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Implementation Guideline| Volume 48, ISSUE 5, SUPPLEMENT , A14-A16, May 2020

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Non-ventilator health care-associated pneumonia (NV-HAP): Long-term care

DOI:https://doi.org/10.1016/j.ajic.2020.03.007
Non-ventilator health care-associated pneumonia (NV-HAP): Long-term care
Previous ArticleNon-ventilator health care-associated pneumonia (NV-HAP): NV-HAP Risk Factors
Next ArticleNon-ventilator health care-associated pneumonia (NV-HAP): Pediatrics

      Abstract

      Nonventilator health care-associated pneumonia (NV-HAP) is costly and preventable with significant impact on patient morbidity and mortality. This chapter outlines the increased risk of NV-HAP among individuals residing in long-term care facilities and the incidence of pneumonia in this health care setting which accounts for up to 18% of all persons admitted to acute care hospital for pneumonia. A description of prevention strategies with detail on modifiable and Nonmodifiable risk factors for acquiring pneumonia are presented along with the need for a robust interdisciplinary team and approach for this vulnerable population. In addition, the lack of active surveillance and infection prevention expertise may result in the spread of pathogens that can cause NVHAP outbreaks.

      Key Words

      Individuals receiving care in nursing homes, also known as long-term care (LTC) facilities, are at increased risk for developing pneumonia for a variety of reasons.
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      , 
      • Muder RR
      Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention.
      Am J Med. 1998; 105: 319-330
      , 
      • Muder RR
      • Brennen C
      • Swenson DL
      • Wagener M
      Pneumonia in a long-term care facility: a prospective study of outcome.
      Arch Intern Med. 1996; 156: 2365-2370
      Some risks are individual intrinsic risks specific to a resident; others are exposure risks from external factors.

      Long-term care definition

      Traditionally, LTC residents have been older adults who can no longer live independently and younger persons requiring extensive biological, psychological, social, or spiritual support. Recently, the focus on shortening acute care stays has resulted in an increasing number of LTC clients who are younger and have more acute needs.
      • Isonaka S
      The enhanced care program: impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities.
      J Hosp Med. 2018; 13: 229
      Given these changes, it is important to clarify the definition of LTC. For purposes of this guide, LTC is defined using the international definition of “nursing home” provided by Sandford and associates.
      • Sanford AM
      • Orrell M
      • Tolson D
      • et al.
      An international definition for “nursing home”.
      J Am Med Dir Assoc. 2015; 16: 181-184
      A facility with a domestic-style environment that provides 24-hour functional support and care for persons who require assistance with activities of daily living and who often have complex health needs and increased vulnerability.Residency within a nursing home may be relatively brief for respite purposes, short-term (rehabilitative), or long-term, and may also provide palliative/hospice and end-of-life care.

      Incidence and consequences of pneumonia in long-term care

      Estimates of pneumonia incidence in LTC range from 0.3 to 2.5 cases per 1,000 resident-days, which is significantly higher than the incidence of community-associated pneumonia.
      • Kerr HD
      • Byrd JC
      Nursing home patients transferred by ambulance to the emergency department.
      J Am Geriatr Soc. 1991; 39: 132-136
      , 
      • Irvine PW
      • Van Buren N
      • Crossley K
      Causes for hospitalization of nursing home residents: the role of infection.
      J Am Geriatr Soc. 1984; 32: 103-107
      , 
      • Bergman H
      • Clarfield AM
      Appropriateness of patient transfer from a nursing home to an acute-care hospital: a study of emergency room visits and hospital admissions.
      J Am Geriatr Soc. 1991; 39: 1164-1168
      , 
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      , 
      • Loeb M
      • McGeer A
      • McArthur M
      • Walter S
      • Simor AE
      Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.
      Arch Intern Med. 1999; 159: 2058-2064
      , 
      • Mehr DR
      • Binder EF
      • Kruse RL
      • et al.
      Predicting mortality in nursing home residents with lower respiratory tract infection: the Missouri LRI Study.
      JAMA. 2001; 286: 2427-2436
      , 
      • Loeb MB
      Pneumonia in nursing homes and long-term care facilities.
      Semin Respir Crit Care Med. 2005; 6: 650-655
      , 
      • Jones AL
      • Dwyer LL
      • Bercovitz AR
      • et al.
      The National Nursing Home Survey: 2004 overview.
      Vital Health Stat. 2009; 167: 1-155
      , 
      • Vergis EN
      • Brennen C
      • Wagener M
      • Muder RR
      Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival.
      Arch Intern Med. 2001; 161: 2378-2381
      , 
      • Marrie TJ
      Pneumonia in the long-term-care facility.
      Infect Control Hosp Epidemiol. 2002; 23: 159-164
      Pneumonia in the LTC population presents a particular challenge because it is a multifactorial and complex condition, resulting from a breakdown of the immune and physiological responses in humans.
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      Pneumonia is the leading cause of death and a major cause of hospitalization of LTC patients and residents. Between 10% and 18% of all persons hospitalized with pneumonia are admitted from LTC.
      • Kerr HD
      • Byrd JC
      Nursing home patients transferred by ambulance to the emergency department.
      J Am Geriatr Soc. 1991; 39: 132-136
      , 
      • Irvine PW
      • Van Buren N
      • Crossley K
      Causes for hospitalization of nursing home residents: the role of infection.
      J Am Geriatr Soc. 1984; 32: 103-107
      , 
      • Bergman H
      • Clarfield AM
      Appropriateness of patient transfer from a nursing home to an acute-care hospital: a study of emergency room visits and hospital admissions.
      J Am Geriatr Soc. 1991; 39: 1164-1168
      , 
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      , 
      • Loeb M
      • McGeer A
      • McArthur M
      • Walter S
      • Simor AE
      Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.
      Arch Intern Med. 1999; 159: 2058-2064
      , 
      • Mehr DR
      • Binder EF
      • Kruse RL
      • et al.
      Predicting mortality in nursing home residents with lower respiratory tract infection: the Missouri LRI Study.
      JAMA. 2001; 286: 2427-2436
      , 
      • Loeb MB
      Pneumonia in nursing homes and long-term care facilities.
      Semin Respir Crit Care Med. 2005; 6: 650-655
      , 
      • Jones AL
      • Dwyer LL
      • Bercovitz AR
      • et al.
      The National Nursing Home Survey: 2004 overview.
      Vital Health Stat. 2009; 167: 1-155
      , 
      • Vergis EN
      • Brennen C
      • Wagener M
      • Muder RR
      Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival.
      Arch Intern Med. 2001; 161: 2378-2381
      , 
      • Marrie TJ
      Pneumonia in the long-term-care facility.
      Infect Control Hosp Epidemiol. 2002; 23: 159-164

      Prevention strategies

      To reduce risk for LTC residents and minimize the incidence of patient hospital readmissions and death, the entire interdisciplinary team—including residents and patients, families, nursing, prescribers, consultants, pharmacists, dietary personnel, therapists, activities personnel, and housekeeping—must focus on preventing pneumonia.
      There are several different perspectives on pneumonia prevention that can provide a framework for identifying and preventing pneumonia risk in LTC. The first step is to identify potentially modifiable risk factors as well as nonmodifiable risk factors (see also Section 3 of this guide). Table 1 highlights factors that have been documented to increase the personal risk of Nonventilator health care-associated pneumonia (NV-HAP) in older adults.
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Muder RR
      Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention.
      Am J Med. 1998; 105: 319-330
      ,
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      ,
      • Loeb M
      • McGeer A
      • McArthur M
      • Walter S
      • Simor AE
      Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.
      Arch Intern Med. 1999; 159: 2058-2064
      ,
      • Flanders SA
      • Collard HR
      • Saint S
      Nosocomial pneumonia: state of the science.
      Am J Infect Control. 2006; 34: 84-93
      , 
      • Montoya A
      • Mody L
      Common infections in nursing homes: a review of current issues and challenges.
      Aging Health. 2011; 7: 889-899
      , 
      • Gravenstein S
      • Davidson HE
      • Taljaard M
      • et al.
      Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial.
      Lancet Respir Med. 2017; 5: 738-746
      , 
      • Thomas RE
      • Jefferson T
      • Lasserson TJ
      Influenza vaccination for healthcare workers who care for people aged 60 or older living in long‐term care institutions.
      Cochrane Database System Rev. 2016; CD005187
      , 
      • Beyer WE
      • McElhaney J
      • Smith DJ
      • et al.
      Cochrane re-arranged: support for policies to vaccinate elderly people against influenza.
      Vaccine. 2013; 31: 6030-6033
      , 
      • Poscia A
      • Collamati A
      • Carfì A
      • et al.
      Influenza and pneumococcal vaccination in older adults living in nursing home: a survival analysis on the shelter study.
      Eur J Public Health. 2017; 27: 1016-1020
      , 
      • Pop‐Vicas A
      • Rahman M
      • Gozalo PL
      • Gravenstein S
      • Mor V
      Estimating the effect of influenza vaccination on nursing home residents’ morbidity and mortality.
      J Am Geriatr Soc. 2015; 63: 1798-1804
      , 
      • Kostova D
      • Reed C
      • Finelli L
      • et al.
      Influenza illness and hospitalizations averted by influenza vaccination in the United States, 2005–2011.
      PLoS One. 2013; 8: e66312
      , 
      • Monto AS
      • Ansaldi F
      • Aspinall R
      • et al.
      Influenza control in the 21st century: optimizing protection of older adults.
      Vaccine. 2009; 27: 5043-5053
      , 
      • Dang TT
      • Majumdar SR
      • Marrie TJ
      • Eurich DT
      Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
      Drugs Aging. 2015; 32: 13-19
      , 
      • Rabie T
      • Curtis V
      Handwashing and risk of respiratory infections: a quantitative systematic review.
      Trop Med Int Health. 2006; 11: 258-267
      , 
      • Bosco E
      • Zullo AR
      • McConeghy KW
      • et al.
      Long-term care facility variation in the incidence of pneumonia and influenza.
      Open Forum Infect Dis. 2019; 6 (ofz230)
      , 
      • Burdsall DP
      • Flores HC
      • Krueger J
      • et al.
      Use of proton pump inhibitors with lack of diagnostic indications in 22 Midwestern US skilled nursing facilities.
      J Am Med Dir Assoc. 2013; 14: 429-432
      , 
      • Quagliarello V
      • Ginter S
      • Han L
      • Van Ness P
      • Allore H
      • Tinetti M
      Modifiable risk factors for nursing home-acquired pneumonia.
      Clin Infect Dis. 2005; 40: 1-6
      , 
      • Liu C
      • Cao Y
      • Lin J
      • et al.
      Oral care measures for preventing nursing home‐acquired pneumonia.
      Cochrane Database Syst Rev. 2018; CD012416
      , 
      • Sarin J
      • Balasubramaniam R
      • Corcoran AM
      • Laudenbach JM
      • Stoopler ET
      Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions.
      J Am Med Dir Assoc. 2008; 9: 128-135
      Table 2 presents factors that have been shown to increase infection risk in the LTC population as a whole.
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      ,
      • Flanders SA
      • Collard HR
      • Saint S
      Nosocomial pneumonia: state of the science.
      Am J Infect Control. 2006; 34: 84-93
      , 
      • Montoya A
      • Mody L
      Common infections in nursing homes: a review of current issues and challenges.
      Aging Health. 2011; 7: 889-899
      , 
      • Gravenstein S
      • Davidson HE
      • Taljaard M
      • et al.
      Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial.
      Lancet Respir Med. 2017; 5: 738-746
      , 
      • Thomas RE
      • Jefferson T
      • Lasserson TJ
      Influenza vaccination for healthcare workers who care for people aged 60 or older living in long‐term care institutions.
      Cochrane Database System Rev. 2016; CD005187
      ,
      • Dang TT
      • Majumdar SR
      • Marrie TJ
      • Eurich DT
      Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
      Drugs Aging. 2015; 32: 13-19
      ,
      • Bosco E
      • Zullo AR
      • McConeghy KW
      • et al.
      Long-term care facility variation in the incidence of pneumonia and influenza.
      Open Forum Infect Dis. 2019; 6 (ofz230)
      ,
      • Sarin J
      • Balasubramaniam R
      • Corcoran AM
      • Laudenbach JM
      • Stoopler ET
      Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions.
      J Am Med Dir Assoc. 2008; 9: 128-135
      , 
      • Manabe T
      • Teramoto S
      • Tamiya N
      • Okochi J
      • Hizawa N
      Risk factors for aspiration pneumonia in older adults.
      PLoS One. 2015; 10e0140060
      , 
      • Haenen APJ
      • Verhoef LP
      • Beckers A
      • et al.
      Surveillance of infections in long-term care facilities (LTCFs): the impact of participation during multiple years on health care-associated infection incidence.
      Epidemiol Infect. 2019; 147: e266
      , 
      • Lim CW
      • Choi Y
      • An CH
      • et al.
      Facility characteristics as independent prognostic factors of nursing home-acquired pneumonia.
      Korean J Intern Med. 2016; 31: 296-304
      , 
      • Lima JC
      • Intrator O
      • Karuza J
      • Wetle T
      • Mor V
      • Katz P
      Nursing home medical staff organization and 30-day rehospitalizations.
      J Am Med Dir Assoc. 2012; 13: 552-557
      , 
      • Kendrick AH
      • Johns DP
      • Leeming JP
      Infection control of lung function equipment: a practical approach.
      Respir Med. 2003; 97: 1163-1179
      , 

      Centers for Disease Control and Prevention. Common causes of pneumonia. Available at: https://www.cdc.gov/pneumonia/causes.html. Accessed November 2, 2019.

      , 

      Centers for Disease Control and Prevention. Current waterborne disease burden data & gaps. Available at:https://www.cdc.gov/healthywater/burden/current-data.html. Accessed November 2, 2019.

      , 

      Centers for Disease Control and Prevention. Healthcare water management program frequently asked questions: Legionnaires’ disease and other infections associated with building water systems. Available at: https://www.cdc.gov/legionella/wmp/healthcare-facilities/healthcare-wmp-faq.html. Accessed November 2, 2019.

      , 

      Centers for Disease Control and Prevention. Reduce risk from water. Available at:https://www.cdc.gov/hai/prevent/environment/water.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhai%2Fprevent%2Fwater-management.html. Accessed November 2, 2019.

      , 

      Centers for Disease Control and Prevention. Toolkit: developing a water management program to reduce Legionella growth and spread in buildings. Available at:https://www.cdc.gov/legionella/wmp/toolkit/index.html. Accessed November 2, 2019.

      Table 1Personal risk factors for pneumonia in LTC
      Potentially modifiableNot modifiable or not easily modifiable
      Vaccine refusal
      • Flanders SA
      • Collard HR
      • Saint S
      Nosocomial pneumonia: state of the science.
      Am J Infect Control. 2006; 34: 84-93
      , 
      • Montoya A
      • Mody L
      Common infections in nursing homes: a review of current issues and challenges.
      Aging Health. 2011; 7: 889-899
      , 
      • Gravenstein S
      • Davidson HE
      • Taljaard M
      • et al.
      Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial.
      Lancet Respir Med. 2017; 5: 738-746
      , 
      • Thomas RE
      • Jefferson T
      • Lasserson TJ
      Influenza vaccination for healthcare workers who care for people aged 60 or older living in long‐term care institutions.
      Cochrane Database System Rev. 2016; CD005187
      , 
      • Beyer WE
      • McElhaney J
      • Smith DJ
      • et al.
      Cochrane re-arranged: support for policies to vaccinate elderly people against influenza.
      Vaccine. 2013; 31: 6030-6033
      , 
      • Poscia A
      • Collamati A
      • Carfì A
      • et al.
      Influenza and pneumococcal vaccination in older adults living in nursing home: a survival analysis on the shelter study.
      Eur J Public Health. 2017; 27: 1016-1020
      , 
      • Pop‐Vicas A
      • Rahman M
      • Gozalo PL
      • Gravenstein S
      • Mor V
      Estimating the effect of influenza vaccination on nursing home residents’ morbidity and mortality.
      J Am Geriatr Soc. 2015; 63: 1798-1804
      , 
      • Kostova D
      • Reed C
      • Finelli L
      • et al.
      Influenza illness and hospitalizations averted by influenza vaccination in the United States, 2005–2011.
      PLoS One. 2013; 8: e66312
      , 
      • Monto AS
      • Ansaldi F
      • Aspinall R
      • et al.
      Influenza control in the 21st century: optimizing protection of older adults.
      Vaccine. 2009; 27: 5043-5053
      		Age
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Muder RR
      Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention.
      Am J Med. 1998; 105: 319-330
      ,
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      ,
      • Loeb M
      • McGeer A
      • McArthur M
      • Walter S
      • Simor AE
      Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.
      Arch Intern Med. 1999; 159: 2058-2064
      Immobility/impaired functional status
      • Dang TT
      • Majumdar SR
      • Marrie TJ
      • Eurich DT
      Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
      Drugs Aging. 2015; 32: 13-19
      		Male gender
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      ,
      • Loeb M
      • McGeer A
      • McArthur M
      • Walter S
      • Simor AE
      Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.
      Arch Intern Med. 1999; 159: 2058-2064
      Lack of staff and resident hand hygiene
      • Rabie T
      • Curtis V
      Handwashing and risk of respiratory infections: a quantitative systematic review.
      Trop Med Int Health. 2006; 11: 258-267
      		Chronic obstructive pulmonary disease (COPD)
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      Smoking
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      		Cardiac/renal/hepatic disease
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      Medication use (sedation, proton pump inhibitors, inhaled steroids)
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      ,
      • Dang TT
      • Majumdar SR
      • Marrie TJ
      • Eurich DT
      Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
      Drugs Aging. 2015; 32: 13-19
      ,
      • Bosco E
      • Zullo AR
      • McConeghy KW
      • et al.
      Long-term care facility variation in the incidence of pneumonia and influenza.
      Open Forum Infect Dis. 2019; 6 (ofz230)
      ,
      • Burdsall DP
      • Flores HC
      • Krueger J
      • et al.
      Use of proton pump inhibitors with lack of diagnostic indications in 22 Midwestern US skilled nursing facilities.
      J Am Med Dir Assoc. 2013; 14: 429-432
      		Diabetes
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      Nutritional deficits
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      ,
      • Quagliarello V
      • Ginter S
      • Han L
      • Van Ness P
      • Allore H
      • Tinetti M
      Modifiable risk factors for nursing home-acquired pneumonia.
      Clin Infect Dis. 2005; 40: 1-6
      		Cancer
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      Behavior
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      		Stroke
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      Dental issues/poor oral care
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Muder RR
      Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention.
      Am J Med. 1998; 105: 319-330
      ,
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      ,
      • Dang TT
      • Majumdar SR
      • Marrie TJ
      • Eurich DT
      Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
      Drugs Aging. 2015; 32: 13-19
      ,
      • Quagliarello V
      • Ginter S
      • Han L
      • Van Ness P
      • Allore H
      • Tinetti M
      Modifiable risk factors for nursing home-acquired pneumonia.
      Clin Infect Dis. 2005; 40: 1-6
      ,
      • Liu C
      • Cao Y
      • Lin J
      • et al.
      Oral care measures for preventing nursing home‐acquired pneumonia.
      Cochrane Database Syst Rev. 2018; CD012416
      		Dementia
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      Increased physical dependence
      • Dang TT
      • Majumdar SR
      • Marrie TJ
      • Eurich DT
      Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
      Drugs Aging. 2015; 32: 13-19
      		Immune-suppression/blunted immune response
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Muder RR
      Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention.
      Am J Med. 1998; 105: 319-330
      ,
      • Flanders SA
      • Collard HR
      • Saint S
      Nosocomial pneumonia: state of the science.
      Am J Infect Control. 2006; 34: 84-93
      ,
      • Dang TT
      • Majumdar SR
      • Marrie TJ
      • Eurich DT
      Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
      Drugs Aging. 2015; 32: 13-19
      Alcohol and drug abuse
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      		Prior pneumonia
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Dang TT
      • Majumdar SR
      • Marrie TJ
      • Eurich DT
      Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
      Drugs Aging. 2015; 32: 13-19
      Microbiome disruption/MDRO colonization
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      		Aspiration/enteral feeding
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      ,
      • Loeb M
      • McGeer A
      • McArthur M
      • Walter S
      • Simor AE
      Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.
      Arch Intern Med. 1999; 159: 2058-2064
      ,
      • Quagliarello V
      • Ginter S
      • Han L
      • Van Ness P
      • Allore H
      • Tinetti M
      Modifiable risk factors for nursing home-acquired pneumonia.
      Clin Infect Dis. 2005; 40: 1-6
      ,
      • Sarin J
      • Balasubramaniam R
      • Corcoran AM
      • Laudenbach JM
      • Stoopler ET
      Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions.
      J Am Med Dir Assoc. 2008; 9: 128-135
      Table 2Community-level risk factors for pneumonia in LTC
      ModifiableNot modifiable
      Poor infection prevention infrastructure
      • Bosco E
      • Zullo AR
      • McConeghy KW
      • et al.
      Long-term care facility variation in the incidence of pneumonia and influenza.
      Open Forum Infect Dis. 2019; 6 (ofz230)
      ,
      • Manabe T
      • Teramoto S
      • Tamiya N
      • Okochi J
      • Hizawa N
      Risk factors for aspiration pneumonia in older adults.
      PLoS One. 2015; 10e0140060
      ,333      		Congregate living
      • Flanders SA
      • Collard HR
      • Saint S
      Nosocomial pneumonia: state of the science.
      Am J Infect Control. 2006; 34: 84-93
      , 
      • Montoya A
      • Mody L
      Common infections in nursing homes: a review of current issues and challenges.
      Aging Health. 2011; 7: 889-899
      , 
      • Gravenstein S
      • Davidson HE
      • Taljaard M
      • et al.
      Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial.
      Lancet Respir Med. 2017; 5: 738-746
      , 
      • Thomas RE
      • Jefferson T
      • Lasserson TJ
      Influenza vaccination for healthcare workers who care for people aged 60 or older living in long‐term care institutions.
      Cochrane Database System Rev. 2016; CD005187
      ,
      • Quagliarello V
      • Ginter S
      • Han L
      • Van Ness P
      • Allore H
      • Tinetti M
      Modifiable risk factors for nursing home-acquired pneumonia.
      Clin Infect Dis. 2005; 40: 1-6
      ,

      Centers for Disease Control and Prevention. Common causes of pneumonia. Available at: https://www.cdc.gov/pneumonia/causes.html. Accessed November 2, 2019.

      Inadequate staffing
      • Bosco E
      • Zullo AR
      • McConeghy KW
      • et al.
      Long-term care facility variation in the incidence of pneumonia and influenza.
      Open Forum Infect Dis. 2019; 6 (ofz230)
      ,
      • Manabe T
      • Teramoto S
      • Tamiya N
      • Okochi J
      • Hizawa N
      Risk factors for aspiration pneumonia in older adults.
      PLoS One. 2015; 10e0140060
      , 
      • Haenen APJ
      • Verhoef LP
      • Beckers A
      • et al.
      Surveillance of infections in long-term care facilities (LTCFs): the impact of participation during multiple years on health care-associated infection incidence.
      Epidemiol Infect. 2019; 147: e266
      , 
      • Lim CW
      • Choi Y
      • An CH
      • et al.
      Facility characteristics as independent prognostic factors of nursing home-acquired pneumonia.
      Korean J Intern Med. 2016; 31: 296-304
      , 
      • Lima JC
      • Intrator O
      • Karuza J
      • Wetle T
      • Mor V
      • Katz P
      Nursing home medical staff organization and 30-day rehospitalizations.
      J Am Med Dir Assoc. 2012; 13: 552-557
      		Building/room arrangement
      • Manabe T
      • Teramoto S
      • Tamiya N
      • Okochi J
      • Hizawa N
      Risk factors for aspiration pneumonia in older adults.
      PLoS One. 2015; 10e0140060
      Inadequate education and competency
      • Thomas RE
      • Jefferson T
      • Lasserson TJ
      Influenza vaccination for healthcare workers who care for people aged 60 or older living in long‐term care institutions.
      Cochrane Database System Rev. 2016; CD005187
      ,
      • Sarin J
      • Balasubramaniam R
      • Corcoran AM
      • Laudenbach JM
      • Stoopler ET
      Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions.
      J Am Med Dir Assoc. 2008; 9: 128-135
      ,
      • Kendrick AH
      • Johns DP
      • Leeming JP
      Infection control of lung function equipment: a practical approach.
      Respir Med. 2003; 97: 1163-1179
      Inappropriate prescribing
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      ,
      • Dang TT
      • Majumdar SR
      • Marrie TJ
      • Eurich DT
      Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
      Drugs Aging. 2015; 32: 13-19
      ,
      • Bosco E
      • Zullo AR
      • McConeghy KW
      • et al.
      Long-term care facility variation in the incidence of pneumonia and influenza.
      Open Forum Infect Dis. 2019; 6 (ofz230)
      Inadequate water management

      Centers for Disease Control and Prevention. Common causes of pneumonia. Available at: https://www.cdc.gov/pneumonia/causes.html. Accessed November 2, 2019.

      , 

      Centers for Disease Control and Prevention. Current waterborne disease burden data & gaps. Available at:https://www.cdc.gov/healthywater/burden/current-data.html. Accessed November 2, 2019.

      , 

      Centers for Disease Control and Prevention. Healthcare water management program frequently asked questions: Legionnaires’ disease and other infections associated with building water systems. Available at: https://www.cdc.gov/legionella/wmp/healthcare-facilities/healthcare-wmp-faq.html. Accessed November 2, 2019.

      , 

      Centers for Disease Control and Prevention. Reduce risk from water. Available at:https://www.cdc.gov/hai/prevent/environment/water.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhai%2Fprevent%2Fwater-management.html. Accessed November 2, 2019.

      , 

      Centers for Disease Control and Prevention. Toolkit: developing a water management program to reduce Legionella growth and spread in buildings. Available at:https://www.cdc.gov/legionella/wmp/toolkit/index.html. Accessed November 2, 2019.

      Infection preventionists and others on the care team need to consider actions that can reduce the risk of pneumonia in vulnerable individuals by first identifying their patient-specific risks for developing pneumonia. These factors must be considered in care planning to design person-centered approaches based on each specific patient's risks.
      Sloane et al developed and validated a nursing home pneumonia risk tool based on information collected from the Minimum Data Set.
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      This tool can rapidly identify residents and patients at risk for pneumonia.
      Modifiable risk factors should be addressed. Smoking cessation, vaccination programs, oral hygiene, and hand hygiene promotion for staff, residents, patients, and visitors are primary considerations.
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Flanders SA
      • Collard HR
      • Saint S
      Nosocomial pneumonia: state of the science.
      Am J Infect Control. 2006; 34: 84-93
      ,
      • Montoya A
      • Mody L
      Common infections in nursing homes: a review of current issues and challenges.
      Aging Health. 2011; 7: 889-899
      ,
      • Dang TT
      • Majumdar SR
      • Marrie TJ
      • Eurich DT
      Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
      Drugs Aging. 2015; 32: 13-19
      ,
      • Liu C
      • Cao Y
      • Lin J
      • et al.
      Oral care measures for preventing nursing home‐acquired pneumonia.
      Cochrane Database Syst Rev. 2018; CD012416
      Influenza vaccination research has shown varied results, but more recent studies with high-dose vaccination demonstrate that influenza vaccination has a significant protective effect when compared to a standard-dose vaccine.
      • Loeb M
      • McGeer A
      • McArthur M
      • Walter S
      • Simor AE
      Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.
      Arch Intern Med. 1999; 159: 2058-2064
      ,
      • Gravenstein S
      • Davidson HE
      • Taljaard M
      • et al.
      Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial.
      Lancet Respir Med. 2017; 5: 738-746
      , 
      • Thomas RE
      • Jefferson T
      • Lasserson TJ
      Influenza vaccination for healthcare workers who care for people aged 60 or older living in long‐term care institutions.
      Cochrane Database System Rev. 2016; CD005187
      , 
      • Beyer WE
      • McElhaney J
      • Smith DJ
      • et al.
      Cochrane re-arranged: support for policies to vaccinate elderly people against influenza.
      Vaccine. 2013; 31: 6030-6033
      , 
      • Poscia A
      • Collamati A
      • Carfì A
      • et al.
      Influenza and pneumococcal vaccination in older adults living in nursing home: a survival analysis on the shelter study.
      Eur J Public Health. 2017; 27: 1016-1020
      , 
      • Pop‐Vicas A
      • Rahman M
      • Gozalo PL
      • Gravenstein S
      • Mor V
      Estimating the effect of influenza vaccination on nursing home residents’ morbidity and mortality.
      J Am Geriatr Soc. 2015; 63: 1798-1804
      , 
      • Kostova D
      • Reed C
      • Finelli L
      • et al.
      Influenza illness and hospitalizations averted by influenza vaccination in the United States, 2005–2011.
      PLoS One. 2013; 8: e66312
      , 
      • Monto AS
      • Ansaldi F
      • Aspinall R
      • et al.
      Influenza control in the 21st century: optimizing protection of older adults.
      Vaccine. 2009; 27: 5043-5053
      ,

      Centers for Disease Control and Prevention. Common causes of pneumonia. Available at: https://www.cdc.gov/pneumonia/causes.html. Accessed November 2, 2019.

      Adequate nutrition support has also been shown to decrease pneumonia risk.
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      If a resident or patient has swallowing difficulties, appropriate dental evaluation and care, aspiration prevention, swallowing evaluation, and dysphagia interventions are essential.
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Muder RR
      Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention.
      Am J Med. 1998; 105: 319-330
      ,
      • Sloane PD
      • Zimmerman S
      • Ward K
      • Reed D
      • Preisser JS
      • Weber DJ
      The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
      J Am Med Dir Assoc. 2017; 18: 810-811
      ,
      • Loeb M
      • McGeer A
      • McArthur M
      • Walter S
      • Simor AE
      Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.
      Arch Intern Med. 1999; 159: 2058-2064
      ,
      • Vergis EN
      • Brennen C
      • Wagener M
      • Muder RR
      Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival.
      Arch Intern Med. 2001; 161: 2378-2381
      ,
      • Dang TT
      • Majumdar SR
      • Marrie TJ
      • Eurich DT
      Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
      Drugs Aging. 2015; 32: 13-19
      ,
      • Liu C
      • Cao Y
      • Lin J
      • et al.
      Oral care measures for preventing nursing home‐acquired pneumonia.
      Cochrane Database Syst Rev. 2018; CD012416
      ,
      • Sarin J
      • Balasubramaniam R
      • Corcoran AM
      • Laudenbach JM
      • Stoopler ET
      Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions.
      J Am Med Dir Assoc. 2008; 9: 128-135
      Alcohol and drug abuse have also been identified as risk factors for pneumonia.
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      Management of these problems requires an interdisciplinary approach.
      • Quinton LJ
      • Walkey AJ
      • Mizgerd JP
      Integrative physiology of pneumonia.
      Physiol Rev. 2018; 98: 1417-1464
      ,
      • Linnebur SA
      • Fish DN
      • Ruscin JM
      • et al.
      Impact of a multidisciplinary intervention on antibiotic use for nursing home-acquired pneumonia.
      Am J Geriatr Pharmacother. 2011; 9 (e1): 442-452
      ,
      • El-Solh AA
      • Alhajhusain A
      • Saliba RG
      • Drinka P
      Physicians’ attitudes toward guidelines for the treatment of hospitalized nursing home-acquired pneumonia.
      J Am Med Dir Assoc. 2011; 12: 270-276
      Consistent pharmacological review is required to ensure appropriately prescribed medication. Antimicrobial stewardship is necessary to prevent the risk of microbiome disruption and multidrug-resistant organism colonization and infection. Proton pump inhibitors and inhaled steroids also increase pneumonia risk. The use of nebulizers and other respiratory support such as continuous positive airway pressure/bilevel positive airway pressure increases risk of pneumonia.
      • Kendrick AH
      • Johns DP
      • Leeming JP
      Infection control of lung function equipment: a practical approach.
      Respir Med. 2003; 97: 1163-1179
      The hazards of immobility related to pneumonia as well as other patient outcomes have been well described for decades.
      • Quagliarello V
      • Ginter S
      • Han L
      • Van Ness P
      • Allore H
      • Tinetti M
      Modifiable risk factors for nursing home-acquired pneumonia.
      Clin Infect Dis. 2005; 40: 1-6
      (See Section 3 of this guide.) When possible, improving functional status and maintaining mobility will address the risks of immobility and increased physical dependence and reduce the likelihood of pneumonia in LTC patients.
      There are multiple specific organisms that can cause pneumonia in LTC patient populations. They include viral agents such as adenovirus, human metapneumovirus, influenza virus, respiratory syncytial virus, human parainfluenza virus, and rhinovirus; a variety of bacteria, such as Streptococcus pneumoniae and Bordetella pertussis; and some types of fungi, including Candida auris.
      If the LTC facility does not have an active infection prevention and control program, the spread of pathogens or respiratory infections may not be recognized in time to stop outbreaks, especially because older LTC residents may not exhibit chills, chest pain, or other typical signs and symptoms of pneumonia.
      • Flanders SA
      • Collard HR
      • Saint S
      Nosocomial pneumonia: state of the science.
      Am J Infect Control. 2006; 34: 84-93
      , 
      • Montoya A
      • Mody L
      Common infections in nursing homes: a review of current issues and challenges.
      Aging Health. 2011; 7: 889-899
      , 
      • Gravenstein S
      • Davidson HE
      • Taljaard M
      • et al.
      Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial.
      Lancet Respir Med. 2017; 5: 738-746
      , 
      • Thomas RE
      • Jefferson T
      • Lasserson TJ
      Influenza vaccination for healthcare workers who care for people aged 60 or older living in long‐term care institutions.
      Cochrane Database System Rev. 2016; CD005187
      , 
      • Beyer WE
      • McElhaney J
      • Smith DJ
      • et al.
      Cochrane re-arranged: support for policies to vaccinate elderly people against influenza.
      Vaccine. 2013; 31: 6030-6033
      , 
      • Poscia A
      • Collamati A
      • Carfì A
      • et al.
      Influenza and pneumococcal vaccination in older adults living in nursing home: a survival analysis on the shelter study.
      Eur J Public Health. 2017; 27: 1016-1020
      , 
      • Pop‐Vicas A
      • Rahman M
      • Gozalo PL
      • Gravenstein S
      • Mor V
      Estimating the effect of influenza vaccination on nursing home residents’ morbidity and mortality.
      J Am Geriatr Soc. 2015; 63: 1798-1804
      , 
      • Kostova D
      • Reed C
      • Finelli L
      • et al.
      Influenza illness and hospitalizations averted by influenza vaccination in the United States, 2005–2011.
      PLoS One. 2013; 8: e66312
      An active surveillance program within an established infection prevention program that includes identification of symptomatic individuals, notification and collaboration with public health, and segregation and cohorting of symptomatic or colonized individuals is an evidence-based approach to reduce the risk of respiratory infections and pneumonia. Essential tools to ensure a high-functioning infection prevention and control program are the Facility Risk Assessment

      Quality Improvement Organizations; Centers for Medicare and Medicaid Services. Facility assessment tool. Available at: https://qioprogram.org/facility-assessment-tool. Accessed November 2, 2019.

      and Infection Prevention and Risk Assessment.

      University of North Carolina at Chapel Hill. Statewide Program for Infection Control and Epidemiology. Template Risk Assess LTC. Available at: https://spice.unc.edu/resources/template-risk-assessment-for-ltc. Accessed November 2, 2019.

      To reduce the risk of pathogen transmission and exposure, LTC facilities must promote prevention strategies such as hand hygiene, respiratory etiquette, a robust vaccination program that includes influenza and pneumococcal vaccinations for staff as well as residents and patients, environmental cleaning and disinfection, and transmission-based precautions.
      Water may contain pneumonia-causing organisms such as Legionella, Pseudomonas, Elizabethkingia, nontuberculous Mycobacteria, and other pathogens.

      Centers for Disease Control and Prevention. Healthcare water management program frequently asked questions: Legionnaires’ disease and other infections associated with building water systems. Available at: https://www.cdc.gov/legionella/wmp/healthcare-facilities/healthcare-wmp-faq.html. Accessed November 2, 2019.

      Environmental controls that include comprehensive water management plans and programs reduce the risk of exposure for LTC residents, patients, staff, and family members.
      Key points
      • •
        Long-term care residents and patients are at increased risk of pneumonia from both intrinsic and extrinsic risk factors.
      • •
        The IP needs to involve the entire interdisciplinary team in a comprehensive, person-centered approach to pneumonia prevention.
      • •
        The Facility Assessment and the Infection Prevention Risk Assessment should identify and address facility-level, staff-level, and resident- and patient-level pneumonia risk factors to help keep residents and patients safe.

      References

        • Quinton LJ
        • Walkey AJ
        • Mizgerd JP
        Integrative physiology of pneumonia.
        Physiol Rev. 2018; 98: 1417-1464
        View in Article
        • Muder RR
        Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention.
        Am J Med. 1998; 105: 319-330
        View in Article
        • Muder RR
        • Brennen C
        • Swenson DL
        • Wagener M
        Pneumonia in a long-term care facility: a prospective study of outcome.
        Arch Intern Med. 1996; 156: 2365-2370
        View in Article
        • Isonaka S
        The enhanced care program: impact of a care transition program on 30-day hospital readmissions for patients discharged from an acute care facility to skilled nursing facilities.
        J Hosp Med. 2018; 13: 229
        View in Article
        • Sanford AM
        • Orrell M
        • Tolson D
        • et al.
        An international definition for “nursing home”.
        J Am Med Dir Assoc. 2015; 16: 181-184
        View in Article
        • Kerr HD
        • Byrd JC
        Nursing home patients transferred by ambulance to the emergency department.
        J Am Geriatr Soc. 1991; 39: 132-136
        View in Article
        • Irvine PW
        • Van Buren N
        • Crossley K
        Causes for hospitalization of nursing home residents: the role of infection.
        J Am Geriatr Soc. 1984; 32: 103-107
        View in Article
        • Bergman H
        • Clarfield AM
        Appropriateness of patient transfer from a nursing home to an acute-care hospital: a study of emergency room visits and hospital admissions.
        J Am Geriatr Soc. 1991; 39: 1164-1168
        View in Article
        • Sloane PD
        • Zimmerman S
        • Ward K
        • Reed D
        • Preisser JS
        • Weber DJ
        The nursing home pneumonia risk index: a simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality.
        J Am Med Dir Assoc. 2017; 18: 810-811
        View in Article
        • Loeb M
        • McGeer A
        • McArthur M
        • Walter S
        • Simor AE
        Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.
        Arch Intern Med. 1999; 159: 2058-2064
        View in Article
        • Mehr DR
        • Binder EF
        • Kruse RL
        • et al.
        Predicting mortality in nursing home residents with lower respiratory tract infection: the Missouri LRI Study.
        JAMA. 2001; 286: 2427-2436
        View in Article
        • Loeb MB
        Pneumonia in nursing homes and long-term care facilities.
        Semin Respir Crit Care Med. 2005; 6: 650-655
        View in Article
        • Jones AL
        • Dwyer LL
        • Bercovitz AR
        • et al.
        The National Nursing Home Survey: 2004 overview.
        Vital Health Stat. 2009; 167: 1-155
        View in Article
        • Vergis EN
        • Brennen C
        • Wagener M
        • Muder RR
        Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival.
        Arch Intern Med. 2001; 161: 2378-2381
        View in Article
        • Marrie TJ
        Pneumonia in the long-term-care facility.
        Infect Control Hosp Epidemiol. 2002; 23: 159-164
        View in Article
        • Flanders SA
        • Collard HR
        • Saint S
        Nosocomial pneumonia: state of the science.
        Am J Infect Control. 2006; 34: 84-93
        View in Article
        • Montoya A
        • Mody L
        Common infections in nursing homes: a review of current issues and challenges.
        Aging Health. 2011; 7: 889-899
        View in Article
        • Gravenstein S
        • Davidson HE
        • Taljaard M
        • et al.
        Comparative effectiveness of high-dose versus standard-dose influenza vaccination on numbers of US nursing home residents admitted to hospital: a cluster-randomised trial.
        Lancet Respir Med. 2017; 5: 738-746
        View in Article
        • Thomas RE
        • Jefferson T
        • Lasserson TJ
        Influenza vaccination for healthcare workers who care for people aged 60 or older living in long‐term care institutions.
        Cochrane Database System Rev. 2016; CD005187
        View in Article
        • Beyer WE
        • McElhaney J
        • Smith DJ
        • et al.
        Cochrane re-arranged: support for policies to vaccinate elderly people against influenza.
        Vaccine. 2013; 31: 6030-6033
        View in Article
        • Poscia A
        • Collamati A
        • Carfì A
        • et al.
        Influenza and pneumococcal vaccination in older adults living in nursing home: a survival analysis on the shelter study.
        Eur J Public Health. 2017; 27: 1016-1020
        View in Article
        • Pop‐Vicas A
        • Rahman M
        • Gozalo PL
        • Gravenstein S
        • Mor V
        Estimating the effect of influenza vaccination on nursing home residents’ morbidity and mortality.
        J Am Geriatr Soc. 2015; 63: 1798-1804
        View in Article
        • Kostova D
        • Reed C
        • Finelli L
        • et al.
        Influenza illness and hospitalizations averted by influenza vaccination in the United States, 2005–2011.
        PLoS One. 2013; 8: e66312
        View in Article
        • Monto AS
        • Ansaldi F
        • Aspinall R
        • et al.
        Influenza control in the 21st century: optimizing protection of older adults.
        Vaccine. 2009; 27: 5043-5053
        View in Article
        • Dang TT
        • Majumdar SR
        • Marrie TJ
        • Eurich DT
        Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients.
        Drugs Aging. 2015; 32: 13-19
        View in Article
        • Rabie T
        • Curtis V
        Handwashing and risk of respiratory infections: a quantitative systematic review.
        Trop Med Int Health. 2006; 11: 258-267
        View in Article
        • Bosco E
        • Zullo AR
        • McConeghy KW
        • et al.
        Long-term care facility variation in the incidence of pneumonia and influenza.
        Open Forum Infect Dis. 2019; 6 (ofz230)
        View in Article
        • Burdsall DP
        • Flores HC
        • Krueger J
        • et al.
        Use of proton pump inhibitors with lack of diagnostic indications in 22 Midwestern US skilled nursing facilities.
        J Am Med Dir Assoc. 2013; 14: 429-432
        View in Article
        • Quagliarello V
        • Ginter S
        • Han L
        • Van Ness P
        • Allore H
        • Tinetti M
        Modifiable risk factors for nursing home-acquired pneumonia.
        Clin Infect Dis. 2005; 40: 1-6
        View in Article
        • Liu C
        • Cao Y
        • Lin J
        • et al.
        Oral care measures for preventing nursing home‐acquired pneumonia.
        Cochrane Database Syst Rev. 2018; CD012416
        View in Article
        • Sarin J
        • Balasubramaniam R
        • Corcoran AM
        • Laudenbach JM
        • Stoopler ET
        Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions.
        J Am Med Dir Assoc. 2008; 9: 128-135
        View in Article
        • Manabe T
        • Teramoto S
        • Tamiya N
        • Okochi J
        • Hizawa N
        Risk factors for aspiration pneumonia in older adults.
        PLoS One. 2015; 10e0140060
        View in Article
        • Haenen APJ
        • Verhoef LP
        • Beckers A
        • et al.
        Surveillance of infections in long-term care facilities (LTCFs): the impact of participation during multiple years on health care-associated infection incidence.
        Epidemiol Infect. 2019; 147: e266
        View in Article
        • Lim CW
        • Choi Y
        • An CH
        • et al.
        Facility characteristics as independent prognostic factors of nursing home-acquired pneumonia.
        Korean J Intern Med. 2016; 31: 296-304
        View in Article
        • Lima JC
        • Intrator O
        • Karuza J
        • Wetle T
        • Mor V
        • Katz P
        Nursing home medical staff organization and 30-day rehospitalizations.
        J Am Med Dir Assoc. 2012; 13: 552-557
        View in Article
        • Kendrick AH
        • Johns DP
        • Leeming JP
        Infection control of lung function equipment: a practical approach.
        Respir Med. 2003; 97: 1163-1179
        View in Article

      37. Centers for Disease Control and Prevention. Common causes of pneumonia. Available at: https://www.cdc.gov/pneumonia/causes.html. Accessed November 2, 2019.

        View in Article

      38. Centers for Disease Control and Prevention. Current waterborne disease burden data & gaps. Available at:https://www.cdc.gov/healthywater/burden/current-data.html. Accessed November 2, 2019.

        View in Article

      39. Centers for Disease Control and Prevention. Healthcare water management program frequently asked questions: Legionnaires’ disease and other infections associated with building water systems. Available at: https://www.cdc.gov/legionella/wmp/healthcare-facilities/healthcare-wmp-faq.html. Accessed November 2, 2019.

        View in Article

      40. Centers for Disease Control and Prevention. Reduce risk from water. Available at:https://www.cdc.gov/hai/prevent/environment/water.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhai%2Fprevent%2Fwater-management.html. Accessed November 2, 2019.

        View in Article

      41. Centers for Disease Control and Prevention. Toolkit: developing a water management program to reduce Legionella growth and spread in buildings. Available at:https://www.cdc.gov/legionella/wmp/toolkit/index.html. Accessed November 2, 2019.

        View in Article
        • Linnebur SA
        • Fish DN
        • Ruscin JM
        • et al.
        Impact of a multidisciplinary intervention on antibiotic use for nursing home-acquired pneumonia.
        Am J Geriatr Pharmacother. 2011; 9 (e1): 442-452
        View in Article
        • El-Solh AA
        • Alhajhusain A
        • Saliba RG
        • Drinka P
        Physicians’ attitudes toward guidelines for the treatment of hospitalized nursing home-acquired pneumonia.
        J Am Med Dir Assoc. 2011; 12: 270-276
        View in Article

      44. Quality Improvement Organizations; Centers for Medicare and Medicaid Services. Facility assessment tool. Available at: https://qioprogram.org/facility-assessment-tool. Accessed November 2, 2019.

        View in Article

      45. University of North Carolina at Chapel Hill. Statewide Program for Infection Control and Epidemiology. Template Risk Assess LTC. Available at: https://spice.unc.edu/resources/template-risk-assessment-for-ltc. Accessed November 2, 2019.

        View in Article

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      Footnotes

      Conflict of interest: None to report.

      Identification

      DOI: https://doi.org/10.1016/j.ajic.2020.03.007

      Copyright

      © 2020 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.

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