Guidelines for the Management of Adults with Health Care-Associated Pneumonia: Implications for Nursing Facility Residents

OBJECTIVE: To review the implications for nursing facility residents of the 2005 American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines for the Management of Adults with Health Care-Associated Pneumonia. DATA SOURCE: A MEDLINE/PUBMED search (1986-February 2006) was conducted to identify pertinent studies of health care associated pneumonia acquired in the nursing facility setting (formerly called nursing home-acquired pneumonia) in the English language. Additional references were obtained from the bibliographies of these studies. STUDY SELECTION AND DATA EXTRACTION: All studies evaluating any aspect of nursing home-acquired pneumonia. DATA SYNTHESIS: Careful review of these guidelines will reveal a failure of the ATS/IDSA committee members to review the large published database available in the field of nursing home-acquired pneumonia. In addition, the committee was devoid of representation from experts in this field. As a result, these guidelines are applicable only to nursing facility residents admitted to the hospital. For the vast majority of nursing facility residents, these guidelines are problematic. The use of invasive means to acquire respiratory tract secretions for culture and susceptibility testing in the nursing facility setting is just not possible. Few facilities are able to manage residents with the two-, three-, or four-drug combination intravenous therapies recommended. As a result of these realities, all residents of nursing facilities with suspected pneumonia would be forced into hospital for diagnostic workup and at least initial empiric therapy if the guidelines were followed "to the letter." The guidelines do not even discuss the issue of site of treatment and how to select residents for outpatient (i.e., infacility) versus inpatient (i.e., in-hospital) management. Infacility management mandated by advanced directives is not even considered by the guidelines. CONCLUSION: There does exist a database upon which the clinician can make informed decisions about likely pathogens, the probability that the resident actually has bacterial pneumonia, objective parameters suggesting the need for hospitalization for initial management, and guidance on when to initiate antimicrobial therapy, and which agent(s) to use. These issues are summarized here, and alternative, evidence-based, practical recommendations for the management of nursing home-acquired pneumonia are outlined.