ie, lingula) |
Sitting upright | Right lower lobe (ie, basilar segments) |
Patient Position at Aspiration | Chest Radiograph Lobar Involvement |
Supine | Right lower lobe (ie, superior or posterior segment) or bilateral infiltrates (ie, all lobes) |
Right side down | Right upper lobe (ie, axillary segment) |
Left side down | Left upper lobe (ie, axillary segment) |
Prone | Right middle lobe (ie, lingula) |
Sitting upright | Right lower lobe (ie, basilar segments) |
Hematogenously acquired pneumonia is not common among patients with CAP or NHAP. Hematogenously acquired pneumonia presents with bilateral symmetrical perihilar infiltrates, as opposed to the localized segmental or lobar distribution characteristic of pneumonia acquired via primary inhalation.
The degree of impaired lung function resulting from NHAP depends on the extent of aspiration and the patient's preexisting physiologic and anatomic lung function. The histologic changes in lung parenchyma resulting from NHAP are the same as those observed resulting from CAP (ie, no cavitation, necrosis, or blood vessel invasion). As with CAP, resolving NHAP restores the lung function that existed prior to acquiring pneumonia.
Frequency
United States
NHAP is one of the most common causes of infection in chronic care facilities and is one the most significant infection-related causes of mortality and morbidity in such facilities.
International
NHAP is a common cause of infection in chronic care facilities.
Mortality/Morbidity
- NHAP is one of the most important infection-related causes of mortality and morbidity in chronic care facilities.
Race
- No race predilection exists.
Sex
- No sex predilection exists.
Age
- By definition, most patients in chronic care facilities and nursing homes are elderly; therefore, NHAP is a disease that primarily afflicts elderly individuals.
- NHAP is less common in chronic care or rehabilitation facilities that have smaller populations of elderly individuals.
Clinical
History
- Patients may complain of fever, cough, chest pain, or rapid respiration.
- Patients with chronic bronchitis are particularly prone to developing pneumonias.
- Patients with aspiration nursing home–acquired pneumonia (NHAP) often have a history of CNS or esophageal disease, or they have a decreased gag reflex that predisposes them to recurrent aspiration.
Physical
- Most, but not all, patients are febrile. Fever, when present, may be high-grade or low-grade.
- Physical findings in the chest include rales over the involved lung segments with or without signs of consolidation or pleural effusion.
Causes
- The most common pathogens that cause NHAP and community-acquired pneumonia (CAP) are S pneumoniae, H influenzae, and M catarrhalis.
- Atypical organisms that cause NHAP are Mycoplasma pneumoniae, Legionella (primarily in chronic care facilities), and C pneumoniae (primarily in elderly residents of nursing homes).
- Overview of NHAP
- NHAP is a common diagnosis applied upon admission but is the definitive diagnosis in only 33% of patients.
- Many physicians perform a suboptimal workup for NHAP, omitting sputum Gram stains and culture studies. Blood culture findings are usually negative.
- The distribution of pathogens observed in NHAP more closely resembles CAP than nosocomial pneumonia (NP).
- Clinically, NHAP differs from NP in that NHAP is not associated with P aeruginosa, it does not produce cavitation on chest radiographs, and patients generally have a shorter hospital stay. The duration of the hospital stay for a patient with NHAP is the same as for a patient with CAP.
- The medical conditions most frequently misdiagnosed as NHAP are congestive heart failure (CHF) and chronic obstructive pulmonary disease.
- Chest radiograph findings in NHAP are useful to rule out CHF. Unilateral segmental or lobar infiltrates are the most common roentgenographic findings in NHAP, as they are in CAP.
- Fever and leukocytosis are more common in patients with NHAP than in patients with noninfectious mimics of NHAP, but these findings are nonspecific.
- Noninfectious infiltrates observed on chest radiographs are frequently misdiagnosed as NHAP.
- Treat NHAP empirically, using the same antibiotics as with CAP, but not as with NP.
More on Nursing Home Acquired Pneumonia |
 Overview: Nursing Home Acquired Pneumonia |
| Differential Diagnoses & Workup: Nursing Home Acquired Pneumonia |
| Treatment & Medication: Nursing Home Acquired Pneumonia |
| Follow-up: Nursing Home Acquired Pneumonia |
| References |
| Further Reading |
| Next Page » |
References
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Keywords
nursing home–acquired pneumonia, NHAP, pneumonia in chronic care facilities, Streptococcus pneumoniae, S pneumoniae, Haemophilus influenzae, H influenzae, Moraxella catarrhalis, M catarrhalis, Legionella, Chlamydia pneumoniae, C pneumoniae, aspiration pneumonia, chronic bronchitis, CNS disease, esophageal disease, decreased gag reflex, community-acquired pneumonia, CAP, nosocomial pneumonia, NP
