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Respiratory Tract Infections in Long-Term Care Residents:
A Case Study

Pneumonia is the second most frequent type of infection occurring in long-term care populations, superseded in numbers only by urinary tract infections; in terms of mortality, nursing home-acquired pneumonia stands out as number one. In fact, the excess mortality rate from nursing home-acquired pneumonia in persons over 65 years of age ranges from 9 to 979 per thousand, depending on the number of comorbid conditions the individual may have.

The following case study, serves to illustrate some of the diagnostic and treatment questions that arise in caring for elderly long-term care facility residents with respiratory tract infections.

The Case Study

The chief complaint of a 73-year-old female resident in a long-term care facility was a "nagging cough." She presented in moderate respiratory distress after a one-week bout of the "flu." (This probably was not influenza, based on the time of year that it occurred; it was probably an upper respiratory viral infection caused by an adenovirus or some similar organism.)

The nursing staff reported evidence of mild dehydration, as manifested by tachycardia, a dry mouth, and decreased skin turgor. The resident also had a cough, producing yellowish-green sputum, and an oral temperature of 100.5°F.

Past medical history included asthma since childhood, chronic bronchitis-with the last acute exacerbation occurring one year prior to this episode, and type 2 diabetes mellitus. Her family history was not remarkable, with the exception of a recent visit by a grandson with a history of upper respiratory tract infections.

The resident smoked one pack of cigarettes per day, abstained from alcohol, and was ambulatory, participating in numerous social activities. She did not require oxygen therapy for chronic bronchitis.

Her medications included an albuterol metered-dose inhaler, two puffs as needed, with a spacer; and glyburide 5 mg once a day in the morning. She had no known drug allergies. Her review of systems was noncontributory, except for the nagging cough.

Physical exam revealed tachycardia, as noted above, and the resident's respiratory rate (30 breaths per minute) was higher than the expected, 20-24 breaths per minute.

Examination of head, ears, eyes, nose, and throat revealed that this individual had dry mucous membranes. Examination of the lungs revealed fine rales (wet sounds) and rhonchi (bronchoconstrictive sounds) bilaterally.

The resident complained of mild pleuritic chest pains, a fairly uncommon complaint among geriatric patients with respiratory tract infections, and exhibited decreased breath sounds in the left lower lobe.

Asking the Right Questions

Some kinds of additional information that could be helpful at this point include:

• Cognition measures, looking for as an alteration in mental status.
• Chest x-ray, though the results may be normal initially, even with pneumonia, because these older individuals often are dehydrated. It is important to rehydrate the patient to obtain a more accurate result. Chest x-rays can also show other pulmonary diseases, such as congestive heart failure, pulmonary fibrosis, emphysematous changes, or even pulmonary malignancies, making differential diagnoses difficult. Another difficulty involves the time that it takes for chest x-ray results to return to normal in older individuals with respiratory tract infections: as long as 16-18 weeks.
• Immunization history, e.g., pneumococcal vaccine, influenza vaccine.
• Labs results in particular can be very useful, because criteria for admitting an individual to an acute-care facility often include abnormal lab results. An important parameter to look for in this regard is whether the white blood cell count (WBC) shows an increase in total counts as well as immature forms, known as bands; in this case, the patient did show such increases (WBC=14,000/ mm3 with 3% bands).

Renal function measures are also important; this individual demonstrated a blood urea nitrogen value (BUN) of 34 mg/dl and a creatinine value of 1.8 mg/dl (she usually had a serum creatinine value in the 1 to 1.2 mg/dl range). Fasting blood sugars, at 125 mg/dl, were reasonable.

The other test that is available in most nursing facilities is an assessment of blood gases; the partial pressure of oxygen is often a factor that has to be evaluated in assessing whether an individual should be admitted to an acute care facility.

Obtaining arterial blood gas measures is difficult in most facilities; however, pulse oximetry using either earlobe or fingertip detection units is usually available. This patient's oxygenation was quite good (pO2=93%), especially in light of the fact that she had chronic respiratory disease; in fact, anything over 90% is considered very good in an older individual. This suggested that she probably did not need hospitalization.

The chest x-ray results in this individual were consistent with the physical exam findings in that there was a left lower lobe infiltrate suggesting that she was suffering from pneumonia.

The sputum gram stain obtained from this patient showed less than 25 polymorphonuclear leukocytes (<25 PMN); greater than 10 epithelial cells (>10 epis), and normal oral flora. These results are indicative of a poor specimen. A "good" specimen should have >25 PMN, <10 epis, and no oral flora.

It should be noted that with most geriatric patients with respiratory tract infections, we end up treating empirically because it is so difficult to get a good sputum specimen. It is very hard to target therapy for lower respiratory infections in this population, because it is difficult for these individuals, especially if they are dehydrated, to bring up sputum; getting cooperation from elderly patients is also an important issue.

For the above reasons, sputum culture and susceptibility testing are frequently not valuable diagnostic tests in evaluating lower respiratory tract infections in long-term care facility residents.

Drug-resistant Pathogens

In all health care settings, Streptococcus pneumoniae is the most frequently isolated pathogen in cases of bacterial pneumonia in geriatric patients. This appears to hold true no matter where the infection is acquired, though hard data in this area are still being compiled.

The emergence of multiple drug-resistant strains of S. pneumoniae in the United States makes this statistic become even more significant. In fact, currently 24% of isolates are either moderately or highly penicillin-resistant. An issue that will become increasingly significant in treating elderly populations is whether we have oral therapies that allow us to treat multiple resistant strains of S. pneumoniae.

We may begin to see a resurgence of the use of the fluoroquinolones in response to this dilemma; however, the first-generation quinolones are not, in the author's opinion, the best agents to use for bacterial respiratory tract infections in geriatric populations. Levofloxacin and trovafloxacin, a second-generation quinolones, are two of the most promising of the newer drugs for use in older residents because of their increased effectiveness against multiply drug-resistant strains of S. pneumococcus.

Should this particular resident be hospitalized? Probably not. She is fairly stable clinically in terms of her vital signs; she has a modest WBC elevation; her chest x-ray shows a fairly isolated left lower lobe infiltrate; her oxygenation status is excellent, considering her age and comorbidities.

She probably does need to have her vital signs checked every shift, and she probably needs to be prescribed an antimicrobial.

IDSA Hospital Admission Criteria

The Infectious Disease Society of America (IDSA) has compiled some tentative guidelines for hospital admission for pneumonia. These include:

• Severely abnormal vital signs. This would include a pulse of over 125 beats per minute, a systolic blood pressure of less than 90 (which most people would consider shock), or a respiratory rate in excess of 30 breaths/minute.
• An alteration in mental status from the patient's baseline.
• Hypoxemia (pO2<60 mm mercury while breathing room air).
• Suppurative complications such as empyema (infection of the pleural cavity), septic arthritis, meningitis, or endocarditis (heart valve infection).
• Severe hematologic or chemical abnormalities, if they differ markedly from the patient's baseline (Na<130, Hct<30%, absolute neutrophil counts [ANC]<1000, BUN>50, Cr>2.5).
• Acute comorbidity, such as chronic obstructive pulmonary disease, neoplastic disease, congestive heart failure, carebrovascular disease, renal or liver disease, requiring acute-care facility admission in its own right.

IDSA Risk Factors for Mortality

ISDA risk factors for mortality in patients with pneumonia include:

• Age greater than 65 years
• Comorbidities such as diabetes mellitus, neurologic disease, cancer, chronic renal failure, or congestive heart failure, or hospitalization within the previous year
• Excessively high or low temperatures (>38.3°C or <37°C)
• Immunosuppression, either with corticosteroids or chemotherapeutic agents, within the previous six months
• High-risk pneumonias such as those due to S. pneumoniae, Legionella, or S. aureus, gram-negative rods, macroaspiration, obstruction
• Bacteremia
• Multilobar involvement on chest x-ray
  

Empiric Treatment Options

The pathogen most likely to be involved in the resident described in the above case study was S. pneumoniae; however, empiric treatment was advisable because of the difficulty of positively identifying the causal organism.

Initially, we questioned whether this resident needed parenteral therapy. This would involve giving intramuscular ceftriaxone once daily, intramuscular cefepime twice daily, or intramuscular cefotaxime twice daily, for two to three days, and then a switch to an oral modality that is much more cost-effective.

Or, can the patient receive oral agents from the outset of treatment? In this case, some agents that could be considered include a macrolide, such as clarithromycin or azithromycin; doxycycline; amoxicillin/clavulanate; ofloxacin; or acephalosporin, such as cefuroxime, cefpodoxime, or cefprozil.

An interesting issue involves the role of the newer agents such as levofloxacin, trovafloxacin and other newly marketed guinolones such as sparfloxacin and grepafloxacin. We may see an upsurge in use of these quinolones as penicillin resistance mounts and we see more therapeutic failures.

In choosing between the newer agents it is important to be aware of the phototoxicity potential of sparfloxacin, which occurs even under artificial lighting. There is also an issue concerning QT interval prolongation with sparfloxacin and grepafloxacin that is not an issue with levofloxacin.

In cases where the first course of therapy is not successful, it is probably useful to consider areas for further exploration. Failures of the initial course of therapy could suggest a number of things: the presence of a resistant pathogen or pathogens, an unsuspected pathogen that treatment is not addressing, a bronchial obstruction (usually malignant), a metastatic infection, tuberculosis or empyema or lung abcess, drug fever, or a non infectious illness that the clinician thought was pneumonia, but is not.

Although I hope that the above case study and observations will be useful to most clinicians who work in the area of infectious diseases in elderly populations, they are by no means exhaustive in their scope. This subject is ripe for further study, as it is becoming increasingly important to the rapidly growing population of elderly institutionalized patients.

Author's Note: The patient in the above case study was placed on clarithromycin 500mg twice daily for 14 days, and clinically resolved. An eight-week followup chest x-ray revealed disappearance of the infiltrate.

Selected References

Bartlett JG, Breiman RF, Mandell CA, file TMJr.
Community-acquired pneumonia in adults: guidelines for management. ClinInfect Dis 1998;26:8111-838.

Callahan CM, Wolinsky FD. Pneumonia in the elderly: empiric antimicrobial therapy. Geriatrics 1991; 46(12):26-32.

Guay D. Infectious Diseases. In Delafuente J, Stewart RB (eds). Therapeutics in the Elderly. Volume 2. Cincinnati, OH, Harvey Whitney Books, 1998 (inpress).

Fine MJ, Smith MA, Carson CA et al. Prognosis and outcomes of patients with community-acquired pneumonia. a meta-analysis. JAMA 1995; 274:134-41.

Gilbert K, Fine MJ. Assessing prognosis and predicting patient outcomes in community-acquired pneumonia. Semin Respir Infect 1994; 9:140-52.

Hasley PB, Albaum MN, Li Y-H et al. Do pulmonary readiographic findings at presentation predict mortality in patients with community-acquired pneumonia. Arch Intern med 1996; 156:2206-12.

Neiderman MS, Fein AM. Pneumonia in the elderly. Geriatr Clin North Am 1986; 2:241-67

Norman DC. Pneumonia in the elderly: empiric antimicrobial therapy.
Geriatrics 1991;46(12):26-32.

Raju L, Khan F. Pneumonia in the elderly: a review. Geriatrics 1988; 43(10):51-62.

Schneider EL. Infectious diseases in the elderly. Ann Intern Med 1983: 98:395-400.

Copyright © 1998, American Society of Consultant Pharmacists, Inc. All rights reserved.