198 LETTERS TO THE EDITOR
1 JAGS
Grants for Longevity Sciences from the Ministry of Health,
Labor and Welfare (20C-1, 19-02,21-005).
Author Contributions: TE: study concept and design,
analysis and interpretation of data, and preparation of let-
ter. SE: study concept and design and preparation of letter.
MY, MA, and SY: acquisition of data. HA: study oversight,
interpretation of data and final approval of letter.
Sponsor’s Role: None.
REFERENCES
1. Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly.
Chest 2003;124:328–336.
2. Teramoto S, Fukuchi Y, Sasaki H et al. High incidence of aspiration pneu-
monia in community- and hospital-acquired pneumonia in hospitalized
patients: A multicenter, prospective study in Japan. J Am Geriatr Soc 2008;56:
577–579.
3. Jasti H, Mortensen EM, Obrosky DS et al. Causes and risk factors for rehos-
pitalization of patients hospitalized with community-acquired pneumonia.
Clin Infect Dis 2008;46:550–556.
4. Arrowsmith H. Nursing management of patients receiving gastrostomy feed-
ing. Br J Nurs 1996;5:268–273.
5. The FOOD trial collaboration. Effect of timing and method of enteral tube
feeding for dysphagic stroke patients (FOOD): A multicentre randomized
controlled trial. Lancet 2005;365:764–772.
6. Watando A, Ebihara S, Ebihara T et al. Effect of temperature on swallowing
reflex in elderly patients with aspiration pneumonia. J Am Geriatr Soc 2004;
52:2143.
7. Ebihara T, Sekizawa K, Nakazawa H et al. Capsaicin and swallowing reflex.
Lancet 1993;341:432.
8. Ebihara T, Takahashi H, Ebihara S et al. Capsaicin troche for swallowing
dysfunction in older people. J Am Geriatr Soc 2005;53:824–825.
9. Ebihara T, Ebihara S, Watando A et al. Effects of menthol on the triggering of
the swallowing reflex in elderly patients with dysphagia. Br J Clin Pharmcol
2006;62:369–371.
10. Ebihara T, Ebihara S, Maruyama M et al. A randomized trial of olfactory
stimulation using black pepper oil in older people with swallowing dysfunc-
tion. J Am Geriatr Soc 2006;54:1401–1406.
INTERVENTIONS TO PREVENT PNEUMONIA IN
NURSING HOME RESIDENTS
To the Editor: We applaud Quagliarello and colleagues for
‘‘Pilot testing of intervention protocols to prevent pneumo-
nia in nursing home residents.’’1 Intervention protocols
were directed toward oral hygiene and swallowing dys-
function. We are writing to ask clinicians to consider two
additional areas with potential preventive efficacy: medi-
cation review and anti-reflux therapy.
Certain medications decrease salivation; impair swal-
lowing, cough, and mobility; facilitate reflux; or promote
gastric colonization with oral respiratory pathogens by re-
ducing acidity or contributing to stagnation or paresis.2 In
addition, inhaled corticosteroids are associated with a
greater risk of pneumonia.3
Residents colonized with gram-negative rods (GNRs),
Staphylococcus aureus, or yeast demonstrated poor pha-
ryngeal clearance of radiolabeled albumin from the oro-
pharynx (stasis).4 Salivary flow and swallowing facilitate
mechanical clearance of the mouth. Studies have shown
that anticholinergic medication decreases salivary produc-
tion and slows clearance of isotope.5 Dry mouth has been
associated with coated tongue and halitosis, and in one
JANUARY 2010–VOL. 58, NO.
study, dry mouth was associated with a greater risk of ven-
tilator-associated pneumonia.2,6
Pulmonary and allergy practice guidelines acknowl-
edge gastroesophageal regurgitation as a possible cause of
cough, asthma, and sinusitis.2 Although a strong associa-
tion between gastroesophageal reflux disease (GERD) and
pneumonia remains an area of controversy, in one study,
35% of deaths attributed to GERD were from aspiration.7
Aspirated gastric contents may contain food, acid, enzymes,
or colonizing microbes. Gastric aspiration events may
therefore produce chemical pneumonitis or bacterial pneu-
monia.2 Hypochlorhydria and stasis (gastroparesis, bowel
obstruction) facilitate gastric bacterial colonization by
oral flora (including GNRs and S. aureus). In a case–
control study, current proton pump inhibitor (PPI) use in
outpatients was associated with a risk of pneumonia 1.9
times as great as in those who stopped the PPI.2
Japanese clinicians conducted small studies in nursing
home residents to assess the effectiveness of interventions de-
signed to reduce gastric regurgitation and aspiration. Twenty-
eight bed-bound residents were placed in a seated position for
2 hours after meals and compared with 34 controls.8 The in-
tervention group sustained 13 febrile days per patient over the
course of the 100-day study, compared with 18 days in the
control group (Po.05). In a second study, residents who had
experienced a cerebrovascular accident and were being fed
using a percutaneous endoscopic gastrostomy tube were stud-
ied for 12 months. Thirty-eight received mosapride, a promo-
tility agent, versus 37 controls. Forty-seven percent of the
intervention group developed pneumonia, compared with
81% in the control group (P 5.004). Mortality was 26% in
the intervention group, compared with 59% in controls
(P 5.01).9 Elevating the head of the bed to prevent reflux,
regurgitation, and aspiration is a standard of care in the in-
tensive care unit, but this position will increase the pressure
applied to the sacral skin.10
In summary, medication review and anti-reflux therapy
may also be the focus of intervention efforts to prevent
pneumonia in nursing home residents.
Paul J. Drinka, MD
Departments of Internal Medicine and Geriatrics
School of Medicine and Public Health
University of Wisconsin
Madison, Wisconsin
Medical College of Wisconsin
Milwaukee, Wisconsin
Ali El-Sohl, MD, MPH
Veterans Affairs Western New York Healthcare System
Buffalo, New York
Department of Medicine and Social and
Preventive Medicine
State University of New York at Buffalo
Buffalo, New York
ACKNOWLEDGMENTS
Conflict of Interest: The editor in chief has reviewed the
conflict of interest checklist provided by the authors and has
determined that the authors have no financial or any other
kind of personal conflicts with this paper.
JAGS JANUARY 2010–VOL. 58, NO. 1
Author Contributions: Drinka and El-Solh: careful
editing and addition of original ideas and references.
Sponsor’s Role: None.
REFERENCES
1. Quagliarello V, Juthani-Mehta M, Ginter S et al. Pilot testing of intervention
protocols to prevent pneumonia in nursing home residents. J Am Geriatr Soc
2009;57:1226–1231.
2. Drinka P. Preventing aspiration in the nursing home: The role of biofilm and
data from the ICU. J Am Med Dir Assoc (in press).
3. Drummond MB, Dasenbrook EC, Pitz MW et al. Inhaled corticosteroids in
patients with stable COPD. JAMA 2008;300:2407–2416.
4. Palmer LB, Albulak K, Fields S et al. Oral clearance and pathogenic oropharyn-
geal colonization in the elderly. Am J Respir Crit Care Med 2001;64:464–468.
5. Munro CL, Grap MJ, Elswick RK et al. Oral health and development of VAP.
Am J Crit Care 2006;15:453–460.
6. La Force FM, Thompson B, Trow R. Effect of atropine on oral clearance of a
radiolabeled sulfur colloid. J Lab Clin Med 1984;104:693–697.
7. Rantanen TK, Salo JA. Gastroesophageal reflux disease as a cause of death:
Analysis of fatal cases under conservative treatment. Scand J Gastroenterol
1999;34:229–233.
8. Matsui T, Yamaya M, Ohrui T et al. Sitting position to prevent aspiration in
bed-bound patients [letter]. J Am Geriatr Soc 2007;55:142–144.
9. He M, Ohrui T and the Pneumonia Prevention Study Group et al. Mosapride
citrate prolongs survival in stroke patients with gastrostomy. J Am Geriatr Soc
2007;55:142–144.
10. Peterson M, Schwab W, McCutcheon K et al. Effects of elevating the head of the
bed on interface pressure in volunteers. Crit Care Med 2008;36:3038–3042.
INFECTIONS IN NURSING HOMES: IS IT TIME TO
REVISE THE MCGEER CRITERIA?
To the Editor: In industrialized countries, over the last cen-
tury, although the incidence of infectious disease has de-
creased in the young, the incidence of major infections has
remained high in the oldest part of the population.1,2 Al-
though morbidity and mortality rates are generally agreed
to be high in nursing home (NH) and long-term care facility
(LTCF) populations, attention has for decades focused on
community- and healthcare-associated infection (HCAI),
with fewer reports concerning NH- and LTCF-associated
infection2–4 (NHAI), particularly in Europe.
In France, more than 600,000 elderly persons already live
in NHs, known as ‘‘Etablissements d’Hébergement pour Per-
sonnes Agées Dépendantes’’ (EHPADs). NHAI is associated
with greater morbidity, hospital transfer, antimicrobial use, and
functional impairment and higher costs. Moreover, as recently
highlighted, coping with the burden of NHAI also means cop-
ing with antibiotic resistance, outbreaks, and infection control
systems,5 but assessment and prevention of the effect of NHAI
requires being able to measure the true incidence of NHAI
itself. More than 15 years ago, McGeer and colleagues sug-
gested new definitions for the most prevalent LTCF-associated
infections, for purposes of surveillance and control.6 It was
argued that the main questions regarding LTCF infection con-
trol systems arose from inadequate definitions of HCAI. LTCFs
and NHs differ in nurse-to-patient ratios and in access to bi-
ological and X-ray analysis.
Most LTCF and NH epidemiology studies worldwide
have used the McGeer or the Centers for Disease Control and
Prevention (CDC) HCAI definition,7–9 despite the fact that no
study has been performed to validate these definitions. This is
reinforced in the latest (Society for Healthcare Epidemiology
LETTERS TO THE EDITOR 199
of America/Association for Professionals in Infection Control
and Epidemiology) guidelines on LTCF infection control that
are still based on the McGeer criteria.6
In France, most LTCFs are hospital based, whereas NHs
(EHPADs) are usually not associated with a hospital. NHs are
in the community and work with the community healthcare
system of general practitioners and private pharmacists, lab-
oratories, and radiologists. There is a medical coordinator for
each NH, paid for an average half day of care per 80 residents.
NHs care for older people and people who are chronically ill
and severely disabled. One of their main features is to congre-
gate residents at high risk of infection and with limited access to
medical and technical support. There are no data on NHAI
epidemiology in France, and the unfavorable ratio of health-
care workers to residents hinders collection of high-quality ep-
idemiological, anamnestic, clinical, and biological data.
Because of these limitations, it was postulated that the
burden of infection could not be properly measured using
the McGeer criteria. To address this question, a French as-
sociation (Observatoire du Risque Infectieux en Gériatrie
(ORIG)), devoted to assessment and strategy in infectious
diseases in older adults, undertook to revise the McGeer
criteria for NHAI.
Thirteen infections defined by McGeer were revised (see
supplementary data). Briefly, ORIG’s definitions used the
McGeer criteria, without any morphological, bacteriological,
or biological criteria but adding the diagnosis made by the
diagnosing physician. When the McGeer criteria were fulfilled,
the infection was to be counted as definite, and when the ORIG
criteria were fulfilled, as probable. We then organized a point-
prevalence transversal survey in 24 volunteer NHs of the Val de
Marne area in France to measure the prevalence of NHAI on
the McGeer and ORIG criteria. Data were collected over a 1-
month period, from January 24 to February 20, 2005. A local
investigator, trained to use Web-based software to collect
data from each NH during the study period, entered data on all
symptoms for each infection, and the software classified the
infection as definite or probable. Two thousand one hundred
forty residents were included (mean age  standard deviation
87.0  8.3). A total of 311 infections were diagnosed during
the study period. Crude prevalence was 4.1% and 14.5% ac-
cording to the McGeer and ORIG criteria, respectively. Bron-
chitis (35.5%), gastroenteritis (23.8%), urinary tract infection
(16.7%), otorhinolaryngological infection (8.7%), and pneu-
monia (7.0%) were the most prevalent infections. The high
prevalence of gastroenteritis was in keeping with the frequency
of outbreaks commonly occurring in such winter periods; even
so, the main finding was that the prevalence rate of infec-
tion was 3.5 times as great using the ORIG criteria as when
using the McGeer criteria. In other countries, according
to the McGeer criteria, overall NHAI incidence is 1.8 to 13.5
infections per 1,000 resident-care days, and prevalence is reg-
ularly less than 10%.3,8–10 We therefore suggest that the global
burden of infection in NHs is higher than previously reported,
because of the use of inappropriate definitions.
Nevertheless, the ORIG definitions may have some
limitations. First, differences may be related to environ-
mental characteristics and specificities regarding popula-
tions (age, disability level, and differences in other
infectious disease risk factors), NH tasks, healthcare bur-
dens, and diagnostic tools available, but both definitions
were applied to the same residents of the 24 NHs, so that, in