Respiratory: Pneumonia
This Clinical Information Sheet (CIS) has been developed to assist RACF staff, medical practitioners and relevant professionals with the prevention and management of pneumonia in residential aged care patients. It addresses issues that may occur in RACF, particularly:
It covers:
The clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Pneumonia
Pneumonia is an acute infection of the lower respiratory tissues accompanied by signs and symptoms and evidence of chest infiltration on x-ray or altered breath sounds on auscultation [1-3].
Depending on their co-morbidities, residents may develop community-acquired, end-of-life or aspiration pneumonia.
Community acquired pneumonia occurs in people living in the community or RACF, who are not in hospital or have been in hospital for less than 48 hours [4]. Antibiotic therapy commenced within 8 hours of presentation with community-acquired pneumonia significantly reduces mortality [4]. This needs to be distinguished from pneumonia occurring at the end-of-life, which has little attributable mortality and antibiotics have little impact on life expectancy [5].
Aspiration pneumonia occurs in residents at risk of aspirating oropharyngeal bacterial pathogens due to nasogastric or gastroscopy tube feeding, or swallowing difficulties, e.g. related to dementia, CVA, sedative use [2, 3].
Due to their age, chronic illness and close living conditions, residents of residential aged care facilities are at high risk of developing infections and dying due to pneumonia.
Older adults have a higher risk of developing pneumonia than any other patient group [2]. Multiple factors contribute to high rates of pneumonia in older adults:
Residents also have an increased risk of pneumonia due to institutional factors, such as; living in close proximity to others; increased risk of exposure to bacteria, e.g. from poor standard precautions; and increased use of anti-microbials leading to anti-microbial resistant organisms within the environment [6, 7].
In RACFs, the reported incidence of pneumonia is about 1 episode per 1,000 days of residential care [6, 8]; a rate 10 times higher than community-dwelling older adults [8]. It represents one of the most common causes of death in the residential aged care population, and older adults with dementia [9]. RACF residents are admitted to hospital with pneumonia at a rate 30 times higher than older adults living in the community [8]. Survivors have high rates of re-hospitalisation, long-term morbidity and mortality [3, 8].
Causes of Pneumonia
Streptococcus pneumoniae (pneumococcus) is responsible for approximately two-thirds of bacterial community-acquired pneumonia cases as well as the most deaths from pneumonia, particularly in the elderly. The risk is highest in individuals with diminished immunocompetence, smokers and those with chronic conditions including cardiovascular or pulmonary disease, and diabetes.
Other common causes include Mycoplasma pneumoniae and Chlamydia pneumonia. Haemophilus influenzae is responsible for less than 5% of cases and is seen predominantly in chronic obstructive airways disease. Less frequently observed organisms should still be considered including Legionella, which has a high mortality rate, influenza virus and para-influenza virus [4, 10].
Prevention
Reduction of risk factors
Reduce risk of aspiration in residents with swallowing difficulties. (See section on aspiration pneumonia).
Prophylactic use of antibiotics have not been shown to reduce the risk of pneumonia, and would be expected to result in increased colonisation with resistant organisms [6, 7].
Immunisation
Regular immunisation is the most effective preventative measure for pneumonia. The NH&MRC Australian Immunization Handbook therefore recommends vaccination of residents of RACFs for influenza and pneumococcus to reduce the prevalence of infection and associated morbidity [10].
Influenza vaccination
Influenza vaccination should be administered annually to all residents and staff of RACFs and has been shown to reduce hospitalisations for heart disease, cerebrovascular disease, influenza and pneumonia, as well as the risk of death from all causes during influenza seasons [12]. For more information on influenza vaccination see the Respiratory: Influenza Clinical Information Sheet.
Pneumococcal vaccination
Pneumococcal vaccination prevents pneumonia and improves all cause mortality [13]. No systematic reviews have found a reduced mortality from pneumococcal vaccines in industrialised countries or on pneumococcal pneumonia in high risk and immunocompromised patients [14]. Nevertheless, there is evidence for benefit from pneumococcal polysacharide vaccine among the elderly population (over 65 years) in Sweden, [15]and in Aboriginal and Torres Strait Islander people in north Queensland [10].
The 23-valent pneumococcal polysaccharide vaccine (23vPPV) provides protection for most types of pneumococcus causing infectious pneumococcal disease in Australian adults. Vaccination with 23vPPV is recommended for [10]:
Adults 65 years and older, with a single revaccination 5 years later; and Aboriginal and Torres Straight Islanders 50 years and older, with a single revaccination 5 years later.
The Victorian State Government, Department of Human Services provides pneumococcal vaccine free for people over 65 years and Aboriginal & Torres Strait Islander people over 50 years. Pneumococcal vaccine for restricted use is also available via PBS.
Vaccination is not recommended for [10, 16]:
Individuals that have been vaccinated within the last 3 years, because of increased risk of local adverse reactions; or
Individuals who have recently used immunosuppressants or undergone radiation of lymph nodes. Once it is considered that an individual is immunologically stable, however, he or she may be vaccinated.
The following adverse reactions may occur [4, 10]:
Low-grade fever occurs occasionally; Approximately 50% of recipients will experience some soreness after the first dose, but pain or swelling severe enough to limit arm movement occurs in less than 5% of recipients; and Re-vaccination is associated with an increase in local adverse reactions, with approximately 75% experiencing soreness at the injection site.
Vaccination can be done at any time of the year, however it can be administered concurrently with the Influenza vaccine for protection before winter starts (i.e. vaccinated between March and May).
Administration of a vaccination should be clearly documented in the resident’s record, with the date, time, type and batch number of vaccination; and any adverse effects from the immunisation.
It is important to maintain the temperature of vaccines between 2°- 8°C during transport and storage. For further details on handling vaccines see the Respiratory: Influenza Clinical Information Sheet.
Assessment
Assessment aims to identify:
Diagnosis of pneumonia type (community acquired, end-of-life, aspiration) and severity; Resident’s goals of care and treatment preferences; The causative organism through appropriate investigations; Co-morbidities, e.g. diabetes, cardiac failure; and Potential complications, e.g. empyema, lung abscess.
Diagnosis
Suspected pneumonia if a resident has at least two of [1-3, 6, 7]:
A new cough, or a cough changed in character; Sputum production or change in colour; Fever or rigor;. Pleuritic chest pain; and Breathlessness.
Assess history of [1, 2, 6]:
Tachypnoea; Lethargy; Functional decline; Incontinence, (new onset); Alteration in sleep-wake cycles; Loss of appetite; Increased confusion and/or agitation; and Wandering and/or falls.
Initial examination should include temperature, blood pressure, respiratory rate, heart rate and pulse oximetry if available. Pneumonia is likely if clinical signs of lung consolidation are present.
It is recommended that RACF staff notify the resident’s GP within one hour of the resident exhibiting 2 or more signs and symptoms of pneumonia for prompt assessment and commencement of therapy [6] (See Reference Card: Pneumonia Assessment.)
Atypical or non-specific presentation of pneumonia in older adults may delay diagnosis and treatment [1, 6]. Tachypnoea or lethargy may be the only early signs in the illness. Classic signs and symptoms are often absent, with up to 50% of pneumonia cases in patients aged over 65 unable to be diagnosed by clinical signs and symptoms alone [2, 6].
Differential diagnoses in patients presenting with signs and symptoms of pneumonia include [3]:
Pulmonary embolism; Pulmonary oedema; Malignancy; Aspiration pneumonitis; and Pulmonary tuberculosis, particularly in residents from high-risk countries or those with history of weight loss and/or chronic cough.
Investigations
Evidence suggests that no combination of presenting clinical signs and symptoms can reliably confirm a diagnosis of pneumonia [2]. The following table details the investigations to consider for residents suspected of having pneumonia.
Table One: Investigations for Pneumonia
|
Investigation
|
Description
|
|
Chest X-ray
|
Confirms diagnosis and provides an indication of severity, underlying co-morbidity and progress once treatment has commenced [2-4, 6, 7, 17].
|
|
Pulse oximetry
|
Should be performed where possible. Hypoxemia (oxygen saturation of less than 90%) serves as an important predictor of short-term (30-day) mortality and ongoing monitoring can indicate impending respiratory failure that may require transfer to an acute care facility [4, 17].
|
|
FBE, U&E's, Glucose
|
|
|
Sputum Cultures
|
If possible, sputum cultures should be collected prior to commencing antibiotics for Gram staining, culture and sensitivity [4]. Sputum cultures are only of use if a deep-cough specimen can be obtained before antibiotic therapy and rapidly transported and processed in the laboratory within 1-2 hours of collection. After that period of time, yield of various microbial agents decreases. In the RACF setting, many residents may be unable to produce a deep cough specimen due to functional or cognitive impairment. [2, 3, 7, 17]. Culture for Mycobacterium tuberculosis should also be conducted for residents with an identified risk of TB [3].
|
|
Urinary Legionella antigen tests
|
Two tests, the pneumococcal urinary antigen assay and Legionella urinary antigen may be conducted [4]. Legionella urinary antigen is sensitive and specific for detection of Legionella Pneumophilia Type 1, which accounts for70% of reported Legionella cases [3]. A positive test can help guide therapy, but a negative test, does not rule out a diagnoses of Legionella.
|
|
Blood cultures
|
Residents identified as having severe pneumonia should have blood cultures performed before antibiotics are administered, if possible [2, 18]. Although positive in up to 6% of patients, routine blood cultures rarely lead to a change in management in less-severe cases[18].
|
Classifying Severity of Pneumonia
Clinical guidelines and expert opinion [2, 3, 6, 7, 19, 20] recommend that the Pneumonia Severity Index score be used to classify the severity of pneumonia to help decide location of treatment, and choice of antibiotics (broader spectrum antibiotics are used for greater severity). The PSI scoring system, which has been validated in residents of RACFs [21], assigns severity points based on numerous variables including age, co-morbidity, physical signs and symptoms and laboratory findings [2-4, 6, 7, 19, 20] (see Reference Card: Pneumonia Severity Index).
However, the PSI requires laboratory testing for accurately classifying patients, and therefore may be difficult to perform in many RACFs. The PSI is a guide only and clinical management should consider the patient’s clinical and social context. Some residents with mild pneumonia (Class 11) may require hospital admission, e.g. if in low level care with minimal supervision or unable to take oral antibiotics. [4]
The following assessment scale can be used to assess residents for severe pneumonia (PSI class IV or V) that requires management in an acute care facility [2-4, 6, 7, 22].
|
Patients displaying 2 or more of the following signs and symptoms are defined as high risk, and have a mortality rate of >30%:
Respiratory rate > 30/min. Pulse > 125/min. Acute change in mental state. Hypotension (systolic < 90mmHg and/or diastolic <60mmHg and/or 20mmHg less than resident’s baseline. History of dementia, cardiovascular disease, liver disease or renal failure. Requiring oxygen at a rate > 3L/min.
|
Ongoing Assessment
Patients should be assessed at least once per shift by trained nursing staff, for signs and symptoms of worsening condition, especially in the first 24-48 hours. Dyspnoea, pain, temperature, BP, respiratory rate, heart rate, pulse oximetry and mental status should be assessed.
If the resident develops worsening of any of these signs and symptoms the resident’s GP should be informed [3, 6]. In particular the GP should be informed if the resident develops:
Rigours (indicate ongoing bacterial sepsis); Shortness of breath; and/or Respiratory rate counted over a full minute of > 30/min (carries worse prognosis) [2, 6, 7].
Pulmonary Function Tests
34% of older adults presenting with pneumonia signs and symptoms are found to have clinical indications consistent with asthma or COPD within 3 years of the pneumonia episode. Consider performing spirometry after the convalescence period to diagnosis any underlying asthma or COPD, particularly if the resident exhibited diffuse wheeze and crackles on auscultation during the pneumonia episode [2]. See Respiratory Asthma Clinical Information Sheet for information on accessing mobile spirometry services.
Management
Goals
In establishing goals of care in residents it is important to distinguish pneumonia in otherwise well older people from pneumonia at the end-of-life, which has little attributable mortality and where antibiotics have little impact on life expectancy [5]. In one study, researchers found that residents who had a Do-Not-Resuscitate (DNR) order were less likely to receive active treatment and hospitalisation for pneumonia than residents without a DNR order [23].
Advance Care Planning should consider the level of intervention a resident would prefer based on severity (eg PSI class), and specify whether the resident would prefer active treatment or transfer to an acute facility. In many instances treatment of pneumonia with antibiotics is appropriate for relief of symptoms within a palliative care context [9]. Further information is available in the Clinical Information Sheets on Advance Care Planning and End-of-Life Care.
Location of Care of Resident
Clinical guidelines and expert opinion recommend that the type and location of optimal treatment of community-acquired pneumonia depends on the assessment of severity [2, 3, 6, 7, 19, 20]. The decision on location of treatment is less clear for RACF residents. PSI Class 1 is NOT applicable to residents of RACFs, as they are elderly. Most residents will fall into Class 3-5 (moderate to severe pneumonia) and will require parenteral therapy.
Classes 4 & 5 (severe pneumonia) are at significantly increased risk for morbidity and mortality such that management in an acute hospital facility should be considered if appropriate [7].
There is little evidence that transfer to hospital improves outcome for patients with less severe pneumonia, and negative aspects of hospitalisation such as physical discomfort, risk of disorientation and exposure to additional pathogens are avoided if the patient can be treated within the RACF [6]. Patients with mild to moderate pneumonia and good functional status seem to do better with treatment in the RACF. Patients with severe pneumonia may have lower short term mortality if hospitalised initially, although longer term mortality may not be improved [24].
Other issues that need to be considered in determining location of treatment include the expressed preferences of the resident/relatives and the Advance Care Plan; the resources available at the RACF, e.g. laboratory; X-ray; nebulizers; suction; oxygen therapy, the number of skilled staff available for intense monitoring and evaluation of patients, and access to Hospital in the Home support [5].
Hospital in the Home (HITH)
Some residents may receive IV antibiotic treatment for pneumonia at the RACF, through a Hospital in the Home service. Hospital-in-the-Home (HITH) services administer acute care, including intravenous medications, for suitable medically stable patients in their own home or RACF. For further information on Hospital in the Home services see the Reference Card: Hospital in the Home Treatment, with the Urinary tract Infection Clinical Information Sheet. Contact your local public hospital to establish Hospital in the Home availability and referral procedures.
Antibiotics for community acquired pneumonia
Antibiotic therapy commenced within 8 hours of presentation with community-acquired pneumonia significantly reduces mortality [4]. Most cases of pneumonia seen in the RACF will require initial empiric antibiotic therapy, as clinical presentation and chest X-ray can not identify a specific causative pathogen.
There are few clinical trials identifying the best treatment for pneumonia in residential aged care patients. Although atypical organisms are uncommon in this patient population, elderly patients with community-acquired pneumonia seem to do best with either combination therapy of a third-generation and a macrolide, or use of a fluoroquinolone alone, compared to other antibiotic regimens [2-4, 6, 7, 25, 26].
Clinical guidelines recommend that empiric therapy be guided by pneumonia severity (eg PSI score) [2-4, 7], and the patient’s clinical and social context. Reassess after 24-48 hours to ensure the resident has not advanced to a higher class.
The antibiotic guidelines recommendations for management of community acquired pneumonia for non-tropical Australia follow:
Antibiotic Regime for mild pneumonia (PSI Class 2): Patients with a PSI Score 1-70 (30 day mortality of 0.9%) are usually treated in RACF to cover pneumococcus, mycoplasma pneumoniae or Chlamydia pneumoniae. Unless the resident is allergic to penicillin, use the antibiotic regime below. If the resident is sensitive to penicillin, replace amoxicillin with cefuroxime [4].
|
Amoxicillin 1g orally 8 hourly hourly for seven days [4]
OR
Cefuroxime 500mg 12 orally 12 hourly for 7 days
PLUS
Doxycycline 200mg stat, then 100mg daily orally or Roxithramycin 300 mg orally daily
OR
Clarithromycin 250mg 12 hourly for 7 days
|
Antibiotic Regime for moderate pneumonia (PSI Class 3): Patients with a PSI Score 71-90 may receive IV therapy in hospital as outlined for PSI Class 4. An alternative for some patients is IV therapy in the RACF with Hospital in the Home support. Daily dose regimes are used for convenience although they are wider spectrum than the regimes used in hospital. A commonly used regime is Ceftriaxone 1g IV or IM daily PLUS Roxithramycin 300 mg orally daily. If resident is allergic to Ceftriaxone, or immediate hypersensitivity to penicillins, use Moxifloxacin 400mg daily orally as a single drug. Antibiotic Regime for severe pneumonia (PSI Class 4): Patients with a PSI Score 91-130 (30 day mortality of 9.3%) are usually treated in hospital with this recommended antibiotic regime:
|
Benzylpenicillin 1.2g IV 4 hourly IV until significantly improved
THEN
Amoxycillin 1g IV 8 hourly for a total of 7 days [4]
PLUS
Doxycycline 100mg 12 hourly orally for 7 days/b>
OR
Roxithramycin 300 mg orally daily for 5 days
OR
Clarithromycin 500mg 12 hourly for 7 days [4]
Extra gram negative cover may be required if gram negatives in sputum/blood cultures. Consider adding: Gentamicin* 4-6 gm IV daily
|
|
*Gentamicin should not be used in patients with renal or hearing impairment. Gentamicin levels and renal function should be checked starting with the 2nd 2nd dose and every 2-3 days thereafter. Initial dose varies with age: 30-60years, 5mg/kg/day; >60 years, 4mg/kg/day)
|
Duration of therapy
Ideal duration of therapy has not specifically been studied in the residential care patient population. Duration of initial empiric therapy depends on the patient’s response to treatment, immunologic capacity of the resident, severity of the illness, pathogen on microbial testing, and chest X-ray findings.
The typical duration of antibiotic therapy is 5-10 days, however, subjective response is usually noted within 1-3 days. Intravenous antibiotic treatment should be changed to oral antibiotic therapy once clinical improvement is evident, usually within 48-72 hours. Less common infections require treatment for longer durations (Mycoplasma, Chlamydia for 14 days; Legionella for 21 days), however, these infections are relatively uncommon in RACF populations [3]. See Therapeutic Guidelines for antibiotic therapy for specific pathogens [4].
Rehydration
Promotion of increased fluids, unless contraindicated, and regular hydration assessment are recommended [6]. Clinical assessment alone is unreliable in this population, therefore U&Es should be monitored regularly to ensure adequacy of fluid replacement. Subcutaneous administration of fluids is a safe and effective alternative to intravenous therapy in this population [27]. See Subcutaneous Hydration Clinical Information Sheet for more information.
Oxygen Therapy
Oxygen should be applied via facemask or nasal prongs at a flow rate to maintain oxygen saturation levels above 90%. Use low flow oxygen (2L/min or less) if the resident has a history of COPD and CO2 retention [6].
Analgesia
Paracetamol is recommended for pain relief and antipyretic action [2]. In a large study on discomfort levels in pneumonia patients, it was found that pain was more severe in patients with pneumonia than those suffering other infections, with breathing difficulties responsible for the most discomfort. In this study pain levels were significantly higher in those residents for whom antibiotic therapy was withheld, despite these residents receiving more interventions to manage pain [9]. Patients with pneumonia should be assessed for pain on a regular basis and additional pharmacological and non-pharmacological interventions should be implemented as required (See Pain Management CIS). Antibiotic therapy should be considered in the context of pain management [9].
Use of Cough Preparations
One of the earliest symptoms of pneumonia is often a cough. Cough is a defence mechanism for clearing sputum from the airways, therefore, suppressing a cough is not always appropriate. Use of a cough suppressant preparation is only justified when the patient has a non-productive, irritating cough [2], and then should only be used when the resident has no medical or pharmacological contra-indications. Expectorants, demulcents, beta-antagonists, codeine, pholcodine (linctus) and dextromorphan (opiate cough suppressant) have all been shown to be ineffective in treatment of cough [2].
Physiotherapy
Chest physiotherapy should be conducted on a regular basis if available.
Infection control
RACF residents have high rates of resistant pathogens, and infection from these conveys a higher risk of death [3, 6]. Basic infection control policies reduce the spread of infections through institutions, and limit the impact of outbreaks when they occur. RACF staff should be provided with regular education on standard infection control principles [7].
Aspiration Pneumonia
Aspiration occurs when materials such as gastric contents, food or saliva is inhaled into the airway. It may present silently, or the resident may have signs and symptoms including cough, choking or acute respiratory distress.
Aspiration of material into the lower respiratory tract may lead to either pneumonia or non-infectious chemical pneumonitis, which does not require antibiotics. Differentiating between the two can be difficult.
Studies suggest that aspiration is the cause of 5-10% of severe pneumonia, however, in most cases the aspiration episode goes unwitnessed ("silent aspiration").
Aspiration pneumonia should be suspected when a resident has a condition that predisposes them to aspiration such as nasogastric or gastroscopy tube feeding, or swallowing difficulties, e.g. related to impaired consciousness eg dementia, CVA, sedative use [2, 3], or impaired coordination eg in Parkinsons disease.
Prevention of Aspiration
Aspiration of oropharyngeal bacterial pathogens into the lungs is one of the most important risk factors for pneumonia in the elderly.
There is an increased risk of aspiration in residents with impaired consciousness, altered airway defenses and depressed immune systems.
Interventions that reduce the risk of aspiration for those residents for whom risk is identified, include:
Minimise sedative and narcotic use; Prevent constipation; Speech therapy assessment and education for patients with dysphagia; Supervision of meals and enteral feeds; and Maintenance of good oral hygiene [10].
Recommendations for reducing the risk of aspiration for residents receiving enteral feeding are outlined in the Gastrostomy Tube Management Clinical Information Sheet.
Antibiotics
Minor aspiration may not require antibiotic treatment.
Aspiration pneumonia will require coverage for anaerobic organisms. Antibiotic coverage for Aerobic Gram-negative bacilli and/or Staphylococcus aureus may be added to the recommended antibiotic regime below, although these infections are uncommon [4].
For initial treatment of aspiration pneumonia use:
|
Benzylpenicillin 1.2g IV 6 hourly IV
PLUS
Metronidazole 500 mg IV, 12-hourly
OR
Metronidazole 400 mg orally, 12-hourly [4]
|
Switch to oral therapy after significant improvement and resolution of signs and the resident can tolerate oral medication. Use Amoxycillin + Clavulanate 875+125mg orally 12-hourly. Seven days therapy is usually adequate for uncomplicated aspiration pneumonia [4].
Sources of Information
Where to go for more information
Therapeutic Guidelines have been prepared by writing groups of experienced clinicians, and represent independent consensus opinion based on the evidence available at the time of publication. The guidelines are available as pocket-sized book, CD-ROMs for installation on personal computers, and electronic versions for use on Health Department intranets, integration with commercial prescribing software, and hand-held computers.
Website:http://www.tg.com.au
Hospital in the Home
Contact your local public hospital to establish Hospital in the Home availability and referral procedures.
References
Kikuchi, R.,al., et, High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med, 1994. 150: p. 251-253. Scottish Intercollegiate Guidelines Network, Community Management of Lower Respratory Tract Infection In Adults - a national clinical guideline. 2002, Edinburgh: SIGN. Bartlett, J. , Dowell, S. , Mandell, L. , File, Jr., T., Musher, D. , Fine, M., Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases, 2000. 31: p. 347-382. eTG, Therapeutic Guidelines: Respiratory Tract infections: pneumonia, in http://www.tg.com.au (accessed August 2006), eTG. 2006 Janssens, J.P.,Krause, K.H., Pneumonia in the very old. Lancet Infect Dis, 2004. 4(2): p. 112-24. Furman, D. , Rayner, A., Tobin, E., Pneumonia in Older Residents of Long-term Care Facilities. American Family Physician, 2004. 70(8): p. 1495-1500. Institute for Clinical Systems Improvement (ICSI), Community-acquired pneumonia in adults. 2003, Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). Muder, R.R., Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention. Am J Med, 1998. 105(4): p. 319-330. Van der Steen, J., Oooms, M, Van der Wel, G., Ribbe, M., Pneumonia: the Demented Patient's Best Friend? Discomfort after Starting or Withholding Antibiotic Treatment. JAGS, 2002. 50: p. 1681-1688. Yamaya, M.,al., et, Interventions to Prevent Pneumonia Among Older Adults. Journal of the American Geriatrics Society, 2001. 49(1): p. 85. National Health and Medical Research Council, . ed. The Australian Immunisation Handbook. 8th ed. 2003, Department of Health and Aging Australian Government. Nichol, K.,al., et, Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly. New England Journal of Medicine, 2003. 348(14): p. 1322-32. Wagner, C.,al., et, Impact of pneumococcal vaccination on morbidity and mortality of geriatric patients: a case-controlled study. Gerontology, 2003. 49(4): p. 246-50. Jefferson, T ,Demicheli, V, Editorial. Polysacharide pneumococcal vaccines. Existing guideline is at variance with the evidence. BMJ, 2002. 325: p. 292-3. Christenson, B, Lundbuergh, P, Hedlund, J, Ortqvist, A, Effects of a large scale intervention with influenza and 23-valent pneumococcal vaccines in adults aged 65 years or older: a prospective study. Department of Human Services, Influenza and Pneumococcal Pneumonia Immunisation, in in www.dhs.vic.gov.au/phd/immunisation/pneumoflu.htm (accessed Feb 2004), Government, Victorian. 2003 Sier, H , Elon, R, Durso, S, Guideline Abstracted from the IDSA Evaluation of Fever and Infection in Long-term Care Facilities. 2001, New York: American Geriatrics Society. Campbell, S.,et al, The contribution of blood cultures to the clinical management of adult patients admitted to the hospital with comm. Chest, 2003. 123: p. 1142-50. Fine, M. ,al., et, A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med, 1997. 336: p. 243-50. Kupronis, B., Richards, Jr., C., Whitney, C., Team, Active Bacterial Core Surveillance, Invasive Pneumococcal Disease in Older Adults Residing in Long-Term Care Facilities and in the Community. JAGS, 2003. 51: p. 1520-1525. Mylotte, J.M.,al., et, Validation and application of the pneumonia prognosis index to nursing home residents with pneumonia. J Am Geriatr Soc, 1998. 46(12): p. 1538-44. Naughton, B.J., Mylotte, L., Tayara, A., Outcome of nursing home-acquired pneumonia: derivation and application of a practical model to predict 30 day mortality. J Am Geriatr Soc, 200. 48(10): p. 1292-9. Zweig, S, Kruse, R, Binder, E, Szafara, K, Mehr, D, Effect of Do-Not-Resuscitate Orders on Hospitalization of Nursing Home Residents Evaluated for Lower Respiratory Infections. J Am Geriatr Soc, 2004. 52: p. 51-58. Fried, T.R., Gillick, M.R., Lipsitz, L.A., Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer. J Am Geriatr Soc, 1997. 44(3): p. 302-6. Gleason, P.,al., et, Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia. Arch Intern Med, 1999. 159: p. 2562-2572. Brown, R.B.,al., et, Impact of initial antibiotic choice on clinical outcomes in community-acquired pneumonia: analysis of a hospital claims-made database. Chest, 2003. 123(5): p. 1503-11. Dasgupta, M., Binns, M., Rochon, P., Subcutaneous fluid infusion in a long-term care setting. J Am Geriatr Soc, 2000. 48(7): p. 795-9. National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS
Levels of Evidence
Background information on pneumoccocal immunisation provided in this Clinical Information Sheet is based on Level IV evidence produced by expert opinions in the field, particularly the Australian Immunization Handbook guidelines developed by the National Health and Medical Research Council (NH&MRC) and the Australian Technical Advisory Group on Immunizations (ATAGI). Information on management of residents with pneumonia is based on Level I evidence, particularly the 2002 Scottish Intercollegiate Guidelines Network (SIGN) guidelines on community-acquired pneumonia. Supporting evidence is based on additional evidence sources specific to pneumonia in the elderly or RACF setting.
The following table outlines the level of evidence of each reference:
|
|
Reference |
Year |
Level of Evidence |
1. |
Kikuchi, R.,al., et, High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med, 1994. 150: p. 251-253. |
1994 |
Level IV C evidence |
2. |
Scottish Intercollegiate Guidelines Network, Community Management of Lower Respratory Tract Infection In Adults - a national clinical guideline. 2002, Edinburgh: SIGN. |
2002 |
Level I evidence |
3. |
Bartlett, J. , Dowell, S. , Mandell, L. , File, Jr., T., Musher, D. , Fine, M., Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases, 2000. 31: p. 347-382. |
2000 |
Level IV B evidence |
4. |
eTG, Therapeutic Guidelines: Respiratory Tract infections: pneumonia, in http://www.tg.com.au (accessed August 2006), eTG. 2006 |
2006 |
Level IV C evidence |
5. |
Janssens, J.P.,Krause, K.H., Pneumonia in the very old. Lancet Infect Dis, 2004. 4(2): p. 112-24. |
2004 |
Level IV C evidence |
6. |
Furman, D. , Rayner, A., Tobin, E., Pneumonia in Older Residents of Long-term Care Facilities. American Family Physician, 2004. 70(8): p. 1495-1500. |
2004 |
Level IV C evidence |
7. |
Institute for Clinical Systems Improvement (ICSI), Community-acquired pneumonia in adults. 2003, Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). |
2003 |
Level IV B evidence |
8. |
Muder, R.R., Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention. Am J Med, 1998. 105(4): p. 319-330. |
1998 |
Level III evidence |
9. |
Van der Steen, J., Oooms, M, Van der Wel, G., Ribbe, M., Pneumonia: the Demented Patient's Best Friend? Discomfort after Starting or Withholding Antibiotic Treatment. JAGS, 2002. 50: p. 1681-1688. |
2002 |
Level IV A evidence |
10. |
Yamaya, M.,al., et, Interventions to Prevent Pneumonia Among Older Adults. Journal of the American Geriatrics Society, 2001. 49(1): p. 85. |
2001 |
Level IV C evidence |
11. |
National Health and Medical Research Council, . ed. The Australian Immunisation Handbook. 8th ed. 2003, Department of Health and Aging Australian Government. |
2003 |
Level IV B evidence |
12. |
Nichol, K.,al., et, Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly. New England Journal of Medicine, 2003. 348(14): p. 1322-32. |
2003 |
Level III evidence |
13. |
Wagner, C.,al., et, Impact of pneumococcal vaccination on morbidity and mortality of geriatric patients: a case-controlled study. Gerontology, 2003. 49(4): p. 246-50. |
2003 |
Level III evidence |
14. |
Jefferson, T ,Demicheli, V, Editorial. Polysacharide pneumococcal vaccines. Existing guideline is at variance with the evidence. BMJ, 2002. 325: p. 292-3. |
2002 |
Level IV C evidence |
15. |
Christenson, B, Lundbuergh, P, Hedlund, J, Ortqvist, A, Effects of a large scale intervention with influenza and 23-valent pneumococcal vaccines in adults aged 65 years or older: a prospective study. |
|
- |
16. |
Department of Human Services, Influenza and Pneumococcal Pneumonia Immunisation, in in www.dhs.vic.gov.au/phd/immunisation/pneumoflu.htm (accessed Feb 2004), Government, Victorian. 2003 |
2004 |
Level IV C evidence |
17. |
Sier, H , Elon, R, Durso, S, Guideline Abstracted from the IDSA Evaluation of Fever and Infection in Long-term Care Facilities. 2001, New York: American Geriatrics Society. |
2001 |
Level IV B evidence |
18. |
Campbell, S.,et al, The contribution of blood cultures to the clinical management of adult patients admitted to the hospital with comm. Chest, 2003. 123: p. 1142-50. |
2003 |
Level IV C evidence |
19. |
Fine, M. ,al., et, A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med, 1997. 336: p. 243-50. |
1997 |
Level III evidence |
20. |
Kupronis, B., Richards, Jr., C., Whitney, C., Team, Active Bacterial Core Surveillance, Invasive Pneumococcal Disease in Older Adults Residing in Long-Term Care Facilities and in the Community. JAGS, 2003. 51: p. 1520-1525. |
2003 |
Level III evidence |
21. |
Mylotte, J.M.,al., et, Validation and application of the pneumonia prognosis index to nursing home residents with pneumonia. J Am Geriatr Soc, 1998. 46(12): p. 1538-44. |
1998 |
Level IV A evidence |
22. |
Naughton, B.J., Mylotte, L., Tayara, A., Outcome of nursing home-acquired pneumonia: derivation and application of a practical model to predict 30 day mortality. J Am Geriatr Soc, 200. 48(10): p. 1292-9. |
|
Level IV A evidence |
23. |
Zweig, S, Kruse, R, Binder, E, Szafara, K, Mehr, D, Effect of Do-Not-Resuscitate Orders on Hospitalization of Nursing Home Residents Evaluated for Lower Respiratory Infections. J Am Geriatr Soc, 2004. 52: p. 51-58. |
2004 |
Level III evidence |
24. |
Fried, T.R., Gillick, M.R., Lipsitz, L.A., Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer. J Am Geriatr Soc, 1997. 44(3): p. 302-6. |
1997 |
Level IV A evidence |
25. |
Gleason, P.,al., et, Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia. Arch Intern Med, 1999. 159: p. 2562-2572. |
1999 |
Level III evidence |
26. |
Brown, R.B.,al., et, Impact of initial antibiotic choice on clinical outcomes in community-acquired pneumonia: analysis of a hospital claims-made database. Chest, 2003. 123(5): p. 1503-11. |
2003 |
Level III evidence |
27. |
Dasgupta, M., Binns, M., Rochon, P., Subcutaneous fluid infusion in a long-term care setting. J Am Geriatr Soc, 2000. 48(7): p. 795-9. |
2000 |
Level IV A evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [28] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Respiratory: Pneumonia
The following reference cards are designed to be used in conjunction with the Respiratory: Pneumonia Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Downloading Reference Cards
To download the reference cards, click on the link and select save to disk. You will be asked to select a folder in which to save the reference card. To download all the reference cards together, use the link under Downloads and Printing.
Reference Cards:
Pneumonia Assessment
Pneumonia Severity Index
Downloads and Printing
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To download the Clinical Information Sheet and/or the entire Reference Card package for this CIS, use the buttons below. To download, click on the link and select save to disk. You will be asked to select a folder in which to save the document. To download individual Reference Cards use the links above. Downloads are in printable formats.
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