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Lower respiratory tract infections (LRIs), principally pneumonia, are a leading cause of morbidity, mortality, and hospitalization of nursing home residents. Nursing-horne-based studies since the mid-1980s suggest an LRI incidence of 540 to 943 per 1000 patient-years with 12 to 28 percent mortality from pneumonia or LRI.I-5 In one study, LRls accounted for 12 percent of all resident hospitalizations.6 Based primarily on hospital data, reviews from the late 1980s uniformly advocated hospitalization or at least broad-spectrum parenteral antibiotics for all cases of nursing-horne-acquired pneumonia.710 Studies from that era showed substantial variation among facilities in how frequently residents were hospitalized for infection. ll , 12 Furthermore, the data suggested that institutional characteristics and practices mattered as much as patient characteristics in predicting hospitalization. Yet for many nursing home residents, hospitalization can lead to serious negative consequences that could outweigh potential benefits. Hospitalized nursing home residents face new caregivers in unfamiliar surroundings. They are prone to such untoward consequences as immobility, urinary catheterization, pressure ulcers, and delirium. 13,14 From a social perspective, hospital costs for treating pneumonia likely substantially exceed nursing home costs. If pneumonia treatment in the nursing home is efficacious, caregiver continuity, patient comfort, and lower costs provide compelling reasons to treat it there. In this issue of the Journal, Thompson and col-

Nursing-Home-Acquired Pneumonia: How and Where to Treat?