eMedicine Specialties > Infectious Diseases > Lower Respiratory Tract Infections

Nursing Home Acquired Pneumonia: Treatment & Medication

Author: Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Contributor Information and Disclosures

Updated: Jun 27, 2008

Treatment

Medical Care

If the physician suspects nursing home–acquired pneumonia (NHAP) and the mimics of pneumonia can be ruled out, early appropriate empiric therapy is the critical component of medical management. Promptly instituting empiric antimicrobial therapy significantly decreases the likelihood of mortality and morbidity associated with NHAP and community-acquired pneumonia (CAP). Direct antimicrobial coverage against the most likely pathogens (ie, S pneumoniae, H influenzae, M catarrhalis, C pneumoniae).

  • Select antibiotics that have the appropriate spectrum and minimal resistance potential, have excellent adverse effect profiles, are cost effective, and are available in intravenous and oral formulations.
  • The duration of therapy usually is 2 weeks, depending on the patient's host defenses and underlying cardiopulmonary status.
  • Consider extending antimicrobial therapy for a few days in more severe cases, but do not automatically prolong therapy simply because persisting pulmonary infiltrates are observed on chest radiographs, low-grade fevers are present, or the patient has minimal leukocytosis.
  • Antimicrobial therapy may be administered intravenously, but this is frequently a problem in elderly patients in chronic care facilities. The absence of intravenous teams and adequate nursing staff makes intravenous antibiotic administration difficult. Elderly patients frequently have poor venous access, further complicating the problem. Therefore, early appropriate antimicrobial therapy with an oral antimicrobial is ideally suited for the early treatment of pneumonia in chronic care facilities. Such early treatment may prevent the further deterioration of the patient and the progression of the pneumonia. Further weakening of the patient's condition may require transfer to an acute care hospital.
  • While some past reports indicated that intramuscular administration of antibiotics is efficacious when intravenous access is not possible, current recommendations indicate that oral antimicrobial therapy is preferred and that physicians should use intravenous therapy instead of intramuscular administration.

Consultations

  • Patients with NHAP typically do not require consultations; however, when attempting to rule out mimics of pneumonia in patients who are transferred to acute care facilities, consider obtaining an infectious disease consultation.
  • Patients with preexisting lung disorders may benefit from pulmonary consultation.
  • Patients with an exacerbation of previous cardiac problems or new cardiac problems will benefit from a cardiac consultation.

Diet

  • Patients do not require dietary alterations.

Activity

  • Physicians usually advise bed rest for patients with NHAP. When the patient is able to ambulate, recommend a gradual transition to ambulation, as tolerated.

Medication

The goals of pharmacotherapy are to reduce morbidity, to eradicate the infection, and to prevent complications.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.


Levofloxacin (Levaquin)

Second-generation quinolone. Acts by interfering with DNA gyrase in bacterial cells. For pseudomonal infections and infections resulting from multi-drug–resistant gram-negative organisms. Highly active against gram-negative and gram-positive organisms, including highly penicillin-resistant S pneumoniae.

Adult

500 mg PO/IV qd for 7-14 d

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Administer antacids 1-2 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; levofloxacin reduces therapeutic effects of phenytoin; probenecid may increase levofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy


Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.

Adult

1 g IV q24h

Pediatric

Neonates >7 days: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
Infants and children: 100 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Gallbladder sludge (eg, pseudobiliary lithiasis) may require cholecystectomy; associated with non-C difficile diarrhea; adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin


Doxycycline (Vibramycin)

Second-generation long-acting tetracycline. More active than tetracycline against many pathogens, especially S pneumoniae and Legionella. Different adverse effect profile and pharmacokinetics compared to tetracycline. Inhibits protein synthesis, thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Adult

100-200 mg PO/IV q12h

Pediatric

<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO/IV in 1-2 divided doses; not to exceed 200 mg/d

Bioavailability decreases minimally with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Documented hypersensitivity; severe hepatic dysfunction

Pregnancy

D - Unsafe in pregnancy

Precautions

Rarely, if ever, causes photosensitivity, but may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines


Cefepime (Maxipime)

Fourth-generation cephalosporin with good gram-negative coverage. Similar to third-generation cephalosporins but has better gram-positive coverage.

Adult

2 g IV q12h

Pediatric

50 mg/kg IV q8h; not to exceed 2 g

Probenecid at high dose decreases cefepime clearance; aminoglycosides increase nephrotoxic potential of cefepime

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Adjust dose in severe renal insufficiency; prolonged use of cefepime may predispose patients to superinfection

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
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Further Reading

For additional information, see Medscape's Pneumonia Resource Center.

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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

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Contributor Information and Disclosures

Author

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Wesley W Emmons, MD, FACP, Assistant Professor, Department of Medicine, Thomas Jefferson University; Consulting Staff, Infectious Diseases Section, Department of Internal Medicine, Christiana Care, Newark, DE
Wesley W Emmons, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and International AIDS Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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