8180
Parenteral Antibiotic Therapy for Patients in Nursing Homes Thomas Mulligan
From the Department of Medicine, Division of Geriatrics, Medical College of Virginia, and the Section of Geriatrics and Extended Care, Hunter Holmes McGuire ~terans Affairs Medical Center, Richmond, Virginia
Today's high-quality medical care is one of the factors that have permitted humans to have unprecedented longevity. However, because people are living longer, there is now a higher incidence of chronic diseases, some of which have debilitating effects. In the United States, one of the consequences of increased life-spans is the growing demand for nursing home care. Cost-containment strategies for acute care that promote early discharge from the acute care hospital complicate nursing home care by sending selected ill patients to nursing homes for long-term recuperation or death [1]. Because of the rising number of nursing home occupants in this country, the tendency to treat sicker patients in nursing homes, and the need to provide quality care in a cost-effective manner, the utilization of parenteral antibiotic therapy for nursing home residents is an important issue. Consider a 90-year-old female resident of a nursing home who has severe senile dementia of the Alzheimer's type and becomes mildly febrile to 100.4"E The nurse reports that the patient seems weaker than usual, has lost her appetite, and sounds congested. Physical examination of the patient reveals a listless, elderly woman with carious teeth, an ejection murmur, diffuse rhonchi, bibasilar rales, and a scaphoid abdomen with normal bowel sounds. She has a white blood cell count of 18,000 with a left shift. Unfortunately, a sputum sample cannot be obtained, and evidence from a chest roentgenogram is suggestive but not diagnostic of pneumonia. Her family has requested that she remain in her nursing home for financial and social reasons rather than being transferred to the acute care hospital. Although they have requested that no
Pleaseaddressrequests for reprintsto Dr. ThomasMulligan (181), Hunter HolmesMcGuireVeterans AffairsMedicalCenter, 1201 BroadRockBoulevard, Richmond, Virginia23249. Reviews of Infectious Diseases 1991;13(Suppl 2):Sl80-3 This article is in the public domain.
heroic measures (e.g., cardiopulmonary resuscitation) be initiated, they believe that easily reversible disorders should be treated. Many questions arise from this scenario: Does this patient have pneumonia? Should parenteral antibiotic therapy be administered? Can this treatment be given in the nursing home? How does one decide which antibiotic is most appropriate for use?
Why Parenteral Antibiotic Therapy Is an Issue During the past 2,000 years, there has been a dramatic increase in the average length of human life. The mean lifespan during the time of Christ was only 30 years, whereas today people can expect to live an average of 77 years [2]. This increased life expectancy can be credited primarily to improvements in public sanitation and health care, the most striking of which is the discovery of antibiotics (penicillin). The continued fight against disease has allowed humans to live longer than ever before but has altered population demographics such that elderly citizens are now the most rapidly growing segment of American society [3]. Currently, those aged >65 years account for 13 % of the American population, or, more specifically, 29 million persons. This increased longevity is a testimony to the advances of modem medicine but results in a spectrum of new problems. With aging comes a change in virtually every organ system in the body. Maximum aerobic capacity declines, velocity of nerve conduction slows, and visual acuity diminishes. From the standpoint of infectious disease, epidermal and endothelial barriers become less effective, and the ability to respond to an infectious challenge wanes [4]. One of the best-studied immune changes brought about by aging is the decrease in thymic mass and secretion ofthymopoietin. By age 70, the thymus is little more than a vestige of its prior structure, and levels of thymopoietin in the blood are barely measurable [5]. The response to intradermal antigens is diminished, as is mitogen-
Downloaded from http://cid.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on June 25, 2015
Since the number of aged Americans who require long-term care in nursing homes is increasing, attention hasbeen focused on the cost-effective provision of medical care in the nursing home. In this health care setting, pneumonia and serious urinary tract infection are common among patients. These infections can now often be treated successfully with use of parenteral antibiotic therapy in the nursing home, thereby not subjecting the patient to the added stress of hospitalization. However, the physician's decision to use parenteral antibiotic therapy for the nursing home resident is complex and must be guided by the patient's condition, the wishes of the patient and family, the frequent shortage of professional staff, and the cost of the drug. Nevertheless, with these factors in mind, compassionate, high-quality care can often be provided in the nursing home in a cost-effective fashion.
RID 1991;13 (Suppl 2)
Parenteral Therapy for Nursing Home Patients
Indications for Parenteral Antibiotic Therapy for Nursing Home Residents The clinical indications for parenteral antibiotic therapy for nursing home residents do not differ greatly from the indications for any other population. For example, pneumonia, pyelonephritis, and bacteremia of unknown source will likely respond best to parenteral antibiotic therapy regardless of whether the patient is being treated in a nursing home or an acute care hospital. However, the physician's view of these indications for a nursing home patient must be tempered with knowledge of the atypical nature of disease in the aged person, the patient's prognosis due to comorbid disease, the patient's or family's wishes, and the stresses placed on the patient by moving him or her from the nursing home to the acute care hospital. Elderly patients in nursing homes who have serious infections often exhibit atypical clinical features and have nonspecific complaints. Bacteremic urinary tract infection usually manifests itself as a decline in the patients' overall ability to care for themselves, lack of appetite, or delirium [11]; symptoms of urgency and frequency and dysuria occur less commonly in nursing home patients. When developingpneumonia, patients may present with similar nonspecific findings of diminished ability to perform activities of daily living or may present with only a fever. Fever in an elderly person is a reliable indicator of the presence of a serious infection, which is often associated with high mortality [12]. However, fever may be absent in the frail, aged, nursing home patient [13]. Therefore, a high index of suspicion for infectious disease is always necessary in the care of these patients, and ail infectious cause should be sought in the face of an otherwise unexplained decline in cognitive function, diminished ability to perform activities of daily living, or lack of appetite. A reasonable approach would be to perform a physical examination and urinalysis and obtain a white blood cell count and chest roentgenogram. Once a presumptive diagnosis of serious infection is made, the nursing home resident's comorbid condition must also be considered prior to making therapeutic decisions. Most nursing home patients suffer from chronic irreversible diseases, such as demential disorders, end-stage vascular disease, and cancer. In view of the terminal nature of many of these diseases, it is not uncommon for the physician to believe that any form of invasive therapy (including iv fluids or drugs) is not in the patient's best interest [14]. This decision is at times primarily medical; nevertheless, it is important to include the patient or family in this decision-making process. In contrast, there are times when the physician may consider a disorder readily treatable (e.g., pneumonia), an opinion that may be in conflict with the patient's or family's wishes. For example, some physicians believe that treatable diseases should always be treated. However, patients who have a living will may have specifically requested that they not betreated
Downloaded from http://cid.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on June 25, 2015
mediated stimulation. The B cell lineage also changes with aging, but this change occurs to a lesser degree. Although absolute numbers of B lymphocytes remain within the normal range, there is a decrease in levels of IgM when compared with those of younger individuals [6]. From the macroscopic standpoint, with advancing age individuals become less able to perform some of the complex tasks required for independent life in the community. Driving, using public transportation, cooking, and managing personal finances become more difficult. Even basic activities of daily living (i.e., toileting, grooming, and bathing) become impossible for the seriously debilitated elderly person. Although the majority of elderly citizens remain independent, 1\.140 % of 90-year-old individuals require assistance in their activities of daily living. Because of this decline in the skills required for independent existence, many persons of advanced age ultimately require the assistance of a full-time family care giver or are placed in nursing homes. A minority of these people become bedridden, need help eating, or require catheters for urination. It is this constellation of increased exposure of elderly individuals to infectious agents through aspirated oral contents or invasive procedures (i.e., urinary catheters), impaired barriers of the host to infection, and altered immune responses of these individuals that results in some of the common infectious diseases seen in the aged population. This troublesome scenario becomes an even larger health problem as the number of aged Americans increases. With the growth of the elderly population, there has been a steady increase in the number of nursing home occupants in this country. Currently, there are 1\.12 million nursing home residents in the United States, and this number is expected to rise to 1\.13 million by the year 2000 [7]. Already there are more beds in nursing homes than in acute care hospitals. This shift in medical treatment from acute care of the young and middleaged populations to long-term care of the aged population causes a change in the spectrum of medical illness of which physicians must be aware. The morbidity and mortality of the nursing home population are indeed different from those of their communitydwelling counterparts. The most common causes of death of individuals in the community are heart disease (51%), cancer (18%), and stroke (16%) followed by influenza and pneumonia (4%). In contrast, infectious disease is the most common cause of death of residents in nursing homes. Pneumonia accounts for one-third of all deaths of occupants of nursing homes, followed by heart failure [8]. Although not a frequent cause of death, urinary tract infection may be the most common form of medical morbidity in the nursing home [9]. Fortunately, most urinary tract infections are diagnosed and treated before the development of urinary sepsis; when urinary sepsis does occur, the mortality can be as high as 13% [10]. Therefore, physicians must be aware of issues of infectious diseases in the medical care of the institutionalized elderly population.
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Choice of Antibiotics Once the decision has been made to treat a serious infection in the nursinghome, the next step is to decide which drug is most appropriate for therapy. This decision should always be based on the presumed or known infecting organism and its sensitivity to the available antimicrobial agents. However, specimens from nursing home residents for culture are often inadequate. Aged, debilitated patients are frequently unable to expectorate sputum because of dementia or delirium, and even a suctioned sputum sample is often less than ideal because of agitation of the patient or an insufficient professional nursing staff. Specimensof urine or blood for culture are usually more readily available, but results from cultures must be interpreted carefully when there are uncertainties regarding the technique of specimen collection (e.g., use of a condom catheter for urine specimens). The likely infectingorganism can often be inferred through an understandingof the pathophysiology of pneumoniaor urinary tract infection in the nursing home resident as well as knowledge of the endemic flora. Dementiaand strokeoften impair the patients'ability to feed themselves and also impair the gag reflex; this combination of factors causes microaspiration in patients. Microaspiration of the indigenous bacterial flora of the nursing home is exacerbated by the age-associated decline in immune function. The microflora endemic in nursing homes is often as virulent as that in an acute care hospital because of prior exposure to multiple antibiotics. The end results of this constellation of factors are a relatively high incidence of pneumonia and a more-severe pneumonia. The most common offending organisms are the gram-negative rods, such as Klebsiella and Pseudomonas species, in descending order of frequency [19]. The pathophysiology of urinary tract infection, like pneumonia, is influenced by aging and site factors [20]. Residual urine that results from a hypocontractile bladder or prostatic hyperplasia provides an excellent medium for the growth of
bacteria. The presence of anatomic abnormalities, such as stones and strictures, or foreign bodies, such as catheters, is another factor that contributes to the development of urinary tract infections in the nursing home population. When these factorscoincidewith the decrease in immune functionbrought about by senescence and the indigenous bacterial flora of a nursing home, a serious urinary tract infection often develops in nursinghome residents. In contrast to community-acquired urinary tract infections, urinary tract infections of residents in nursing homes are more likely to be caused by Proteus species, Pseudomonas species, Escherichia coli, or Klebsiella species, in decreasing order of frequency [21]. In addition to activity against the offending organism, another major factor that should be considered when deciding which drug to utilize in therapy for the nursing home patient is ease of administration. The physician must remember that the nursing staff in a nursing home is smaller than that in an acute care hospital. One registered nurse may be responsible for an entire wing of patients during the day and the entire nursinghome during nightsor weekends. Becauseof this scarcity of professional nurses, intravenous therapy for nursing home patients is usually not a realistic option. Therefore, a physician's selection of an agentthat can be administered conveniently would be prudent. In addition to ease of administration, the physician must considerthe cost of the drug utilizedin therapy beforeprescribing it for the patient. The cost for nursing home care is paid directly by approximately one-half of the patients in nursing homes, and the remainder of patients are covered by Medicaid or Medigap policies [22]. Especially for non-Medicaid patients, the patient or family is often billed separately for the cost of administereddrugs, whichis not usuallyreimbursed completely by Medicare or Medigap. The remaining cost can be substantial. After these various factors are considered, what then are the options for treatment of pneumonia for the nursing home patient? Given that adequate sputum samples are often not available and that aspirate is the most frequently obtained precipitate, the options for treatment of pneumonia include a third-generation cephalosporin (ceftriaxoneor ceftazidime) or a quinolone (ciprofloxacinor norfloxacin)with or without penicillin or clindamycin. For coverage of aspirated gramnegative rods, ceftrlaxone (l g im once daily) or ceftazidime (500 mg im twice daily) should be effective. The efficacy of ciprofloxacin(500 mg po twice daily) or norftoxacin(400 mg po twice daily) in this situation has remained debatable [23], although it has merit on theoretical grounds. If a cephalosporin is to be administered for therapy, the choice betweenceftriaxone and ceftazidime should be based on the site-specific prevalence of pseudomonalinfections (ceftazidimehas greater activity against pseudomonads) and the preference for an injection given once daily or twice daily. The use of penicillin or clindamycin as adjunctive therapy for nursing homeacquired pneumonia has remained a controversialissue. Not-
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aggressively (e.g., be allowed to die) should they develop a serious debilitating disorder or dementia or require nursing home care [15]. Finally, the family of an incompetent patient may ask that no further treatment (including antibiotics) be initiated. The physician must consider these ethical issues when making therapeutic decisions for a nursing home patient [16, 17]. Finally, the stress placed on the patient by the treatment must also be considered. Relocation stress, such as that experienced by an elderly resident of a nursing home who is moved to an acute care hospital, can be manifestedin various ways. Perhaps the most common manifestation is delirium associated with nocturnal hallucinations (sundown syndrome) [18]. Usually transient, relocation stressis a serious disorder, and the decisionto move a resident of a nursing home to an acute care hospital must include consideration of this disorder.
RID 1991;13 (Suppl 2)
RID 1991;13 (Suppl 2)
Parenteral Therapy for Nursing Home Patients
References 1. Sager MA, Easterling DV, Kindig DA, Anderson OW. Changes in the locationof deathafter passageof Medicare'sprospectivepaymentsystem, a national study. N Engl J Med 1989;320:433-9
2. Brody JA. Life expectancy and the health of older persons. JAm Geriatr Soc 1982;30:681-3 3. Grundy E. Demographyand old age. JAm Geriatr Soc 1983;31:325-32 4. Felser JM, Raff MJ. Infectious diseases and aging: immunologic perspectives. J Am Geriatr Soc 1983;31:802-7 5. Lewis VM, TwomeyJJ, Bealmear P, Goldstein G, Good RA. Age, thymic involution, and circulating thymic hormone activity.J Clin Endocrinol Metab 1978;47:145-50 6. Phair JP, KauffmanCA, Bjornson A, Gallagher J, Adams L, Hess EV. Host defenses in the aged: evaluation of components of the inflammatory and immune responses. J Infect Dis 1978;138:67-73 7. WaldoDR, Lazenby HC. Demographic characteristics and health care use and expendituresby the agedin the U.S.: 1977-1984.HealthCare Finane Rev 1984;6:1-29 8. Gross JS, NeufeldRR, LibowLS, Gerber I, RodsteinM. Autopsystudy of the elderly institutionalized patient. Reviewof 234 autopsies. Arch Intern Med 1988;148:173-6 9. Garibaldi RA, Brodine S, Matsumiya S. Infections among patients in nursing homes: policies, prevalence, and problems. N Engl J Med 1981;305:731-5 10. Yoshikawa TI, Norman DC. Infections in the nursinghome population. In: Aging andclinicalpractice:infectiousdiseasesdiagnosisand treatment. New York: Igaku-Shoin, 1987:73-81 11. Yoshikawa TT, Norman DC. Genitourinary tract infection. In: Aging and clinicalpractice: infectious diseasesdiagnosisand treatment. New York: Igaku-Shoin, 1987:173-84 12. Keating HJ 3rd, Klimek n, Levine OS, Kiernan FJ. Effectof aging on the clinical significanceof fever in ambulatory adult patients. J Am Geriatr Soc 1984;32:282-7 13. Gleckman R, Hibert D. Afebrile bacteremia: a phenomenonin geriatric patients. JAMA 1982;248:1478-81 14. Braithwaite S, Thomasma DC. New' guidelines on foregoing life-sustaining treatment in incompetent patients: an anti-cruelty policy. Ann Intern Med 1986;104:711-5 15. Emanuel LL, Emanuel EJ. The medical directive. A new comprehensive advance care document. JAMA 1989;261:3288-93 16. Besdine RW. Decisions to withhold treatment from nursing home residents. J Am Geriatr Soc 1983;31:602-6 17. Murphy OJ. Do-not-resuscitate orders: time for reappraisalin long-termcare institutions. JAMA 1988;260:2098-101 18. RockwoodK. Acute confusion in elderly medical patients. JAm Geriatr Soc 1989;37:150-4 19. Verghese A, Berk SL. Bacterialpneumoniain the elderly. Medicine(Baltimore) 1983;62:271-85 20. Nicolle LE, Bjornson J, Harding GKM, MacDonell JA. Bacteriuria in elderly institutionalized men. N Engl J Med 1983;309:1420-5 21. Sherman FT, Tucci V, Libow LS, Isenberg HD. Nosocomial urinarytract infections in a skilled nursing facility. J Am Geriatr Soc 1980;28:456-61 22. Kane RL, Ouslander JG, Abrass m. Long-term-care resources. In: Essentialsof clinicalgeriatrics. New York: McGraw-Hill,1984:303-20 23. WolfsonJS, Hooper DC. Norftoxacin: a new targeted ftuoroquinolone antimicrobial agent. Ann Intern Med 1988;108:238-51
Downloaded from http://cid.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on June 25, 2015
withstanding, penicillin (500 mg po four times daily) or clindamycin (300 mg po four times daily) should suffice for coverage of aspirated anaerobes if deemed necessary. Similar to the coverage of gram-negative rods for nursing home-acquired pneumonia, the options for treatment of serious urinary tract infections include ceftriaxone (1 g im once daily), ceftazidime (500 mg im twice daily), ciprofloxacin (500 mg po twice daily), or norfloxacin (400 mg po twice daily). The decision to utilize either a quinolone or a cephalosporin should again be based on the convenience of oral therapy and the proven efficacy of third-generation cephalosporins in the treatment of serious nursing home-acquired urinary tract infections. If a cephalosporin is chosen for therapy, the choice between cephalosporins should be based on the prevalence of pseudomonal infections and the preference for an injection given once daily or twice daily. In addition to antibiotic therapy, treatment of serious urinary tract infections of residents in nursing homes should include removal of anatomic abnormalities or foreign bodies when possible. Resection of prostatic hyperplasia will aid in the elimination of residual urine, just as the removal of urethral catheters will aid in the elimination of the infecting organism. When use of a urethral catheter cannot be terminated completely, utilization of intermittent catheterization rather than a chronically indwelling catheter will help to remove the infecting organism. In summary, infectious complications of residents in nursing homes are increasing in frequency and represent a growing financial burden; these complications may already be a more serious problem than infections of patients in acute care hospitals. The physician's decision to use parenteral antibiotic therapy must be guided by the patient's condition, the patient's and family's wishes, the shortage of professional staff, and the cost of the drug. The choice of drug is contingent on the pathophysiology of the infection and knowledge of the local flora. Nevertheless, with appropriate consideration of the various clinical, ethical, and financial constraints, many seriously ill patients in nursing homes who have infections can be successfully and cost-effectively treated without leaving their nursing home.
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Parenteral Antibiotic Therapy for Patients in Nursing Homes Thomas Mulligan
From the Department of Medicine, Division of Geriatrics, Medical College of Virginia, and the Section of Geriatrics and Extended Care, Hunter Holmes McGuire ~terans Affairs Medical Center, Richmond, Virginia
Today's high-quality medical care is one of the factors that have permitted humans to have unprecedented longevity. However, because people are living longer, there is now a higher incidence of chronic diseases, some of which have debilitating effects. In the United States, one of the consequences of increased life-spans is the growing demand for nursing home care. Cost-containment strategies for acute care that promote early discharge from the acute care hospital complicate nursing home care by sending selected ill patients to nursing homes for long-term recuperation or death [1]. Because of the rising number of nursing home occupants in this country, the tendency to treat sicker patients in nursing homes, and the need to provide quality care in a cost-effective manner, the utilization of parenteral antibiotic therapy for nursing home residents is an important issue. Consider a 90-year-old female resident of a nursing home who has severe senile dementia of the Alzheimer's type and becomes mildly febrile to 100.4"E The nurse reports that the patient seems weaker than usual, has lost her appetite, and sounds congested. Physical examination of the patient reveals a listless, elderly woman with carious teeth, an ejection murmur, diffuse rhonchi, bibasilar rales, and a scaphoid abdomen with normal bowel sounds. She has a white blood cell count of 18,000 with a left shift. Unfortunately, a sputum sample cannot be obtained, and evidence from a chest roentgenogram is suggestive but not diagnostic of pneumonia. Her family has requested that she remain in her nursing home for financial and social reasons rather than being transferred to the acute care hospital. Although they have requested that no
Pleaseaddressrequests for reprintsto Dr. ThomasMulligan (181), Hunter HolmesMcGuireVeterans AffairsMedicalCenter, 1201 BroadRockBoulevard, Richmond, Virginia23249. Reviews of Infectious Diseases 1991;13(Suppl 2):Sl80-3 This article is in the public domain.
heroic measures (e.g., cardiopulmonary resuscitation) be initiated, they believe that easily reversible disorders should be treated. Many questions arise from this scenario: Does this patient have pneumonia? Should parenteral antibiotic therapy be administered? Can this treatment be given in the nursing home? How does one decide which antibiotic is most appropriate for use?
Why Parenteral Antibiotic Therapy Is an Issue During the past 2,000 years, there has been a dramatic increase in the average length of human life. The mean lifespan during the time of Christ was only 30 years, whereas today people can expect to live an average of 77 years [2]. This increased life expectancy can be credited primarily to improvements in public sanitation and health care, the most striking of which is the discovery of antibiotics (penicillin). The continued fight against disease has allowed humans to live longer than ever before but has altered population demographics such that elderly citizens are now the most rapidly growing segment of American society [3]. Currently, those aged >65 years account for 13 % of the American population, or, more specifically, 29 million persons. This increased longevity is a testimony to the advances of modem medicine but results in a spectrum of new problems. With aging comes a change in virtually every organ system in the body. Maximum aerobic capacity declines, velocity of nerve conduction slows, and visual acuity diminishes. From the standpoint of infectious disease, epidermal and endothelial barriers become less effective, and the ability to respond to an infectious challenge wanes [4]. One of the best-studied immune changes brought about by aging is the decrease in thymic mass and secretion ofthymopoietin. By age 70, the thymus is little more than a vestige of its prior structure, and levels of thymopoietin in the blood are barely measurable [5]. The response to intradermal antigens is diminished, as is mitogen-
Downloaded from http://cid.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on June 25, 2015
Since the number of aged Americans who require long-term care in nursing homes is increasing, attention hasbeen focused on the cost-effective provision of medical care in the nursing home. In this health care setting, pneumonia and serious urinary tract infection are common among patients. These infections can now often be treated successfully with use of parenteral antibiotic therapy in the nursing home, thereby not subjecting the patient to the added stress of hospitalization. However, the physician's decision to use parenteral antibiotic therapy for the nursing home resident is complex and must be guided by the patient's condition, the wishes of the patient and family, the frequent shortage of professional staff, and the cost of the drug. Nevertheless, with these factors in mind, compassionate, high-quality care can often be provided in the nursing home in a cost-effective fashion.
RID 1991;13 (Suppl 2)
Parenteral Therapy for Nursing Home Patients
Indications for Parenteral Antibiotic Therapy for Nursing Home Residents The clinical indications for parenteral antibiotic therapy for nursing home residents do not differ greatly from the indications for any other population. For example, pneumonia, pyelonephritis, and bacteremia of unknown source will likely respond best to parenteral antibiotic therapy regardless of whether the patient is being treated in a nursing home or an acute care hospital. However, the physician's view of these indications for a nursing home patient must be tempered with knowledge of the atypical nature of disease in the aged person, the patient's prognosis due to comorbid disease, the patient's or family's wishes, and the stresses placed on the patient by moving him or her from the nursing home to the acute care hospital. Elderly patients in nursing homes who have serious infections often exhibit atypical clinical features and have nonspecific complaints. Bacteremic urinary tract infection usually manifests itself as a decline in the patients' overall ability to care for themselves, lack of appetite, or delirium [11]; symptoms of urgency and frequency and dysuria occur less commonly in nursing home patients. When developingpneumonia, patients may present with similar nonspecific findings of diminished ability to perform activities of daily living or may present with only a fever. Fever in an elderly person is a reliable indicator of the presence of a serious infection, which is often associated with high mortality [12]. However, fever may be absent in the frail, aged, nursing home patient [13]. Therefore, a high index of suspicion for infectious disease is always necessary in the care of these patients, and ail infectious cause should be sought in the face of an otherwise unexplained decline in cognitive function, diminished ability to perform activities of daily living, or lack of appetite. A reasonable approach would be to perform a physical examination and urinalysis and obtain a white blood cell count and chest roentgenogram. Once a presumptive diagnosis of serious infection is made, the nursing home resident's comorbid condition must also be considered prior to making therapeutic decisions. Most nursing home patients suffer from chronic irreversible diseases, such as demential disorders, end-stage vascular disease, and cancer. In view of the terminal nature of many of these diseases, it is not uncommon for the physician to believe that any form of invasive therapy (including iv fluids or drugs) is not in the patient's best interest [14]. This decision is at times primarily medical; nevertheless, it is important to include the patient or family in this decision-making process. In contrast, there are times when the physician may consider a disorder readily treatable (e.g., pneumonia), an opinion that may be in conflict with the patient's or family's wishes. For example, some physicians believe that treatable diseases should always be treated. However, patients who have a living will may have specifically requested that they not betreated
Downloaded from http://cid.oxfordjournals.org/ at University of Iowa Libraries/Serials Acquisitions on June 25, 2015
mediated stimulation. The B cell lineage also changes with aging, but this change occurs to a lesser degree. Although absolute numbers of B lymphocytes remain within the normal range, there is a decrease in levels of IgM when compared with those of younger individuals [6]. From the macroscopic standpoint, with advancing age individuals become less able to perform some of the complex tasks required for independent life in the community. Driving, using public transportation, cooking, and managing personal finances become more difficult. Even basic activities of daily living (i.e., toileting, grooming, and bathing) become impossible for the seriously debilitated elderly person. Although the majority of elderly citizens remain independent, 1\.140 % of 90-year-old individuals require assistance in their activities of daily living. Because of this decline in the skills required for independent existence, many persons of advanced age ultimately require the assistance of a full-time family care giver or are placed in nursing homes. A minority of these people become bedridden, need help eating, or require catheters for urination. It is this constellation of increased exposure of elderly individuals to infectious agents through aspirated oral contents or invasive procedures (i.e., urinary catheters), impaired barriers of the host to infection, and altered immune responses of these individuals that results in some of the common infectious diseases seen in the aged population. This troublesome scenario becomes an even larger health problem as the number of aged Americans increases. With the growth of the elderly population, there has been a steady increase in the number of nursing home occupants in this country. Currently, there are 1\.12 million nursing home residents in the United States, and this number is expected to rise to 1\.13 million by the year 2000 [7]. Already there are more beds in nursing homes than in acute care hospitals. This shift in medical treatment from acute care of the young and middleaged populations to long-term care of the aged population causes a change in the spectrum of medical illness of which physicians must be aware. The morbidity and mortality of the nursing home population are indeed different from those of their communitydwelling counterparts. The most common causes of death of individuals in the community are heart disease (51%), cancer (18%), and stroke (16%) followed by influenza and pneumonia (4%). In contrast, infectious disease is the most common cause of death of residents in nursing homes. Pneumonia accounts for one-third of all deaths of occupants of nursing homes, followed by heart failure [8]. Although not a frequent cause of death, urinary tract infection may be the most common form of medical morbidity in the nursing home [9]. Fortunately, most urinary tract infections are diagnosed and treated before the development of urinary sepsis; when urinary sepsis does occur, the mortality can be as high as 13% [10]. Therefore, physicians must be aware of issues of infectious diseases in the medical care of the institutionalized elderly population.
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Mulligan
Choice of Antibiotics Once the decision has been made to treat a serious infection in the nursinghome, the next step is to decide which drug is most appropriate for therapy. This decision should always be based on the presumed or known infecting organism and its sensitivity to the available antimicrobial agents. However, specimens from nursing home residents for culture are often inadequate. Aged, debilitated patients are frequently unable to expectorate sputum because of dementia or delirium, and even a suctioned sputum sample is often less than ideal because of agitation of the patient or an insufficient professional nursing staff. Specimensof urine or blood for culture are usually more readily available, but results from cultures must be interpreted carefully when there are uncertainties regarding the technique of specimen collection (e.g., use of a condom catheter for urine specimens). The likely infectingorganism can often be inferred through an understandingof the pathophysiology of pneumoniaor urinary tract infection in the nursing home resident as well as knowledge of the endemic flora. Dementiaand strokeoften impair the patients'ability to feed themselves and also impair the gag reflex; this combination of factors causes microaspiration in patients. Microaspiration of the indigenous bacterial flora of the nursing home is exacerbated by the age-associated decline in immune function. The microflora endemic in nursing homes is often as virulent as that in an acute care hospital because of prior exposure to multiple antibiotics. The end results of this constellation of factors are a relatively high incidence of pneumonia and a more-severe pneumonia. The most common offending organisms are the gram-negative rods, such as Klebsiella and Pseudomonas species, in descending order of frequency [19]. The pathophysiology of urinary tract infection, like pneumonia, is influenced by aging and site factors [20]. Residual urine that results from a hypocontractile bladder or prostatic hyperplasia provides an excellent medium for the growth of
bacteria. The presence of anatomic abnormalities, such as stones and strictures, or foreign bodies, such as catheters, is another factor that contributes to the development of urinary tract infections in the nursing home population. When these factorscoincidewith the decrease in immune functionbrought about by senescence and the indigenous bacterial flora of a nursing home, a serious urinary tract infection often develops in nursinghome residents. In contrast to community-acquired urinary tract infections, urinary tract infections of residents in nursing homes are more likely to be caused by Proteus species, Pseudomonas species, Escherichia coli, or Klebsiella species, in decreasing order of frequency [21]. In addition to activity against the offending organism, another major factor that should be considered when deciding which drug to utilize in therapy for the nursing home patient is ease of administration. The physician must remember that the nursing staff in a nursing home is smaller than that in an acute care hospital. One registered nurse may be responsible for an entire wing of patients during the day and the entire nursinghome during nightsor weekends. Becauseof this scarcity of professional nurses, intravenous therapy for nursing home patients is usually not a realistic option. Therefore, a physician's selection of an agentthat can be administered conveniently would be prudent. In addition to ease of administration, the physician must considerthe cost of the drug utilizedin therapy beforeprescribing it for the patient. The cost for nursing home care is paid directly by approximately one-half of the patients in nursing homes, and the remainder of patients are covered by Medicaid or Medigap policies [22]. Especially for non-Medicaid patients, the patient or family is often billed separately for the cost of administereddrugs, whichis not usuallyreimbursed completely by Medicare or Medigap. The remaining cost can be substantial. After these various factors are considered, what then are the options for treatment of pneumonia for the nursing home patient? Given that adequate sputum samples are often not available and that aspirate is the most frequently obtained precipitate, the options for treatment of pneumonia include a third-generation cephalosporin (ceftriaxoneor ceftazidime) or a quinolone (ciprofloxacinor norfloxacin)with or without penicillin or clindamycin. For coverage of aspirated gramnegative rods, ceftrlaxone (l g im once daily) or ceftazidime (500 mg im twice daily) should be effective. The efficacy of ciprofloxacin(500 mg po twice daily) or norftoxacin(400 mg po twice daily) in this situation has remained debatable [23], although it has merit on theoretical grounds. If a cephalosporin is to be administered for therapy, the choice betweenceftriaxone and ceftazidime should be based on the site-specific prevalence of pseudomonalinfections (ceftazidimehas greater activity against pseudomonads) and the preference for an injection given once daily or twice daily. The use of penicillin or clindamycin as adjunctive therapy for nursing homeacquired pneumonia has remained a controversialissue. Not-
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aggressively (e.g., be allowed to die) should they develop a serious debilitating disorder or dementia or require nursing home care [15]. Finally, the family of an incompetent patient may ask that no further treatment (including antibiotics) be initiated. The physician must consider these ethical issues when making therapeutic decisions for a nursing home patient [16, 17]. Finally, the stress placed on the patient by the treatment must also be considered. Relocation stress, such as that experienced by an elderly resident of a nursing home who is moved to an acute care hospital, can be manifestedin various ways. Perhaps the most common manifestation is delirium associated with nocturnal hallucinations (sundown syndrome) [18]. Usually transient, relocation stressis a serious disorder, and the decisionto move a resident of a nursing home to an acute care hospital must include consideration of this disorder.
RID 1991;13 (Suppl 2)
RID 1991;13 (Suppl 2)
Parenteral Therapy for Nursing Home Patients
References 1. Sager MA, Easterling DV, Kindig DA, Anderson OW. Changes in the locationof deathafter passageof Medicare'sprospectivepaymentsystem, a national study. N Engl J Med 1989;320:433-9
2. Brody JA. Life expectancy and the health of older persons. JAm Geriatr Soc 1982;30:681-3 3. Grundy E. Demographyand old age. JAm Geriatr Soc 1983;31:325-32 4. Felser JM, Raff MJ. Infectious diseases and aging: immunologic perspectives. J Am Geriatr Soc 1983;31:802-7 5. Lewis VM, TwomeyJJ, Bealmear P, Goldstein G, Good RA. Age, thymic involution, and circulating thymic hormone activity.J Clin Endocrinol Metab 1978;47:145-50 6. Phair JP, KauffmanCA, Bjornson A, Gallagher J, Adams L, Hess EV. Host defenses in the aged: evaluation of components of the inflammatory and immune responses. J Infect Dis 1978;138:67-73 7. WaldoDR, Lazenby HC. Demographic characteristics and health care use and expendituresby the agedin the U.S.: 1977-1984.HealthCare Finane Rev 1984;6:1-29 8. Gross JS, NeufeldRR, LibowLS, Gerber I, RodsteinM. Autopsystudy of the elderly institutionalized patient. Reviewof 234 autopsies. Arch Intern Med 1988;148:173-6 9. Garibaldi RA, Brodine S, Matsumiya S. Infections among patients in nursing homes: policies, prevalence, and problems. N Engl J Med 1981;305:731-5 10. Yoshikawa TI, Norman DC. Infections in the nursinghome population. In: Aging andclinicalpractice:infectiousdiseasesdiagnosisand treatment. New York: Igaku-Shoin, 1987:73-81 11. Yoshikawa TT, Norman DC. Genitourinary tract infection. In: Aging and clinicalpractice: infectious diseasesdiagnosisand treatment. New York: Igaku-Shoin, 1987:173-84 12. Keating HJ 3rd, Klimek n, Levine OS, Kiernan FJ. Effectof aging on the clinical significanceof fever in ambulatory adult patients. J Am Geriatr Soc 1984;32:282-7 13. Gleckman R, Hibert D. Afebrile bacteremia: a phenomenonin geriatric patients. JAMA 1982;248:1478-81 14. Braithwaite S, Thomasma DC. New' guidelines on foregoing life-sustaining treatment in incompetent patients: an anti-cruelty policy. Ann Intern Med 1986;104:711-5 15. Emanuel LL, Emanuel EJ. The medical directive. A new comprehensive advance care document. JAMA 1989;261:3288-93 16. Besdine RW. Decisions to withhold treatment from nursing home residents. J Am Geriatr Soc 1983;31:602-6 17. Murphy OJ. Do-not-resuscitate orders: time for reappraisalin long-termcare institutions. JAMA 1988;260:2098-101 18. RockwoodK. Acute confusion in elderly medical patients. JAm Geriatr Soc 1989;37:150-4 19. Verghese A, Berk SL. Bacterialpneumoniain the elderly. Medicine(Baltimore) 1983;62:271-85 20. Nicolle LE, Bjornson J, Harding GKM, MacDonell JA. Bacteriuria in elderly institutionalized men. N Engl J Med 1983;309:1420-5 21. Sherman FT, Tucci V, Libow LS, Isenberg HD. Nosocomial urinarytract infections in a skilled nursing facility. J Am Geriatr Soc 1980;28:456-61 22. Kane RL, Ouslander JG, Abrass m. Long-term-care resources. In: Essentialsof clinicalgeriatrics. New York: McGraw-Hill,1984:303-20 23. WolfsonJS, Hooper DC. Norftoxacin: a new targeted ftuoroquinolone antimicrobial agent. Ann Intern Med 1988;108:238-51
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withstanding, penicillin (500 mg po four times daily) or clindamycin (300 mg po four times daily) should suffice for coverage of aspirated anaerobes if deemed necessary. Similar to the coverage of gram-negative rods for nursing home-acquired pneumonia, the options for treatment of serious urinary tract infections include ceftriaxone (1 g im once daily), ceftazidime (500 mg im twice daily), ciprofloxacin (500 mg po twice daily), or norfloxacin (400 mg po twice daily). The decision to utilize either a quinolone or a cephalosporin should again be based on the convenience of oral therapy and the proven efficacy of third-generation cephalosporins in the treatment of serious nursing home-acquired urinary tract infections. If a cephalosporin is chosen for therapy, the choice between cephalosporins should be based on the prevalence of pseudomonal infections and the preference for an injection given once daily or twice daily. In addition to antibiotic therapy, treatment of serious urinary tract infections of residents in nursing homes should include removal of anatomic abnormalities or foreign bodies when possible. Resection of prostatic hyperplasia will aid in the elimination of residual urine, just as the removal of urethral catheters will aid in the elimination of the infecting organism. When use of a urethral catheter cannot be terminated completely, utilization of intermittent catheterization rather than a chronically indwelling catheter will help to remove the infecting organism. In summary, infectious complications of residents in nursing homes are increasing in frequency and represent a growing financial burden; these complications may already be a more serious problem than infections of patients in acute care hospitals. The physician's decision to use parenteral antibiotic therapy must be guided by the patient's condition, the patient's and family's wishes, the shortage of professional staff, and the cost of the drug. The choice of drug is contingent on the pathophysiology of the infection and knowledge of the local flora. Nevertheless, with appropriate consideration of the various clinical, ethical, and financial constraints, many seriously ill patients in nursing homes who have infections can be successfully and cost-effectively treated without leaving their nursing home.
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