Abstract
The incidence of community-acquired pneumonia (CAP), an infectious disease, sharply increases among the elderly and the main risk factor for CAP in this age group is chronic comorbidity. The use of the term CAP in the elderly population should be reserved for pneumonia acquired outside of the nursing home setting, since nursing home-acquired pneumonia differs from CAP in terms of its aetiology and clinical manifestations.
The main aetiology for CAP is Streptococcus pneumoniae, but atypical pathogens also play an important role as causative agents. The clinical presentations of CAP in the elderly can be different from those in younger patients, and therefore it is important to be aware of and familiar with these differences to avoid unnecessary delays in reaching the correct diagnosis. Imaging is essential to diagnose CAP and to assess its severity. Clinical and laboratory indices can be used to identify elderly patients with CAP who are at low risk for mortality and who can be treated as outpatients. The decision not to hospitalise elderly patients with CAP is contingent on a good clinical condition and the existence of home support systems. The aetiology of CAP cannot be determined on the basis of clinical manifestations, imaging or routine laboratory test results, and the initial antibiotic therapy for elderly patients with CAP should be empirical, based on accepted guidelines.
In the light of developments in recent years, elderly patients with CAP, except those who are severely ill, can be treated empirically with once-daily antibiotic monotherapy in the initial phase, using a third-generation fluoroquinolone preparation, such as sparfloxacin, levofloxacin or moxifloxacin, or a new macrolide such as clarithromycin, azithromycin or dirithromycin. In addition to antibiotic therapy, it is critically important to identify and treat the physiological disturbances that accompany CAP as well as decompensation of chronic comorbid conditions. As soon as the patient’s condition permits, oral antibiotic therapy should replace intravenous therapy and early discharge from the hospital should be considered. Since influenza and pneumococcus immunisation can reducemorbidity andmortality from CAP, it is important to implement regular immunisation programmes in the primary care setting.
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References
Marston BJ, Plouffe JF, File Jr TM, et al. Incidence of community-acquired pneumonia requiring hospitalization: results of a population-based active surveillance study in Ohio. The Community-Based Pneumonia Incidence Study Group. Arch Intern Med 1997; 157: 1709–18
Marrie TJ. Pneumonia in the elderly. Curr Opin Clin Med 1996; 2: 192–7
Marrie TJ, Blanchard W. A comparison of nursing home-acquired pneumonia patients with patients with community-acquired pneumonia and nursing home patients without pneumonia. J Am Geriatric Soc 1997; 45: 50–5
Fein AM, Feinsilver SH, Niederman MS. Atypical manifestation of pneumonia in the elderly. Clin Chest Med 1991; 12: 319–36
Garb JL, Brown RB, Garb JR, et al. Differences in etiology of pneumonias in nursing home and community patients. JAMA 1978; 240: 2169–75
Marrie TJ, Haldane EV, Faulkner RS, et al. Community-acquired pneumonia requiring hospitalization: is it different in the elderly? J Am Geriatric Soc 1985; 33: 671–80
Dhar S, Shastri SR, Lenora RAK. Aging and the respiratory system. Med Clin North Am 1976; 60: 1121–39
Goodman RM, Yerin BM, Landa JF, et al. Relationship of smoking history and pulmonary function tests to tracheal mucous velocity in nonsmokers, young smokers, ex-smokers, and patients with chronic bronchitis. Am Rev Respir Dis 1978; 117: 205–14
Riquelme R, Torres A, El-Ebiary M, et al. Community-acquired pneumonia in the elderly: a multivariate analysis of risk and prognostic factors. Am J Respir Crit Care Med 1996; 154: 1450–5
Torres A, Dorca J, Zalacain R, et al. Community-acquired pneumonia in chronic obstructive pulmonary disease: a Spanish multicenter study. Am J Respir Crit Care Med 1996; 54: 1456–61
Koivula I, Sten M, Makela PH. Risk factors for pneumonia in the elderly. Am J Med 1994; 96: 313–20
Lieberman D, Lieberman D, Schlaeffer F, et al. Community-acquired pneumonia in old age: a prospective study of 91 patients admitted from home. Age Ageing 1997; 26: 69–75
Granton JT, Grossman RF. Community-acquired pneumonia in the elderly patient: clinical features, epidemiology, and treatment. Clin Chest Med 1993; 14: 537–53
Venkatesan P, Glanoman J, Macfarlane JT, et al. Ahospital study of community acquired pneumonia in the elderly. Thorax 1990; 45: 254–8
Niederman MS, Fein AM. Pneumonia in the elderly. Geriatr Clin North Am 1986; 2: 241–68
Verghese A, Berk SL. Bacterial pneumonia in the elderly. Medicine 1983; 62: 271–85
White RJ, Blainey AD, Harrison KJ, et al. Causes of pneumonia presenting to a district general hospital. Thorax 1981; 36: 566–70
Fein AM, Niederman MS. Severe pneumonia in the elderly. Clin Ger Med 1994; 10: 121–43
Janssens JP, Gauthey L, Herrmann F, et al. Community-acquired pneumonia in older patients. J Am Geriatric Soc 1996; 44: 539–44
Fang GD, Fine M, Orloff J, et al. New and emerging etiologies for community-acquired pneumonia with implications for therapy: a prospective multicenter study of 359 cases. Medicine 1990; 69(5): 307–16
Cunha BA, Gingrich D, Rosenbaum GS. Pneumonia syndromes: a clinical approach in the elderly. Geriatrics 1990; 45: 49–55
Mylotte JM, Ksiazek S, Bently DW. Rational approach to the antibiotic treatment of pneumonia in the elderly. Drugs Aging 1994; 4: 21–33
Marik P, Careau P. The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: a prospective study. Chest 1999; 115: 178–83
Riquelme R, Torres A, El-Ebiary M, et al. Community-acquired pneumonia in the elderly: clinical and nutritional aspects. Am J Respir Crit Care Med 1997; 156: 1908–14
Musgrave T, Verghese A. Clinical features of pneumonia in the elderly. Semin Respir Infect 1990; 5: 269–75
Ahkee S, Srinath L, Ramirez J. Community-acquired pneumonia in the elderly: association of mortality with lack of fever and leukocytosis. South Med J 1997; 90: 863–4
Metlay JP, Schulz R, Li YH, et al. Influence of age on symptoms at presentation in patients with community-acquired pneumonia. Arch Intern Med 1997; 157: 1453–9
Esposito AL. Community-acquired bacteremic pneumococcal pneumonia: effect of age on manifestations and outcome. Arch Intern Med 1984; 144: 945–8
Syrjala H, Broad M, Suramo I, et al. High-resolution computed tomography for the diagnosis of community-acquired pneumonia. Clin Infect Dis 1998; 27: 358–63
Cassiere HA, Niederman MS. Community-acquired pneumonia. Dis Mon 1998; 44: 613–75
Tanaka H, Matsumoto T, Kuramitsu T, et al. High resolution CT findings in community-acquired pneumonia. J ComputAssist Tomogr 1996; 20: 600–8
Kauppinen MT, Lahde S, Syrjala H. Roentgenographic findings of pneumonia caused by Chlamydia pneumoniae: a comparison with streptococcal pneumonia. Arch Intern Med 1996; 156: 1851–6
Farr BM, Kaiser DL, Harrison BD, et al. Prediction of microbial aetiology at admission to hospital for pneumonia from the presenting clinical features. Thorax 1989; 44: 1031–5
American Thoracic Society. Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. Am Rev Respir Dis 1993; 148: 1418–26
Bartlett JG, Breiman RF, Mandell LA, et al. Community-acquired pneumonia in adults: guidelines for management. Clin Infect Dis 1998; 26: 811–38
Fine MJ, Auble TE, Yealy DM, et al. Aprediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336: 243–50
Porath A, Schlaeffer F, Lieberman D. Appropriateness of hospitalization of patients with community acquired pneumonia. Ann Emerg Med 1996; 27: 176–83
Padiglione AA, Willis J, Bailey M, et al. Characteristics of patients with community-acquired pneumococcal pneumonia. Med J Aust 1999; 170: 165–7
Finkelstein MS, Petkun WM, Freedman ML, et al. Pneumococcal bacteremia inadults: age-dependent differences in presentation and in outcome. J Am Geriatr Soc 1983; 31: 19–37
Ebright JR, Rytel MW. Bacterial pneumonia in the elderly. J Am Geriatr Soc 1980; 28: 220–3
McCue JD. Pneumonia in the elderly: special considerations in a special population. Postgrad Med 1993; 94: 39–51
Fein AM. Pneumonia in the elderly. Med Clin North Am 1994; 78: 1015–33
Norman DC. Pneumonia in the elderly: empiric antimicrobial therapy. Geriatrics 1991; 46: 26–32
Whitson B, Campbell Jr GD. Community-acquired pneumonia: new outpatient guidelines based on age, severity of illness. Geriatrics 1994; 49: 24–36
Brown RB. Community-acquired pneumonia: diagnosis and therapy of older adults. Geriatrics 1993; 48: 43–50
Lieberman D. Atypical pathogens in community-acquired pneumonia. Clin Chest Med 1999; 20: 489–97
Ewig S, Ruiz M, Torres A, et al. Pneumonia acquired in the community through drug-resistant Streptococcus pneumoniae. Am J Respir Crit Care Med 1999; 159: 1835–42
Edelstein PH. Antimicrobial chemotherapy for Legionnaires’ disease: a review. Clin Infect Dis 1995; 21Suppl. 3: S265–76
Ortquist A, Valtonen M, Cars O, et al. Oral empiric treatment of community-acquired pneumonia: a multicenter, double-blind, randomized study comparing sparfloxacin with roxithromycin. The Scandinavian Sparfloxacin Study Group. Chest 1996; 110: 1499–506
Donowitz GR, Brandon ML, Salisbury JP, et al. Sparfloxacin versus cefaclor in the treatment of patients with community-acquired pneumonia: a randomized, double-masked, comparative, multicenter study. Clin Ther 1997; 19: 936–53
Portier H, May T, Proust A. Comparative efficacy of sparfloxacin in comparison with amoxycillin plus ofloxacin in the treatment of community-acquired pneumonia: French Study Group. J Antimicrob Chemother 1996; 37Suppl. A: 83–91
File Jr TM, Segreti J, Dunbar L, et al. Amulticenter, randomized study comparing the efficacy and safety of intravenous and/or oral levofloxacin versus ceftriaxone and/or cefuroxime axetil in treatment of adults with community-acquired pneumonia. Antimicrob Agents Chemother 1997; 41: 1965–72
Balfour JA, Wiseman LR. Moxifloxacin. Drugs 1999; 57: 363–73
Lipsky BA, Baker CA. Fluoroquinolone toxicity profiles: a review focusing on newer agents. Clin Infect Dis 1999; 28: 352–64
Dunn CJ, Barradell LB. Azithromycin: a review of its pharmacological properties and use as 3-day therapy in respiratory tract infections. Drugs 1996; 51: 483–505
Langtry HD, Brogden RN. Clarithromycin: a review of its efficacy in the treatment of respiratory tract infections in immunocompetent patients. Drugs 1997; 53: 973–1004
Hernandez JM, Sides GD, Conforti PM, et al. Clinical efficacy of dirithromycin in patients with bacteremic pneumonia. Clin Ther 1996; 18: 1128–38
Genne D, Siegrist HH, Humair L, et al. Clarithromycin versus amoxicillin-clavulinic acid in the treatment of community-acquired pneumonia. Eur J Clin Microbiol Infect Dis 1997; 16: 783–8
Kuzman I, Soldo I, Schonwald S, et al. Azithromycin for treatment of community-acquired pneumonia caused by Legionella pneumophila: a retrospective study. Scand J Infect Dis 1995; 27: 503–5
Omidvari K, de Boisblanc BP, Karam G, et al. Early transition to oral antibiotic therapy for community-acquired pneumonia: duration of therapy, clinical outcomes, and cost analysis. Respir Med 1998; 92: 1032–9
Siegel RE, Halpern NA, Almenoff PL, et al. Aprospective randomized study of inpatient iv. antibiotics for community-acquired pneumonia: the optimal duration of therapy. Chest 1996; 110: 965–71
Rhew DC, Hackner D, Henderson L, et al. The clinical benefit of in-hospital observation in ‘low-risk’ pneumonia patients after conversion from parenteral to oral antimicrobial therapy. Chest 1998; 113: 142–6
Shapiro ED, Berg AT, Austrian R, et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med 1991; 325: 1453–60
Center for Disease Control. Control of influenza A outbreaks in nursing homes: amantadine as an adjunct to vaccine. MMWR Morbid Mortal Wkly Rep 1991; 40: 841–4
Ortquist A, Hedlund J, Burman LA, et al. Randomized trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people: Swedish Pneumococcal Vaccination Study Group. Lancet 1998; 351: 399–403
Niederman MS, McCombs JS, Unger AN, et al. The cost of treating community-acquired pneumonia. Clin Ther 1998; 20: 820–37
Fine MJ, Medsger AR, Stone RA, et al. The hospital discharge decision for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study. Arch Intern Med 1997; 157: 47–56
Fine MJ, Hough LJ, Medsger AR, et al. The hospital admission decision for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study. Arch Intern Med 1997; 157: 36–44
Whittle J, Lin CJ, Lave JR, et al. Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia. Med Care 1998; 36: 977–87
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Lieberman, D., Lieberman, D. Community-Acquired Pneumonia in the Elderly. Drugs & Aging 17, 93–105 (2000). https://doi.org/10.2165/00002512-200017020-00002
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DOI: https://doi.org/10.2165/00002512-200017020-00002