Clinical Inquiries

Are antibiotics effective in preventing pneumonia for nursing home patients?

Mouw DR, Langlois JP, Turner LF, Neher JO. J Fam Pract. 2004 Dec;53(12):994-6.

Evidence-based Answer

Antibiotics should not be used for prophylaxis of pneumonia in nursing homes. We found no studies testing the effectiveness of antibiotics in preventing pneumonia in any population, including persons with predisposing conditions such as influenza. Three measures effectively prevent pneumonia in nursing home patients: influenza vaccination of residents (strength of recommendation [SOR]: B, based on systematic review of homogenous cohort observational studies); influenza vaccination of caregivers (SOR: B, based on individual randomized controlled trial); pneumococcal vaccination of residents (SOR: B, based on randomized, nonblinded clinical trials and consistent case-control studies).

Two other suggested interventions have not been extensively tested: antiviral chemoprophylaxis during an influenza outbreak in the nursing home, and oral hygiene programs for nursing home residents.

Evidence-based Summary

Overuse of antibiotics is already a problem in nursing homes. A large portion of bacterial pneumonia in the nursing home population results from aspiration of oropharyngeal bacteria, which is more likely to be drug-resistant if the resident has been on antibiotics.1 We found no studies that testing antibacterial agents for prevention of pneumonia in nursing home patients. However, 3 measures are clearly helpful in preventing pneumonia in nursing home patients:

Two other proposed interventions require further study to evaluate their role in prophylaxis. Antiviral prophylaxis to prevent pneumonia during nursing home outbreaks of influenza has not been evaluated in controlled trials. Observational studies strongly suggest that amantadine, rimantadine, and oseltamivir are all effective in reducing spread of influenza during outbreaks in nursing homes (Table). Oseltamivir acts against influenza B as well as A and has fewer side effects, but it is more expensive.5,6 Presumably, decreasing the rate of influenza also reduces the rate of subsequent pneumonia.

Oral hygiene programs for nursing home residents may also reduce pneumonia. In a single study, 366 patients in 11 Japanese nursing homes were divided into controls (self-care) and those treated with rigorous oral care (by staff). The intervention group had a relative risk of 0.6 (95% CI, 0.36–0.99; NNT=12.5) for pneumonia over a 2-year period. 7 The NNT for preventing a death by pneumonia was 11 (P<.01). This intriguing result merits follow up in larger groups in US nursing homes to see if this approach is feasible.

Clinical Commentary

Prevention is key for reducing pneumonia mortality

Pneumonia is one of the most common causes of death for nursing home patients. While pneumonia can present with the classic fever, productive cough, and air hunger, it often presents with such nonspecific findings as altered mental status or mild tachypnea, which can significantly delay diagnosis. Additionally, many older adults poorly tolerate the metabolic demands of the disease and become critically ill very rapidly. Thus, prevention remains a key strategy for reducing mortality. Nursing home policies that facilitate vaccination and reduce disease transmission are critically important in this regard.

Recommendations from Others

There are no recommendations about the use of antibiotic prophylaxis for pneumonia in either the nursing home or in the outpatient settings; however, there are clear recommendations against the overuse of antibiotics.8

The CDC Advisory Committee on Immunization Practices (ACIP) recommends:

Figures

Available treatment and prophylactic regimens for influenza
Drug name Regimen for treatment* Regimen for prophylaxis† Comments Cost‡
Oseltamivir (Tamiflu) 75 mg orally twice daily for 5 days 75 mg orally once daily for >7 days Influenza A and B 10 tabs $59.99 (no generic)
Rimantidine (Flumadine) 100 mg orally twice daily (100 mg orally once daily in elderly) 100 mg orally twice daily (100 mg orally once daily in elderly) Influenza A only 14 tabs $33.45 (no generic)
Amantadine (Symmetrel) 100 mg orally twice daily (100 mg orally once daily in elderly) 100 mg orally twice daily (100 mg orally once daily in elderly) Influenza A only (consider lower doses in debilitated patients) 60 tabs $75.58 (brand), $18.99 (generic)
Zanamivir (Relenza) 2 inhalations (10 mg) every 12 hours for 5 days Not indicated Influenza A and B (inhalations may be difficult to administer to debilitated patients) 20 inhalation doses $54.41 (no generic)
Source: Epocrates RX: Online and PDA-Based Reference, June 12, 2004.
* Start treatment within 48 hours of onset of symptoms.
† Start prophylaxis immediately or within 48 hours of exposure.
‡ Approximate retail price from www.drugstore.com, June 2004.

References

  1. Yamaya M, Yanai M, Ohrui T, Arai H, Sasaki Hnull Interventions to prevent pneumonia among older adults. J Am Geriatr Soc. 2001. Volume 49. Page(s): 85-90.
  2. Gross PA, Hermogenes AW, Sacks HS, Lau J, Levandowski RAnull The efficacy of influenza vaccine in elderly persons. A meta-analysis and review of the literature. Ann Intern Med. 1995. Volume 123. Page(s): 518-527.
  3. Potter J, Stott DJ, Roberts MAet al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. J Infect Dis. 1997. Volume 175. Page(s): 1-6.
  4. McCormack O, Meza J, Martin S, Tatum Pnull Is pneumococcal vaccine effective in nursing home patients? J Fam Pract. 2003. Volume 52. Page(s): 150-154.
  5. Arden NH, Patriarca PA, Fasano MBet al. The roles of vaccination and amantadine prophylaxis in controlling an outbreak of influenza A (H3N2) in a nursing home. Arch Intern Med. 1988. Volume 148. Page(s): 865-868.
  6. Parker R, Loewen N, Skowronski Dnull Experience with oseltamivir in the control of a nursing home influenza B outbreak. Can Commun Dis Rep. 2001. Volume 27. Page(s): 37-40.
  7. Yoneyama T, Yoshida M, Ohrui Tet al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc. 2002. Volume 50. Page(s): 430-433.
  8. Strassbaugh LJ, Crossley KB, Nurse BA, Thrupp LDnull Antimicrobial resistance in long-term care facilities. Infection Control and Hospital Epidemiology. 1996. Volume 17. Page(s): 129-140.
  9. No author listed. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1999. Volume 48(RR-4). Page(s): 1-28.
  10. No author listed. Prevention of Pneumococcal Disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1997. Volume 46(RR-8). Page(s): 1-24.
  11. Bridges CB, Fukuda K, Uyeki TM, Cox NJ, Singleton JAnull Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Prevention and Control of Influenza. Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2002. Volume 51(RR-3). Page(s): 1-31.