Nursing Home-Acquired Pneumonia (NHAP)

1
Nursing Home-Acquired Pneumonia (NHAP)

• NHAP is defined as pneumonia occurring in a
  resident of a long-term care facility
• Second leading cause of infection and a
  significant cause of morbidity and mortality
  among residents of long-term care facilities
• More closely resembles community-acquired
  pneumonia (CAP) than hospital-acquired pneumonia
  (HAP)
• NHAP is a common diagnosis applied at admission
  but is the definitive diagnosis in only 33 of
  residents

2
DIAGNOSISClinical diagnosis

• Chest x-ray... New, persistent infiltrate- best
• indicator. NHAP often mimics congestive
  heart failure,
• pulmonary embolism, bronchogenic
  malignancies,
• COPD, and others. Non-infectious infiltrates
  frequently
• misdiagnosed as NHP
• Symptoms and physical findings of infection
• Fever, frequently 102 and above -may be low
  or absent Cough
• Rales over involved lung segments, signs of
  consolidation, or pleural effusion
• Shortness of breath, pulse above 100,
  respirations above 25. oxygen saturation 94
• Acute change in cognitive or functional
  status

3
Laboratory findings

• Leukocytosis Not helpful because results are
  nonspecific. Left shift due to stress to the
  individual may also occure with MI, pulmonary
  embolism, dehydrations, any stress
• Blood cultures usually positive if causative
  agent is Streptococcus Pneumoniae or Haemophilus
  influenza
• Sputum culture may be useful if specimen reflects
  lower respiratory flora
• Definitive microbiologic method specimen
  collected by bronchoscopy, or transtracheal
  aspirate

4
Most common pathogens

• Streptococcus pneumoniae
• Haemophilus influenza
• Gram-negative rods
• Moxcella
• Note Antibiogram will provide information
• specific to the organization
• Role of viruses as cause of NHAP is unclear

5
Treatment goal

• Reduce morbidity and mortality, and
• eradicate infection
• Clinicians generally approach treatment of NHAP
  and CAP with similar antibiotic coverage
• Initiation of empiric therapy critical in the
  medical management of NHAP
• Select agents that have appropriate spectrum,
  minimal resistance profiles and are
  cost-effective

6
Management of Pneumonia with a Clinical Pathway,
LTCF
Loeb M JAMA 2006
7
Aspiration Pneumonia

• Aspiration pneumonia results microbioligically
  from aspirated anaerobic oropharyngeal flora into
  one or more lung segments or lobes. May also
  occur if distant focus of infection disseminates
  to the lungs
• Preventing aspiration reduces the risk of the
  resident
• acquiring aspiration pneumonia
• Major sources of aspiration
• Dysphagia
• Mouth/oral cavity
• Gastric regurgitation/Gasto-esophygeal reflux
  disease (GERD)

8
Dysphagia

• DIAGNOSIS
• Symptoms, by observation
• Sudden appearance of respiratory symptoms -
  coughing associated with eating or drinking
• Regurgitation of gastric contents
• Voice changes after swallowing
• Confirmatory tests, such as
• Modified barium swallow
• Video fluoroscopy (a swallowing study)
• Fiberoptic endoscopy
• Evaluation by qualified O.T. or speech and
  language pathologist

9
Dysphagia, Prevention Strategies

• Scant literature available that provides
  evidence-based
• interventions. Basic care appears to be the most
• effective preventive measure
• Optimize nutritional status - Suggest developing
  facility meal/feeding program or guidelines -
  include caregiver education, encourage food and
  fluid, positioning, adaptiveeating equipment,
  utilize assisted-eating techniques,
  careful,appropriate decisions regarding non-oral
  feeding
• and
• Encourage sedentary residents to ambulate -
  stand,
• walk, or propel their wheelchairs

10
Prevent aspiration via ORAL CARE

• Resident hygiene is recognized as an important
  aspect of nursing care but mouth care is often a
  stressful and neglected procedure.
• Evidence increasingly recognizes that aspiration
  of oral secretions and their bacteria are
  important factors in pneumonia.
• In a study published in 2002, oral care was shown
  to reduce NHAP, reinforcing that adequate oral
  care is a modifiable risk factor. Subsequent
  research agrees

11
Preventing NHAP, cont. ORAL CARE

• GOAL Develop and implement a
• comprehensive oral hygiene program
• for all residents.
• 1. Oral health assessment and individualized
  program
• 2. Daily oral care - real teeth, dentures,
  edentuous
• 3. Preventive care by dental professionals

12
Oral Care, continued

• EDUCATION
• Healthcare worker
• Basic information
• Organizations protocol
• Resident/family
• COMMUNICATION TECHNIQUES during care

13
Preventing NHAP, cont. GERD

• Minimize use of medications that block acid
  secretion and promote bacterial overgrowth.
• Offer between meal snacks for residents with
  GERD, or GI-conditions that limit bulk food
  intake
• Treat GI symptoms that may hinder absorption of
  nutrients.
• Avoid NPO restriction whenever possible
• Elevate head of bed at all times (30-45 degrees)

14
Prevention strategy VACCINATION

• Residents
• Two separate vaccine directed at preventing
  pneumonia
• Pneumoccocal conjugate vaccine (PCV13,
  Prevnar-13) and
• Pneumococcal polysaccharide vaccine
  (PPSV23,
• Pneumovax 23) MMWR
  9-18-2014
• Influenza - annual
• Healthcare personnel (HP)
• Influenza - annual
• Note Specifics to be presented Day 3

15
Performance Measures Process and Outcome

• PROCESS examples
• 1. Vaccination Assess population
• a. Influenza residents and HPs
• b. Pneumococcal residents
• 2. Oral care
• a. Assess availability of supplies
• b. Assess adherence to protocol
• OUTCOME examples
• Incidence pneumonia, influenza/influenza-like
  illness
• Targeted - before and after prevention strategies
  implemented

16
References and Resources

• Raghavendran K et al. Periodontics 2000,
  200744164-177, Nursing home-associated
  pneumonia, hospital-acquired pneumonia and
  ventilator-associated pneumonia the contribution
  of dental biofilms and periodontal inflammation
• Cunha B, Bronze M. Nursing Home Acquired
  Pneumonia. Nursing Home Acquired Pnemonia.
  httpemedicine.medscape.com/article/234916-overvie
  w
• Multiple references and resources are cited with
  links and ordering information in the MARR 2008
  Long-Term Care Toolkit 2998. Steps 1,2
  currently in revision
• MMWR update vaccine-preventable pneumonia
  (ACIP)
• http//www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.
  htm