This is the second of 2 parts of a narrative review of
nursing home-associated
pneumonia (
NHAP) that deals with etiology and treatment in the
nursing home. In the 1980s and 1990s, the etiology of
NHAP was considered to be similar to community-acquired
pneumonia (CAP). This belief was reflected in CAP guidelines until 2005 when the designation
healthcare-associated pneumonia or HCAP was introduced and
nursing home residents were included in the HCAP category. Patients in the HCAP group were thought to be at high risk for
pneumonia because of multidrug resistant organisms and required empiric broad-spectrum
antibiotic therapy much like people with hospital-acquired
infection. Subsequent studies of the etiology of
NHAP using sophisticated diagnostic testing found limited evidence of resistant organisms such as methicillin-resistant Staphylococcus aureus or resistant gram-negative organisms or atypical organisms. In terms of management of
NHAP in the
nursing home there are several considerations that are discussed: hospitalization decision, initial oral or parenteral
therapy, timing of switch to an oral regimen if parenteral
therapy is initially prescribed,
duration of therapy with an emphasis on shorter courses, and follow-up during
therapy including the use of the "
antibiotic time out" protocol. The oral and parenteral
antibiotic regimens recommended for treatment of
NHAP in this report are based on limited information because there are no randomized controlled trials to define the optimum regimen. In conclusion, most residents with
pneumonia can be treated successfully in the
nursing home. However, there is an urgent need for a specific
NHAP diagnosis and treatment guideline that will give providers guidance in the management of this
infection in the
nursing home.