• J Degelau, D Guay, K Straub, and M G Luxenberg.
• Department of Internal Medicine, St. Paul Ramsey Medical Center.
• J Am Geriatr Soc. 1995 Mar 1; 43 (3): 245-51.

ObjectiveTo determine factors associated with success or failure of oral antibiotic treatment for nursing home-acquired pneumonia (NHAP).DesignRetrospective study of outcomes for all identifiable NHAP cases in 1991.SettingThe Nursing Home Services Program of St. Paul Ramsey Medical Center and 31 metropolitan St. Paul, Minnesota, community nursing homes.ParticipantsNursing home (NH) cohort: 124 patients (mean age 85.2 years) with a new respiratory symptom and new infiltrate on portable chest X-ray for whom oral antibiotics were prescribed. Hospital cohort: 74 NH patients (mean age 84.3 years) admitted to hospital with new X-ray infiltrate and pneumonia diagnosis. Supportive care status patients were excluded. Forty-three physician/nurse practitioner (MD/NP) teams were represented.MeasurementsNursing home cohort: Outcomes of hospitalization within 14 days or 30-day mortality. A discriminant model was applied to predict outcome and discriminant rule performance was analyzed. Hospital cohort: 30-day mortality.ResultsOf 198 episodes of NH pneumonia, 63% were treated in the facility; 30.6% (38) failed NH treatment. Thirty-day mortality was 13%. There was no examination by the MD or NP for 59% of NH-treated episodes. The hospital cohort had a higher mean pulse (P < .05) but a similar frequency of feeding dependence. Hospital cohort mortality was 17.6%. The NH treatment failure group had significantly higher proportions of pulse > 90/min, temperature > 100.5 degrees F, respirations > 30/min, feeding dependence, and mechanically altered diets. A discriminant model using these factors was significant (P = .002). The NH treatment failure rate was 11% for no factors present, 23% for two or fewer factors, and 59.5% for three or more (likelihood ratio 3.1). Thirty-two percent of the hospital cohort had zero or one factor present and were alive at 30 days.ConclusionThe majority of NHAP episodes were treated successfully with oral antibiotics, but 31% failed treatment in the NH. Patients with a mechanically altered diet or requiring feeding assistance by staff had significantly higher failure rates. Feeding dependence and need for a mechanically altered diet as well as abnormal vital signs are associated with oral antibiotic treatment failure. These factors should be considered in treatment decisions for NHAP.

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