New Approaches to Treating Pneumonia in Nursing Homes
The question of whether community-acquired or hospital-acquired pneumonia has developed in patients in nursing homes with medical care has not yet been resolved, making it difficult to choose an empirical treatment.
The strategy for optimal management of pneumonia patients developed in a nursing home with medical care remains controversial. The reason is the lack of information accumulated in clinical trials and the inconsistency of data on the etiology of the disease. Part of the source of conflicting etiology information was from studies that used sputum culture tests for diagnosis without assessing the quality of the samples. Aerobic Gram-negative bacilli, as well as Staphylococcus aureus, were often isolated from sputum in these studies. However, in studies that assessed the representativeness of sputum samples, aerobic Gram-negative and S. aureus bacilli were infrequent, and the most common pathogens were Streptococcus pneumoniae and Haemophilus influenzae.
Since Gram-negative bacilli and S.aureus often cause nosocomial pneumonia, some experts attributed the pneumonia that developed in a nursing home with medical care to the nosocomial group. However, in many publications, this disease is considered a kind of community-acquired pneumonia. Depending on the group to which the disease belongs, the treatment recommendations also differ.
In addition to the choice of antibiotic therapy, certain other aspects must be taken into account when caring for patients: the need for hospitalization, the route of administration of the antimicrobial drug prescribed as starting treatment in a nursing home. nursing care, the transition time from parenteral to oral administration and the duration of treatment.
In accordance with the latest recommendations to start the treatment of pneumonia developed in nursing homes, the fluoroquinolones (levofloxacin, gatifloxacin or moxifloxacin) or the amoxicillin / clavulanate in combination with the macrolide must be used directly in the establishment. In the event of hospitalization, parenteral administration of fluoroquinolones (listed above) or generation II-III cephalosporins in combination with macrolide is recommended. Based on data obtained from elderly patients with severe pneumonia requiring mechanical ventilation, for the treatment of nosocomial pneumonia (which also includes pneumonia developed in nursing homes), cephalosporin with anti-Pseudomonas or carbapenem activity, or anti-Pseudomonas penicillin should be used. beta-lactamase in combination with ciprofloxacin and vancomycin or linezolid. However, these recommendations do not apply to most non-intubated elderly patients who are hospitalized for pneumonia.
When choosing an empirical therapy, it is necessary to take into account factors such as recent antibiotic therapy and colonization previously identified by a resistant microorganism, for example, strains resistant to methicillin S.aureus.
Scientists in the Netherlands recently conducted several studies on the concept of abstinence from antibiotic treatment of pneumonia in nursing homes in patients with severe dementia in a terminal condition.
Additional efforts should be focused on developing rapid methods to identify the pathogen, resolve the issue of optimal regimen and duration of treatment, and determine the criteria indicating that antibiotic therapy is not necessary in elderly patients. with severe dementia.