Treatment guideline for nursing home-acquired pneumonia based on communitypractice

OBJECTIVES: To describe the findings of a retrospective study of the treatm ent of nursing home-acquired pneumonia (NHAP) in 11 nursing homes in one co mmunity and the development of a treatment guideline for NHAP using data fr om the retrospective study. DESIGN: A retrospective chart review of 239 episodes of NHAP occurring betw een November 1, 1997, and April 30, 1998, was performed. Data regarding ant ibiotic treatment of NHAP were used to revise a treatment guideline develop ed by the authors. Further refinements of the guideline were made based on small group discussions with physicians and nurse practitioners caring for the study population. SETTING: Residents with NHAP were identified among the populations of 11 nu rsing homes in the metropolitan Buffalo, New York area (Erie county). These 11 nursing homes had a total of 2375 beds, comprising nearly one-third of all nursing home beds in the county. PARTICIPANTS: Nursing home residents with chest X-rays showing infiltrates and signs and symptoms of pneumonia. MEASUREMENTS: Antibiotic treatment (dr ug used, route of administration, and duration of treatment), location of i nitial treatment (nursing home or hospital), and status (alive or dead) of each resident were recorded 30 days after diagnosis of NHAP. RESULTS: Of the 239 episodes of NHAP, 171 (72%) were initially treated in n ursing homes. Of these 171 patients, 105 (61%) were treated only with an or al regimen, whereas 66 (39%) were treated initially with an intramuscular a ntibiotic and subsequently with an oral regimen. There was no significant d ifference in 30-day mortality rates between those initially treated in nurs ing homes (22%) and those initially treated in hospitals (31%; P = .15) or between those initially treated with an oral regimen in nursing homes (21%) and those initially treated with an intramuscular antibiotic in nursing ho mes (25%; P = .56). There was no consistency in how physicians made the cho ice to use intramuscular antibiot-ics in nursing homes, and a logistic mode l for predicting this approach could explain very little. The frequency of the prescription of various antibiotic agents in nursing homes and in hospi tals was tabulated as well as the duration of treatment; specific attention was paid to the timing of the switch to an oral agent among episodes initi ally treated with a parenteral agent. These data were used in the guideline to make specific recommendations regarding which agent to prescribe, the d uration of parenteral therapy, the timing of the switch to an oral regimen, and the duration of treatment. In the setting of informal small groups, th e guideline was discussed with physicians who cared for residents with NHAP in the study nursing homes. Revisions made to the guideline were based on these discussions. CONCLUSIONS: A treatment guideline for NHAP was developed primarily on the basis of the practices of geriatricians in one community. These treatment p ractices were similar to those reported in the literature in terms of the p roportion of patients treated in nursing homes and the antibiotics prescrib ed. The guideline also provided specific recommendations for timing of the switch to an oral agent after parenteral therapy and for duration of treatm ent. Studies are in progress to determine if use of this guideline will red uce some of the variation observed in the treatment of NHAP.