Pneumonia Case Study Questions

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In most cases of nursing home–acquired pneumonia, the causative pathogen is unidentified.

Estimates of the relative incidence of pneumonia from different infectious organisms rely mostly on studies that evaluated blood cultures and Gram stains of good-quality sputum specimens (more than 25 polymorphonuclear leukocytes and fewer than 10 epithelial cells per low-power field).

For information about the SORT evidence rating system, go to https://org/afpsort Although several recommendations are outlined here, identifying candidates for diagnostic testing and treatment ultimately depends on a patient's overall prognosis, advance directive, and goals of care.

Over a two-year period, immunization with the 23-valent pneumococcal polysaccharide vaccine (Pneumovax) prevents one case of pneumonia for every 12 patients immunized in nursing homes.

FULLERTON, MD; and NICHOLAS SOMERVILLE, MD, MPH, University of Virginia School of Medicine, Charlottesville, Virginia Am Fam Physician. This clinical content conforms to AAFP criteria for continuing medical education (CME). Pneumonia in older adults residing in nursing homes can be challenging to diagnose and treat.

Pneumococcal and influenza immunizations decrease the risk of pneumonia and are recommended for all nursing home patients.

A small case-control study of 67 nursing home residents with acute infection found that oxygen saturation was lower in patients with pneumonia than in those with nonrespiratory infections.19 An oxygen saturation of less than 94% had a sensitivity of 80% and a specificity of 91% for pneumonia (positive likelihood ratio = 8.8; negative likelihood ratio = 0.22).

IDSA guidelines recommend obtaining pulse oximetry measurements if patients are ill and show symptoms of infection, and if they are candidates for treatment based on their overall condition and life expectancy.10 The diagnosis is confirmed with chest radiography.

The median reported incidence of pneumonia in this population is 1 to 1.2 per 1,000 patient-days.12 This article summarizes evidence behind answers to the most common questions on diagnosing and treating pneumonia in this patient population.

There is controversy, however, about whether the evaluation and treatment of pneumonia in nursing home patients should follow guidelines for health care–associated pneumonia, as suggested by the Infectious Diseases Society of America (IDSA), or for community-acquired pneumonia (CAP), as recommended by the U.


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