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American family physician

Treatment of Nursing Home–
Acquired Pneumonia
KYLE MILLS, PharmD, BCPS, and A. CHRISTIE NELSON, PharmD
University of Wyoming School of Pharmacy, Laramie, Wyoming
BRADFORD T. WINSLOW, MD, FAAFP, Swedish Family Medicine Residency Program, Littleton, Colorado
KATHRYN LEE SPRINGER, MD, Greater Denver Infectious Diseases, Denver, Colorado
Pneumonia is an important cause of morbidity and mortality in nursing home residents, with 30-day mortality rates
ranging from 10 to 30 percent. Streptococcus pneumoniae
is the most common cause of nursing home–acquired pneu-
monia, although Staphylococcus aureus
and gram-negative organisms may be more common in severe cases. Antibiotic
therapy for nursing home–acquired pneumonia should target a broad range of organisms, and drug-resistant microbes
should be considered when making treatment decisions. In the nursing home setting, treatment should consist of an
antipneumococcal fluoroquinolone alone or
either a high-dose beta-lactam/beta-lactamase inhibitor or a second- or
third-generation cephalosporin, in combination with azithromycin. Treatment of hospitalized patients with nursing
home–acquired pneumonia requires broad-spectrum antibiotics with coverage of many gram-negative and gram-positive
organisms, including methicillin-resistant S. aureus
. Appropriate dosing of antibiotics for nursing home–acquired
pneumonia is important to optimize effectiveness and avoid adverse effects. Because many nursing home residents take
multiple medications, it is important to consider possible drug interactions. (Am Fam Physician.
2009;79(11):976-982.
Copyright 2009 American Academy of Family Physicians.)

See related editorial
on page 938.
Pneumonia is the second most com- infection with multidrug-resistant patho- mon cause of infection in nursing gens include antibiotic therapy within home residents, and is associated the preceding 90 days, a high incidence of with notable morbidity and mortal- antibiotic resistance in the community or ity.1 Attributable 30-day mortality rates range facility, chronic hemodialysis, and immu-from 10 to 30 percent.2-4 Prompt diagnosis nosuppression.7 One study found that recent and management are therefore essential. antibiotic use and the inability to perform This article reviews the clinical management activities of daily living were independently of nursing home–acquired pneumonia, with associated with antibiotic-resistant nurs-an emphasis on antimicrobial therapy.
ing home–acquired pneumonia requir-ing intensive care unit (ICU) admission or Etiology
Nursing home–acquired pneumonia is usu- Nursing home–acquired pneumonia can ally bacterial in origin, although the specific also be caused by viral infection (Table 15-12). microbiologic cause is often not identified.5-12 Influenza and respiratory syncytial virus Common bacterial etiologies are listed in (RSV) are important causes of respiratory Table 1.5-12 Streptococcus pneumoniae is the illness and mortality in nursing home resi-most common causative agent. However, dents.13,14 Physicians should suspect viral eti-in severe cases of nursing home–acquired ologies from late fall through early spring, pneumonia requiring hospitalization and and whenever outbreaks of respiratory infec-mechanical ventilation, the rates of infec- tion occur. Influenza predisposes patients tion with Staphylococcus aureus and enteric to a secondary bacterial pneumonia.15 In gram-negative organisms appear to exceed a population-based analysis involving 381 those of S. pneumoniae.5 nursing homes over a period of four years, These organisms can be associated with investigators found that each year influenza antimicrobial resistance, especially in infection was associated with approximately the nursing home setting. Risk factors for 28 hospitalizations; 147 courses of antibiotics; 976  American Family Physician
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Nursing Home–Acquired Pneumonia
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Physicians should suspect infection with resistant organisms in nursing home patients who received antibiotics within the previous 90 days; when there is a high incidence of antibiotic resistance in the community or facility; and in patients who receive chronic dialysis, are immunosuppressed, or have difficulty performing activities of daily living.
Nursing home–acquired pneumonia should be suspected in patients with new or progressive infiltrate plus a new-onset fever, leukocytosis, purulent sputum, or hypoxia.
Nonhospitalized nursing home patients requiring treatment for pneumonia should be treated with an antipneumococcal fluoroquinolone, or either a high-dose beta-lactam/beta-lactamase inhibitor or a second- or third-generation cephalosporin, in combination with azithromycin (Zithromax).
Empiric coverage of methicil in-resistant Staphylococcus aureus and double coverage of Pseudomonal pneumonia should be prescribed for patients requiring intensive care unit admission.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.
and 15 deaths per 1,000 residents with heart or lung dis- more, presence of crackles, or absence of wheezes on aus- ease, diabetes mellitus, or immunosuppression. Similarly, cultation.18 The 2005 American Thoracic Society/Infec-RSV accounted for approximately 15 hospitalizations, tious Diseases Society of America (ATS/IDSA) guideline 76 courses of antibiotics, and 17 deaths per 1,000 resi- recommends that the clinical diagnosis of health care– dents with similar conditions.13 A recent report described associated pneumonia, including nursing home–human metapneumovirus as the cause of an outbreak of acquired pneumonia, be based on a new or progressive respiratory infections, including pneumonia, in a Cana- infiltrate on chest radiography plus clinical findings con- sistent with pneumonia (i.e., new-onset fever [tempera-ture greater than 100.4° F (38° C)], leukocytosis, purulent Diagnosis
The clinical manifestations of pneumonia in older adults The 2005 ATS/IDSA guideline also recommends that may be subtle. In one study, investigators found that per- lower respiratory tract samples be obtained from nurs- sons 65 years and older are less likely to complain of fever, ing home residents hospitalized with nursing home–chills, myalgia, and pleuritic chest pain than younger per- acquired pneumonia, particularly from those who are sons.17 One prospective study revealed that 80 percent of intubated, to guide treatment.7 Although respiratory nursing home residents with pneumonia exhibit three or cultures from nonintubated patients, and from those fewer respiratory signs or symptoms, but 92 percent have managed in the nursing home, could be considered, it is at least one identifiable respiratory manifestation, such important to note that these are infrequently obtained, as cough, respiratory rate of 30 breaths per minute or tend to produce a low yield of pathogenic microorgan- isms, and are commonly contaminated with oropharyn-geal microflora, making interpretation difficult.19,20 Table 1. Common Etiologies of Nursing  
Blood cultures are infrequently positive in patients with Home–Acquired Pneumonia
pneumonia, but may be considered in those who require intensive care. Rapid antigen tests of respiratory secre- tions, such as nasal washings, nasopharyngeal swabs, or throat swabs, can assist with the diagnosis of influenza and RSV during the appropriate seasons.21 Urinary anti- gen testing for S. pneumoniae and Legionella pneumoph- ila serotype 1 may be considered, although most studies examining its use have been performed in patients with community-acquired pneumonia (CAP).22-26 One limita- tion of urinary antigen testing is the lack of information about antibiotic susceptibility. Therefore, a sputum Gram stain and culture should be considered if patients are able Information from references 5 through 12. to generate a useful sample and the results can be obtained in time to influence therapeutic decision-making.21 June 1, 2009Volume 79, Number 11 American Family Physician  977
Nursing Home–Acquired Pneumonia
Evaluation of Suspected Aspiration Pneumonia
Signs and symptoms of lower respiratory tract infection In many nursing home residents with History of gastric content aspiration (definite or suspected)? pneumonia, a diagnosis of aspiration pneu-monitis or aspiration pneumonia should be considered. Aspiration pneumonitis is an inflammatory syndrome that does not typi- cally require antibiotic therapy,27 whereas aspiration pneumonia is an infection for which antibiotic therapy should be initiated. Risk factors for these conditions include a history of stroke, dementia, gastroesopha-geal reflux disease, and tube-feeding require- ments. Pathogens isolated from nursing home patients with severe aspiration pneumonia have included enteric gram-negative bacte- ria, S. aureus, and anaerobes.6 The results of a recent prospective cohort study validated a new algorithm for diagnosis of aspiration pneumonitis versus aspiration pneumonia Treatment
IN THE NURSING HOME SETTING

Figure  1. Algorithm for the evaluation of suspected aspiration
There is little evidence to suggest the clinical pneumonia.
superiority of one antibiotic over another for Adapted with permission from Mylotte JM, Goodnough S, Gould M. Pneumonia versus nursing home–acquired pneumonia, par- aspiration pneumonitis in nursing home residents: prospective application of a clinical algo- ticularly in the nursing home setting. Previ- rithm. J Am Geriatr Soc. 2005;53(5):756. ous guidelines have recommended antibiotic therapy based primarily on microbiologic data.7,29,30 apy after three days of parenteral therapy. Successful The 2005 ATS/IDSA guideline for the treatment of response was documented in 78 percent of patients health care–associated pneumonia does not specifically treated with cefepime and 66 percent of patients treated address treatment of nursing home–acquired pneumo- with ceftriaxone (P = not significant).32 Each year, the nia in the nursing home setting.7 Guidelines based on Centers for Disease Control and Prevention (CDC) limited data and expert opinion recommend the use of recommendations for influenza treatment should be an antipneumococcal fluoroquinolone (e.g., levofloxa- consulted for updates on recent resistance patterns and cin [Levaquin] or moxifloxacin [Avelox]) alone or either treatment or prevention recommendations.
a high-dose beta-lactam/beta-lactamase inhibitor (e.g., When a viral etiology of nursing home–acquired amoxicillin/clavulanate [Augmentin]) or a second- or pneumonia is diagnosed and there is low suspicion of third-generation cephalosporin (e.g., cefuroxime [Cef- secondary bacterial infection, antibiotics often can be tin], cefpodoxime [Vantin], ceftriaxone [Rocephin]), discontinued. However, it should be noted that older in combination with azithromycin (Zithromax). Oral patients with influenza are at high risk of bacterial therapy is preferred over parenteral therapy in mild to superinfection. Oseltamivir (Tamiflu) and zanamivir moderate cases.29,30 Intramuscular cephalosporins also (Relenza) are approved for the treatment of influenza may be used.1,31 A and B in adults, but therapy should begin within two A randomized, double-blind trial compared the safety days of symptom onset to confer the most benefit, and and effectiveness of once-daily intramuscular injections increasing resistance to oseltamivir has recently been of cefepime (Maxipime) and ceftriaxone for nursing reported.33 These agents may lessen the severity of influ-home–acquired pneumonia treated within the nurs- enza manifestations and may reduce the incidence of ing home. Sixty-nine residents 60 years and older with post-influenza bacterial pneumonia.34radiographically-confirmed pneumonia and creatinine Influenza vaccination is recommended for the preven- clearances of less than 60 mL per minute were included tion of influenza in nursing home residents, but does not in the study. Most patients were switched to oral ther- provide complete protection.34 Similarly, pneumococcal 978  American Family Physician
Volume 79, Number 11June 1, 2009 Nursing Home–Acquired Pneumonia
Table 2. Initial Intravenous, Adult Doses of 
Antibiotics for Empiric Therapy of Hospital-
Acquired Pneumonia, Including Ventilator-
Associated Pneumonia, and Healthcare–
vaccination is recommended for all nursing home Associated Pneumonia in Patients with 
patients in accordance with the latest CDC guidelines for Late-Onset Disease or Risk Factors for  
the prevention of pneumococcal pneumonia.35 Oseltami- Multidrug–Resistant Pathogens
vir should be used prophylactically when an outbreak of influenza A or B occurs within a nursing home.34 There are no data to support specific treatments for RSV and human metapneumovirus in nursing home residents.36 IN HOSPITALIZED PATIENTS
Intravenous antimicrobial therapy should be initiated for nursing home patients hospitalized with pneumonia, with empiric coverage of methicillin-resistant S. aureus (MRSA) and Pseudomonas aeruginosa. Antibiotic cover- age of atypical organisms is controversial, and there are no data to support such therapy. If an etiologic agent is identified, antibiotic therapy should be narrowed to minimize antibiotic resistance, toxicity, and cost. Hos- pitalized patients are more likely to have drug-resis- tant and highly pathogenic organisms.5-7,11 Antibiotics administered in the past 90 days generally should not be prescribed again, because the risk of infection with resis- Nursing home residency is a major risk factor for MRSA colonization, which can lead to subsequent infection. Rates of MRSA from six nursing homes and one skilled- *—Dosages are based on normal renal and hepatic function. nursing facility in the United States ranged from 24 to †—Trough levels for gentamicin and tobramycin should be less than 1 µg/ml, and for amikacin they should be less than 4–5 µg/ml. 77 percent.38-40 Vancomycin (Vancocin; given intrave- ‡—Trough levels for vancomycin should be 15–20 µg/ml. nously) and linezolid (Zyvox; given orally or intrave- Reprinted with permission from American Thoracic Society; Infec- nously) are recommended for the treatment of MRSA tious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare- Risk factors for pneumonia caused by P. aeruginosa associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):402. were identified in a study of 559 cases of CAP, including 45 cases of nursing home–acquired pneumonia. They include hospitalization within the previous 30 days or For hospitalized patients with nursing home–acquired pulmonary comorbid illness (e.g., chronic obstructive pneumonia, the 2005 ATS/IDSA guideline7 recom-pulmonary disease, asthma, chronic bronchitis, bron- mends a combination antibiotic therapy consisting of chiectasis, interstitial lung disease).42 When choosing the following: antipseudomonal agents, the physician should refer to • An antipseudomonal cephalosporin, an antipseu- local pseudomonal susceptibility patterns.
domonal carbapenem, or an extended-spectrum beta- One prospective, randomized trial compared the effec- tiveness of cefepime, with or without metronidazole (Fla- gyl), versus ertapenem (Invanz) for hospital- or skilled • An antipseudomonal fluoroquinolone or an amino- facility–acquired pneumonia in nonventilated, non-ICU glycoside patients.43 The addition of vancomycin was permitted for patients with suspected MRSA infection. Enterobacteria- • An anti-MRSA agent (vancomycin or linezolid).
ceae, S. pneumoniae, and S. aureus comprised 19.5, 12.9, The broad empiric therapy includes coverage of MRSA and 11.6 percent of the pathogens recovered, respectively. and double-coverage of P. aeruginosa. Specific antibiot-Forty percent of the S. aureus isolates were methicillin- ics and recommended dosages are provided in (Table 2).7 resistant. Outcomes were similar; 87.3 percent of patients These recommendations are based on microbiologic data who received ertapenem and 86.0 percent of patients who from patients with severe pneumonia. Treatment should received cefepime improved.
be tailored to the local microbiology, resistance patterns, June 1, 2009Volume 79, Number 11 American Family Physician  979
Nursing Home–Acquired Pneumonia
and specific patient risk factors.7 Aminoglycoside use cilastatin (Primaxin), which can cause seizures, should increased mortality in a retrospective review.44 If chosen be avoided in older patients with renal impairment.
as therapy, aminoglycosides should be used with caution Vancomycin dosing should be optimized to maintain in patients with impaired renal function. Tigecycline trough concentrations in the range of 15 to 20 mcg per (Tygacil) and doripenem (Doribax) are newer antibiot- mL.7 However, a retrospective review of patients with ics being investigated in the treatment of health care– MRSA pneumonia did not demonstrate any correlation associated pneumonia, but they are not approved by the between serum vancomycin trough concentrations and U.S. Food and Drug Administration for this indication. mortality.51These medications may play a role in the treatment of hospitalized patients with nursing home–acquired pneu- ADVERSE EFFECTS OF ANTIMICROBIAL AGENTS  
IN OLDER ADULTS

Adverse drug events are more likely to occur in older Pharmacotherapeutics
adults than in other patients.50 The safest and most effec- TIMING AND DURATION OF ANTIBIOTIC THERAPY
tive medication should be prescribed in an appropriate The timing of initiation of antibiotic therapy in hospital- dose for the shortest duration possible to adequately treat ized patients with nursing home–acquired pneumonia the infection. In a study of nursing home patients, use of
may be an important predictor of outcome.45 Therapy antibiotics was associated with preventable adverse drug
given within four hours of admission was associated reactions (Table 3 50).52
with decreased length of stay and decreased mortality
in one retrospective study, and is an important outcome DRUG INTERACTIONS WITH ANTIMICROBIAL AGENTS  
IN OLDER ADULTS
measure for the Centers for Medicare and Medicaid Ser-vices.45,46 However, other studies have not demonstrated Increasing age is associated with an increasing number a survival benefit or a more rapid clinical response.47,48 of medications used on a daily or weekly basis.53 Up to The 2007 IDSA/ATS guideline recommends initiation of 67 percent of nursing home patients will experience an antibiotic therapy for CAP within the emergency depart- adverse drug reaction during a six- to 12-month stay, and ment or as soon as possible after the diagnosis is made, use of more than eight medications is associated with rather than within a specified time period.21 Although no studies have specifically measured outcomes for nurs-ing home patients, similar recommendations apply to Table 3. Adverse Effects of Antibiotics  
in Older Patients
The IDSA/ATS guideline recommends a seven- to eight-day duration of therapy for health care– associated pneumonia that has been treated with appro- priate empiric antibiotics, has clinically improved, and that is not caused by nonfermenting gram-negative bac- Diarrhea, Clostridium difficile–associated disease, drug-related fever, interstitial nephritis, rash, thrombocytopenia, DOSING OF ANTIBIOTICS IN THE NURSING HOME PATIENT
Critically ill patients often have altered pharmacoki- Diarrhea, C. difficile–associated disease netics and pharmacodynamics, and antibiotics must be dosed more aggressively than in other patients.49 Empiric antibiotics in critically ill patients with nursing home– acquired pneumonia should be dosed as outlined in Table 2.7 As renal function declines with age, proper dos- ing of antibiotic agents must be ensured to avoid adverse effects.50 The Cockcroft-Gault equation is commonly used to estimate creatinine clearance; manufacturers generally use this equation to estimate creatinine clear- Adapted with permission from Faulkner CM, Cox HL, Wil iamson JC. ance when making recommendations about drug dosing Unique aspects of antimicrobial use in older adults. Clin Infect Dis. in patients with renal insufficiency. Aminoglycosides, which can cause nephro- and ototoxicity, and imipenem/ 980  American Family Physician
Volume 79, Number 11June 1, 2009 Nursing Home–Acquired Pneumonia
Table 4. Selected Drug Interactions of Common Antibiotics
Loop diuretics, nonsteroidal anti-inflammatory drugs, Aluminum, magnesium, iron, zinc, calcium, sucralfate Serotonergic agents (selective serotonin reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors, tramadol [Ultram]) Adapted with permission from Faulkner CM, Cox HL, Wil iamson JC. Unique aspects of antimicrobial use in older adults. Clin Infect Dis. 2005;40(7):1001. increased rates of adverse drug reactions.54 Because of Hitchcock Medical Center in Lebanon, N.H., and a fellowship in infectious
the large number of medications prescribed in nursing diseases at the University of Colorado Health Sciences Center, Denver.
home patients, the potential for drug interactions is very Address correspondence to Kyle Mills, PharmD, BCPS, Swedish Medical
high. Table 4 lists some common drug interactions with Center, 501 E. Hampden Ave., #3260, Englewood, CO 80113 (e-mail:
which prescribers should be familiar.50 Most antibiotics kmills1@uwyo.edu). Reprints are not available from the authors.
alter the anticoagulant effects of warfarin (Coumadin), Author disclosure: Nothing to disclose.
primarily by increasing these effects. All patients concur-
rently taking antibiotics and warfarin should have their REFERENCES
International Normalized Ratio monitored closely dur-
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3. Muder RR, et al. Pneumonia in a long-term care facility. A prospective study of outcome. Arch Intern Med. 1996;156(20):2365-2370.
The Authors
4. Houston MS, et al. Risk factors for 30-day mortality in elderly patients with lower respiratory tract infection. Community-based study. Arch KYLE MILLS, PharmD, BCPS, is a clinical assistant professor of pharmacy Intern Med. 1997;157(19):2190-2195.
practice at the University of Wyoming School of Pharmacy, Laramie; is on 5. El-Solh AA, et al. Etiology of severe pneumonia in the very elderly. Am J the faculty of the Swedish Family Medicine Residency Program in Little- Respir Crit Care Med. 2001;163(3 pt 1):645-651.
ton, Colo.; and is an assistant clinical professor of family medicine at the 6. El-Solh AA, et al. Microbiology of severe aspiration pneumonia in institu- University of Colorado–Denver/Health Sciences Center in Aurora. Dr. Mil s tionalized elderly. Am J Respir Crit Care Med. 2003;167(12):1650-1654.
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Respir Crit Care Med. 2005;171(4):388-416.
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10. Mylotte JM. Nursing home-acquired pneumonia: update on treatment options. Drugs Aging. 2006;23(5):377-390.
BRADFORD T. WINSLOW, MD, FAAFP, is residency director of the Swedish Family Medicine Residency Program, and is assistant professor of family 11. El-Solh AA, et al. Indicators of potential y drug-resistant bacte- medicine at the University of Colorado–Denver in Aurora. Dr. Winslow ria in severe nursing home-acquired pneumonia. Clin Infect Dis. 2004;39(4):474-480.
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KATHRYN LEE SPRINGER, MD, is a consultant in infectious diseases in Den- 13. El is SE, et al. Influenza- and respiratory syncytial virus-associated mor- ver. She received her medical degree from the University of North Carolina bidity and mortality in the nursing home population. J Am Geriatr Soc. at Chapel Hil , and completed a residency in internal medicine at Dartmouth- June 1, 2009Volume 79, Number 11 American Family Physician  981
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43. Yakovlev SV, et al. Ertapenem versus cefepime for initial empirical 23. Gutíerrez F, et al. Evaluation of the immunochromatographic Binax treatment of pneumonia acquired in skil ed-care facilities or in hos- NOW assay for detection of Streptococcus pneumoniae urinary antigen pitals outside the intensive care unit. Eur J Clin Microbiol Infect Dis. in a prospective study of community-acquired pneumonia in Spain. Clin Infect Dis. 2003;36(3):286-292.
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49. Pea F, et al. The antimicrobial therapy puzzle: could pharmacokinetic- 30. Mandell LA, et al., for the Infectious Diseases Society of America. pharmacodynamic relationships be helpful in addressing the issue of Update of practice guidelines for the management of community- appropriate pneumonia treatment in critical y ill patients? Clin Infect acquired pneumonia in immunocompetent adults. Clin Infect Dis. 50. Faulkner CM, et al. Unique aspects of antimicrobial use in older adults. 31. Naughton BJ, et al. Treatment guideline for nursing home-acquired Clin Infect Dis. 2005;40(7):997-1004.
pneumonia based on community practice. J Am Geriatr Soc. 2000; 51. Jeffres MN, et al. Predictors of mortality for methicil in-resistant Staphy- lococcus aureus health-care–associated pneumonia: specific evaluation 32. Paladino JA, et al. Once-daily cefepime versus ceftriaxone for nursing of vancomycin pharmacokinetic indices. Chest. 2006;130(4):947-955.
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52. Field TS, et al. Risk factors for adverse drug events among nursing home 33. Centers for Disease Control and Prevention. Summary: interim recom- residents. Arch Intern Med. 2001;161(13):1629-1634.
mendations for the use of influenza antiviral medications in the setting 53. Kaufman DW, et al. Recent patterns of medication use in the ambula- of oseltamivir resistance among circulating influenza A (H1N1) viruses, tory adult population of the United States: the Slone survey. JAMA. 2008-09 influenza season. http://www.cdc.gov/flu/professionals/anti- virals/summary.htm. Accessed April 15, 2009.
54. Nguyen JK, Fouts MM, Kotabe SE, Lo E. Polypharmacy as a risk fac- 34. Smith NM, et al. Prevention and control of influenza: recommenda- tor for adverse drug reactions in geriatric nursing home residents. Am tions of the Advisory Committee on Immunization Practices (ACIP) J Geriatr Pharmacother. 2006;4(1):36-41.
[published correction appears in MMWR Morb Mortal Wkly Rep. 2006;55(29):800]. MMWR Recomm Rep. 2006;55(RR-10):1-42.
982  American Family Physician
Volume 79, Number 11June 1, 2009

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Woensdag 27-11-’96 Peter heeft last gehad van darmkrampen. Na het ontbijt begonnen we te pakken. De man van de tafellakens kwam langs. Wim ging onze terugreis bevesigen. Om 10u zouden we bericht I.v.m. ons terugreis krijgen. Ik vroeg Manney om de boodschapper om 2 kokosnoten : een in de bast en een andere zonder omhulsel te gaan kopen. We gaven Arun nog een pakje mignonetten en gaven fooien aan

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