title: Guidelines for the management of adults with health care-associated pneumonia: implications for nursing facility residents.
abstract: OBJECTIVE
  To review the implications for nursing facility residents of the 2005 American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) guidelines for the Management of Adults with Health Care-Associated Pneumonia.
  
  
  METHODS
  A MEDLINE/PUBMED search (1986-February 2006) was conducted to identify pertinent studies of health care associated pneumonia acquired in the nursing facility setting (formerly called nursing home-acquired pneumonia) in the English language. Additional references were obtained from the bibliographies of these studies.
  
  
  METHODS
  All studies evaluating any aspect of nursing home-acquired pneumonia.
  
  
  RESULTS
  Careful review of these guidelines will reveal a failure of the ATS/IDSA committee members to review the large published database available in the field of nursing home-acquired pneumonia. In addition, the committee was devoid of representation from experts in this field. As a result, these guidelines are applicable only to nursing facility residents admitted to the hospital. For the vast majority of nursing facility residents, these guidelines are problematic. The use of invasive means to acquire respiratory tract secretions for culture and susceptibility testing in the nursing facility setting is just not possible. Few facilities are able to manage residents with the two-, three-, or four-drug combination intravenous therapies recommended. As a result of these realities, all residents of nursing facilities with suspected pneumonia would be forced into hospital for diagnostic workup and at least initial empiric therapy if the guidelines were followed "to the letter." The guidelines do not even discuss the issue of site of treatment and how to select residents for outpatient (i.e., infacility) versus inpatient (i.e., in-hospital) management. Infacility management mandated by advanced directives is not even considered by the guidelines.
  
  
  CONCLUSIONS
  There does exist a database upon which the clinician can make informed decisions about likely pathogens, the probability that the resident actually has bacterial pneumonia, objective parameters suggesting the need for hospitalization for initial management, and guidance on when to initiate antimicrobial therapy, and which agent(s) to use. These issues are summarized here, and alternative, evidence-based, practical recommendations for the management of nursing home-acquired pneumonia are outlined.
authors.affiliation: Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Menneapolis, MN 55455, USA. guayx001@umn.edu
authors.forename: David R
authors.initials: DR
authors.lastname: Guay
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003428:Cross Infection / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D024901:Drug Resistance, Multiple, Bacterial; D006761:Hospitals; D006801:Humans; D009735:Nursing Homes; D018410:Pneumonia, Bacterial / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D017410:Practice Guidelines as Topic; D012955:Societies, Medical; D012122:Ventilators, Mechanical / Q000009:adverse effects
chemical_list: D000900:Anti-Bacterial Agents