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To the Editor: The clinical trial by Dr Loeb and colleagues¹ evaluated a pathway for the management of lower respiratory tract infection (LRTI) including pneumonia in nursing home residents in Hamilton, Ontario, concluding that its use can result in outcomes comparable to usual care while reducing hospitalizations and costs. However, I believe that several limitations affect its general applicability.

First, while the criteria for hospitalization were similar to a recent consensus guideline for the management of nursing home–acquired pneumonia,² the decision to hospitalize residents with suspected pneumonia may be influenced by several factors. Deterioration after regular hours and marked respiratory insufficiency predicted hospital transfer in residents with documented pneumonia.³ Family and resident preferences may also be important factors in the hospitalization decision.

Second, although the pathway was tested in nursing home residents with pneumonia, there was radiographic confirmation of an infiltrate in only one third of the episodes. In a . . . [Full Text of this Article]

Joseph M. Mylotte, MD
mylotte@buffalo.edu
School of Medicine and Biomedical Sciences University at Buffalo
Buffalo, NY