Characteristics and Management of Community-Acquired Pneumonia in the Era of Global Aging
Abstract
:1. Introduction
2. Epidemiology
3. Frailty in the Elderly: A Predisposing Risk Factor for CAP
- (A)
- Non-frail elderly patients with CAP: patients with no significant comorbidities or mental or social problems and able to perform basic and instrumental daily life activities independently.
- (B)
- Frail elderly patients with CAP: in this group, frailty is further differentiated into mild and moderate-severe.
3.1. Age-Related Changes (Immunosenescence and Sarcopenia)
4. Clinical Presentation of Pneumonia
5. Evaluation of Severity
6. Therapy
7. Prevention
7.1 Influenza Vaccine
7.2 Pneumococcal Vaccine
7.2.1. Current Advisory Committee on Immunization Practices (ACIP) Recommendations for PCV13 and PPV23 in Adults [87,88]
7.2.2. Current ACIP Recommendations for PCV13 and PPV23 in Patients Aged 19–64 Years with Immunocompromising Conditions or Anatomical or Functional Asplenia, Cerebrospinal Fluid Leaks or Cochlear Implants
- Pneumococcal vaccine-naïve: initial dose of PCV13 followed by one dose of PPV23 (≥8 weeks following dose of PCV13). A second dose of PPV23 is recommended five years after the first PPV23 dose for persons aged 19–64 with immunocompromising conditions or with anatomical or functional asplenia.
- Previously vaccinated with PPV23: one dose of PCV13 (≥1 year after receipt of most recent PPSV23 dose) followed by one dose of PPV23 (≥8 weeks following dose of PCV13 and ≥5 years since most recent dose of PPV23).
7.3 Other Preventive Measures:
- Higher consumption of alcohol (reduce alcohol consumption).
- Exposure to cigarette smoke (smoking cessation).
- Dental hygiene (improve oral hygiene and annual visits to the dentist).
- Being underweight (ensure good nutritional status).
- Contact with children (avoid contact with children with lower respiratory infections).
8. Conclusions
Acknowledgments
Conflict of Interest
References
- Barnett, K.; Mercer, S.W.; Norbury, M.; Watt, G.; Wyke, S.; Guthrie, B. Epidemiology of Multimorbidity and Implications for Health Care, Research and Medical Education: A Cross-Sectional Study. Lancet Lond. Engl. 2012, 7, 37–43. [Google Scholar] [CrossRef]
- Cillóniz, C.; Polverino, E.; Ewig, S.; Aliberti, S; Gabarrús, A.; Menéndez, R.; Mensa, J.; Blasi, F.; Torres, A. Impact of Age and Comorbidity on Cause and Outcome in Community-Acquired Pneumonia. Chest 2013, 144, 999–1007. [Google Scholar]
- Weiskopf, D.; Weinberger, B.; Grubeck-Loebenstein, B. The Aging of the Immune System. Transpl. Int. Off. J. Eur. Soc. Organ Transplant. 2009, 11, 1041–1050. [Google Scholar] [CrossRef] [PubMed]
- World Population Prospects: The 2017 Revision | Multimedia Library - United Nations Department of Economic and Social Affairs. Available online: https://www.un.org/development/desa/publications/world-population-prospects-the-2017-revision.html (accessed on 9 February 2018).
- Mandell, L.A.; Wunderink, R.G.; Anzueto, A.; Bartlett, J.G.; Campbell, G.D.; Dean, N.C.; Dowell, S.F.; File, T.M.J.; Musher, D.M.; Niederman, M.S.; et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am. 2007, 44, S27–72. [Google Scholar] [CrossRef] [PubMed]
- Ochoa-Gondar, O.; Vila-Córcoles, A.; De Diego, C.; Arija, V.; Maxenchs, M.; Grive, M.; Martin, E.; Pinyol, J.L.; EVAN-65 Studi Group. The Burden of Community-Acquired Pneumonia in the Elderly: The Spanish EVAN-65 Study. BMC Public Health 2008, 8, 222. [Google Scholar] [CrossRef] [PubMed]
- Vila-Corcoles, A.; Ochoa-Gondar, O.; Rodriguez-Blanco, T.; Raga-Luria, X.; Gomez-Bertomeu, F.; EPIVAC Study Group. Epidemiology of Community-Acquired Pneumonia in Older Adults: A Population-Based Study. Respir. Med. 2009, 103, 309–316. [Google Scholar] [CrossRef] [PubMed]
- Ewig, S.; Birkner, N.; Strauss, R.; Schaefer, E.; Pauletzki, J.; Bischoff, H.; Schraeder, P.; Welte, T.; Hoefken, G. New Perspectives on Community-Acquired Pneumonia in 388 406 Patients. Results from a Nationwide Mandatory Performance Measurement Programme in Healthcare Quality. Thorax 2009, 64, 1062–1069. [Google Scholar] [CrossRef] [PubMed]
- Jain, S.; Self, W.H.; Wunderink, R.G.; Fakhran, S.; Balk, R.; Bramley, A.M.; Reed, C.; Grijalva, C.G.; Anderson, E.J.; Courtney, C.M.; et al. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N. Engl. J. Med. 2015, 373, 415–427. [Google Scholar] [CrossRef] [PubMed]
- Ramirez, J.A.; Wiemken, T.L.; Peyrani, P.; Arnold, F.W.; Kelley, R; Mattingly, W.A.; Nakamatsu, R.; Pena, S.; Guinn, B.E.; Furmanek, S.P.; et al. Adults Hospitalized with Pneumonia in the United States: Incidence, Epidemiology & Mortality. Clin. Infect. Dis. 2017, 65, 1806–1812. [Google Scholar] [PubMed]
- Rozenbaum, M.H.; Mangen, M.J.J.; Huijts, S.M.; Van der Werf, T.S.; Postma, M.J. Incidence, Direct Costs and Duration of Hospitalization of Patients Hospitalized with Community Acquired Pneumonia: A Nationwide Retrospective Claims Database Analysis. Vaccine 2015, 33, 3193–3139. [Google Scholar] [CrossRef] [PubMed]
- Konomura, K.; Nagai, H.; Akazawa, M. Economic Burden of Community-Acquired Pneumonia Among Elderly Patients: A Japanese Perspective. Pneumonia Nathan Qld 2017, 9, 19. [Google Scholar] [CrossRef] [PubMed]
- Klausen, H.H.; Petersen, J.; Lindhardt, T.; Bandholm, T.; Hendriksen, C.; Kehlet, H.; Vestbo, J.; Andersen, O. Outcomes in Elderly Danish Citizens Admitted with Community-Acquired Pneumonia. Regional Differencties, in a Public Healthcare System. Respir. Med. 2012, 106, 1778–1787. [Google Scholar] [CrossRef] [PubMed]
- Mangen, M.J.J.; Huijts, S.M.; Bonten, M.J.M.; De Wit, G.A. The Impact of Community-Acquired Pneumonia on the Health-Related Quality-of-Life in Elderly. BMC Infect. Dis. 2017, 17, 208. [Google Scholar] [CrossRef] [PubMed]
- Morley, J.E.; Vellas, B.; Abellan Van Kan, G.; Anker, S.D.; Bauer, J.M.; Bernabei, R.; Cesari, M.; Chumlea, W.C.; Doehner, W.; Evans, J. Frailty Consensus: A Call to Action. J. Am. Med. Dir. Assoc 2013, 14, 392–397. [Google Scholar] [CrossRef] [PubMed]
- Clegg, A.; Young, J.; Iliffe, S.; Rikkert, M.O.; Rockwood, K. Frailty in Elderly People. Lance.t Lond. Engl. 2013, 381, 752–762. [Google Scholar] [CrossRef]
- Collard, R.M.; Boter, H.; Schoevers, R.A.; Oude Voshaar, R.C. Prevalence of Frailty in Community-Dwelling Older Persons: A Systematic Review. J. Am. Geriatr. Soc. 2012, 60, 1487–1492. [Google Scholar] [CrossRef] [PubMed]
- Kojima, G.; Iliffe, S.; Taniguchi, Y.; Shimada, H.; Rakugi, H.; Walters, K. Prevalence of Frailty in Japan: A Systematic Review and Meta-Analysis. J. Epidemiol. 2017, 27, 347–353. [Google Scholar] [CrossRef] [PubMed]
- Da Mata, F.A.F.; Pereira, da S.P.P.; Andrade, K.R.C.; De Figueiredo, A.C.M.G.; Silva, M.T.; Pereira, M.G. Prevalence of Frailty in Latin America and the Caribbean: A Systematic Review and Meta-Analysis. PloS One. 2016, 11, e0160019. [Google Scholar] [CrossRef] [PubMed]
- Polverino, E.; Dambrava, P.; Cillóniz, C.; Balasso, V.; Marcos, M.A.; Esquinas, C.; Mensa, J.; Ewig, S.; Torres, A. Nursing Home-Acquired Pneumonia: A 10 Year Single-Centre Experience. Thorax 2010, 65, 354–359. [Google Scholar] [CrossRef] [PubMed]
- Flaatten, H.; De Lange, D.W.; Morandi, A.; Andersen, F.H.; Artigas, A.; Bertolini, G.; Boumendil, A.; Cecconi, M.; Christensen, S.; Faraldi, L.; et al. The Impact of Frailty on ICU and 30-Day Mortality and the Level of Care in Very Elderly Patients (≥80 Years). Intensive Care Med. 2017, 43, 1820–1828. [Google Scholar] [CrossRef] [PubMed]
- Rockwood, K.; Song, X.; MacKnight, C.; Bergman, H.; Hogan, D.B.; McDowell, I.; Mitnitski, A. A Global Clinical Measure of Fitness and Frailty in Elderly People. CMAJ 2005, 173, 489–495. [Google Scholar] [CrossRef] [PubMed]
- González-Castillo, J.; Martín-Sánchez, F.J.; Llinares, P.; Menéndez, R.; Mujal, A.; Navas, E.; Barberán, J. Consensus Guidelines for the Management of Community Acquired Pneumonia in the Elderly Patient. Rev. Espanola Geriatr. Gerontol. 2014, 49, 279–291. [Google Scholar]
- Rubenstein, L.Z.; Stuck, A.E.; Siu, A.L.; Wieland, D. Impacts of Geriatric Evaluation and Management Programs on Defined Outcomes: Overview of the Evidence. J. Am. Geriatr. Soc 1991, 39, 8S–16S, discussion 17S–18S. [Google Scholar] [CrossRef] [PubMed]
- Martín-Sánchez, F.J.; Fernández-Alonso, C.; Gil-Gregorio, P. Key Points in Healthcare of Frail Elders in the Emergency Department. Med. Clin. (Barc). 2013, 140, 24–29. [Google Scholar] [CrossRef] [PubMed]
- Ebihara, S.; Ebihara, T.; Kohzuki, M. Effect of Aging on Cough and Swallowing Reflexes: Implications for Preventing Aspiration Pneumonia. Lung 2012, 190, 29–33. [Google Scholar] [CrossRef] [PubMed]
- Jackson, M.L.; Nelson, J.C.; Jackson, L.A. Risk Factors for Community-Acquired Pneumonia in Immunocompetent Seniors. J. Am. Geriatr Soc. 2009, 57, 882–888. [Google Scholar] [CrossRef] [PubMed]
- Almirall, J.; Rofes, L.; Serra-Prat, M.; Icart, R.; Palomera, E.; Arreola, V.; Clavé, P. Oropharyngeal Dysphagia is a Risk Factor for Community-Acquired Pneumonia in the Elderly. Eur. Respir. J. 2013, 41, 923–928. [Google Scholar] [CrossRef] [PubMed]
- Almirall, J.; Bolíbar, I.; Serra-Prat, M.; Roig, J.; Hospital, I.; Carandell, E.; Agurtí, M.; Ayuso, P.; Estela, A.; Torres, A.; et al. New Evidence of Risk Factors for Community-Acquired Pneumonia: A Population-Based Study. Eur. Respir. J. 2008, 31, 1274–1284. [Google Scholar] [CrossRef] [PubMed]
- El-Solh, A.A.; Sikka, P.; Ramadan, F.; Davies, J. Etiology of Severe Pneumonia in the Very Elderly. Am J Respir Crit. Care Med. 2001, 163, 645–651. [Google Scholar] [CrossRef] [PubMed]
- Maruyama, T.; Gabazza, E.C.; Morser, J.; Takagi, T.; D’Alessandro-Gabazza, C.; Hirohata, S.; Nakayama, S.; Ramirez, A.Y.; Fujiwara, A.; Naito, M.; et al. Community-Acquired Pneumonia and Nursing Home-Acquired Pneumonia in the Very Elderly Patients. Respir. Med. 2010, 104, 584–592. [Google Scholar] [CrossRef] [PubMed]
- Ewig, S.; Klapdor, B.; Pletz, M.W.; Rohde, G.; Schütte, H.; Schaberg, T.; Bauer, T.T.; Welte, T. Nursing-Home-Acquired Pneumonia in Germany: An 8-Year Prospective Multicentre Study. Thorax 2012, 67, 132–138. [Google Scholar] [CrossRef] [PubMed]
- Prina, E.; Ranzani, O.T.; Polverino, E.; Cillóniz, C.; Ferrer, M.; Fernandez, L.; Puig de la Bellacasa, J.; Menéndez, R.; Mensa, J.; Torres, A. Risk Factors Associated with Potentially Antibiotic-Resistant Pathogens in Community-Acquired Pneumonia. Ann Am Thorac. Soc. 2014, 12, 153–160. [Google Scholar] [CrossRef] [PubMed]
- Cillóniz, C.; Gabarrús, A.; Ferrer, M.; Puig de la Bellacasa, J.; Rinaudo, M.; Mensa, J.; Niederman, M.S.; Torres, A. Community-Acquired Pneumonia due to Multidrug and non-Multidrug Resistant Pseudomonas aeruginosa. Chest 2016. [Google Scholar] [CrossRef] [PubMed]
- Aliberti, S.; Cilloniz, C.; Chalmers, JD.; Zanaboni, A.M.; Cosentini, R.; Tarsia, P.; Pesci, A.; Blasi, F.; Torres, A.; et al. Multidrug-resistant pathogens in hospitalised patients coming from the community with pneumonia: A European perspective. Thorax 2013, 68, 997–999. [Google Scholar] [CrossRef] [PubMed]
- Fernández-Sabé, N.; Carratalà, J.; Rosón, B.; Dorca, J.; Verdaguer, R.; Manresa, F.; Guidol, F. Community-Acquired Pneumonia in Very Elderly Patients: Causative Organisms, Clinical Characteristics and Outcomes. Medicine (Baltimore) 2003, 82, 159–169. [Google Scholar] [CrossRef] [PubMed]
- Taylor, J.K.; Fleming, G.B.; Singanayagam, A.; Hill, A.T.; Chalmers, J.D. Risk Factors for Aspiration in Community-Acquired Pneumonia: Analysis of a Hospitalized UK Cohort. Am. J. Med. 2013, 126, 995–1001. [Google Scholar] [CrossRef] [PubMed]
- Viasus, D.; Núñez-Ramos, J.A.; Viloria, S.A.; Carratalà, J. Pharmacotherapy for Community-Acquired Pneumonia in the Elderly. Expert Opin. Pharmacother. 2017, 18, 957–964. [Google Scholar] [CrossRef] [PubMed]
- Froes, F.; Blasi, F.; Torres, A. Achoo, Achis, ATCHIN! Vaccine You…. Eur. Respir. J. 2018, 51. [Google Scholar] [CrossRef] [PubMed]
- Vestergaard, L.S.; Nielsen, J.; Krause, T.G.; Espenhain, L.; Tersago, K.; Bustos Sierra, N.; Denissov, G.; Innos, K.; Virtanen, M.J.; Fouillet, A.; et al. Excess All-Cause and Influenza-Attributable Mortality in Europe, December 2016 to February 2017. Euro. Surveill. 2017, 22. [Google Scholar] [CrossRef] [PubMed]
- Demicheli, V.; Jefferson, T.; Di Pietrantonj, C.; Ferroni, E.; Thorning, S.; Thomas, R.E.; Rivetti, A. Vaccines for Preventing Influenza in the Elderly. Cochrane Database Syst. Rev. 2018, 2, CD004876. [Google Scholar] [CrossRef] [PubMed]
- Torres, A.; Peetermans, W.E.; Viegi, G.; Blasi, F. Risk Factors for Community-Acquired Pneumonia in Adults in Europe: A Literature Review. Thorax 2013, 68, 1057–1065. [Google Scholar] [CrossRef] [PubMed]
- Weiskopf, D.; Weinberger, B.; Grubeck-Loebenstein, B. The Aging of the Immune System. Transpl. Int. 2009, 22, 1041–1050. [Google Scholar] [CrossRef] [PubMed]
- Ray, D.; Yung, R. Immune Senescence, Epigenetics and Autoimmunity. Clin. Immunol. 2018, 30210–30219. (In Press) [Google Scholar] [CrossRef] [PubMed]
- High, K.P. Nutritional Strategies to Boost Immunity and Prevent Infection in Elderly Individuals. Clin. Infect. Dis. 2001, 33, 1892–1900. [Google Scholar] [CrossRef] [PubMed]
- Ginde, A.A.; Blatchford, P.; Breese, K.; Zarrabi, L.; Linnebur, S.A.; Wallace, J.I.; Schwartz, R.S. High-Dose Monthly Vitamin D for Prevention of Acute Respiratory Infection in Older Long-Term Care Residents: A Randomized Clinical Trial. J. Am. Geriatr. Soc. 2017, 65, 496–503. [Google Scholar] [CrossRef] [PubMed]
- Li, Y.; Li, G. Is Vitamin C Beneficial to Patients with CAP? Curr. Infect. Dis. Rep. 2016, 18, 24. [Google Scholar] [CrossRef] [PubMed]
- Shlisky, J.; Bloom, D.E.; Beaudreault, A.R.; Tucker, K.L.; Keller, H.H.; Freund-Levi, Y.; Fielding, R.A.; Cheng, F.W.; Jensen, G.L.; Wu, D.; et al. Nutritional Considerations for Healthy Aging and Reduction in Age-Related Chronic Disease. Adv. Nutr. 2017, 8, 17–26. [Google Scholar] [CrossRef] [PubMed]
- Gariballa, S.; Alessa, A. Sarcopenia: Prevalence and Prognostic Significance in Hospitalized Patients. Clin. Nutr. 2013, 32, 772–776. [Google Scholar] [CrossRef] [PubMed]
- Landi, F.; Cruz-Jentoft, A.J.; Liperoti, R.; Russo, A.; Giovannini, S.; Tosato, M.; Capoluongo, E.; Bernabei, R.; Onder, G. Sarcopenia and Mortality Risk in Frail Older Persons Aged 80 Years and Older: Results from Ilsirente Study. Age Ageing 2013, 42, 203–209. [Google Scholar] [CrossRef] [PubMed]
- Tanimoto, Y.; Watanabe, M.; Sun, W.; Sugiura, Y.; Tsuda, Y.; Kimura, M.; Hayashida, I.; Kusabiraki, T.; Kono, K. Association Between Sarcopenia and Higher-Level Functional Capacity in Daily Living in Community-Dwelling Elderly Subjects in Japan. Arch Gerontol Geriatr. 2012, 55, 9–13. [Google Scholar] [CrossRef] [PubMed]
- Janssens, J.P. Pneumonia in the Elderly (Geriatric) Population. Curr. Opin. Pulm. Med. 2005, 1, 226–230. [Google Scholar] [CrossRef]
- Martinez, B.P.; Batista, A.K.; Gomes, I.B.; Olivieri, F.M.; Camelier, F.W.; Camelier, A.A. Frequency of Sarcopenia and Associated Factors Among Hospitalized Elderly Patients. BMC Musculoskelet Disord. 2015, 16, 108. [Google Scholar] [CrossRef] [PubMed]
- Vlietstra, L.; Hendrickx, W.; Waters, D.L. Exercise Interventions in Healthy Older Adults with Sarcopenia: A Systematic Review and Meta-Analysis. Australas. J. Ageing. 2018. [CrossRef] [PubMed]
- Cruz-Jentoft, A.J.; Kiesswetter, E.; Drey, M.; Sieber, C.C. Nutrition, Frailty, and Sarcopenia. Aging Clin. Exp. Res. 2017, 29, 43–48. [Google Scholar] [CrossRef] [PubMed]
- Gutiérrez, F.; Masiá, M. Improving Outcomes of Elderly Patients with Community-Acquired Pneumonia. Drugs Aging 2008, 25, 585–610. [Google Scholar] [CrossRef] [PubMed]
- Faverio, P.; Aliberti, S.; Bellelli, G.; Suigo, G.; Lonni, S.; Pesci, A.; Restrepo, M.I. The Management of Community-Acquired Pneumonia in the Elderly. Eur. J. Intern. Med. 2014, 25, 312–319. [Google Scholar] [CrossRef] [PubMed]
- Pieralli, F.; Vannucchi, V.; Mancini, A.; Grazzini, M.; Paolacci, G.; Morettini, A.; Nozzoli, C. Delirium is a Predictor of In-Hospital Mortality in Elderly Patients with Community Acquired Pneumonia. Intern. Emerg. Med. 2014, 9, 195–200. [Google Scholar] [CrossRef] [PubMed]
- Weir, D.L.; Majumdar, S.R.; McAlister, F.A.; Marrie, T.J.; Eurich, D.T. The Impact of Multimorbidity on Short-Term Events in Patients with Community-Acquired Pneumonia: Prospective Cohort Study. Clin. Microbiol. Infect. 2015, 21, 264–e7. [Google Scholar] [CrossRef] [PubMed]
- Murray, M.A.; Chotirmall, S.H. The Impact of Immunosenescence on Pulmonary Disease. Mediators Inflamm. 2015, 2015, 692546. [Google Scholar] [CrossRef] [PubMed]
- Solana, R.; Tarazona, R.; Gayoso, I.; Lesur, O.; Dupuis, G.; Fulop, T. Innate Immunosenescence: Effect of Aging on Cells and Receptors of the Innate Immune System in Humans. Semin. Immunol. 2012, 24, 331–341. [Google Scholar] [CrossRef] [PubMed]
- Nouvenne, A.; Ticinesi, A.; Folesani, G.; Cerundolo, N.; Prati, B.; Morelli, I.; Guida, L.; Lauretani, F.; Maggio, M.; Aloe, R.; et al. The Association of Serum Procalcitonin and High-Sensitivity C-Reactive Protein with Pneumonia in Elderly Multimorbid Patients with Respiratory Symptoms: Retrospective Cohort Study. BMC Geriatr. 2016, 16, 16. [Google Scholar] [CrossRef] [PubMed]
- Akirov, A.; Shimon, I. The Prognostic Significance of Admission Blood Glucose Levels in Elderly Patients with Pneumonia (GAP Study). J. Diabetes Complications 2016, 30, 845–851. [Google Scholar] [CrossRef] [PubMed]
- Cataudella, E.; Giraffa, C.M.; Di Marca, S.; Pulvirenti, A.; Alaimo, S.; Pisano, M.; Terranova, V.; Corriere, T.; Ronsisvalle, M.L.; Di Quattro, R.; et al. Neutrophil-To-Lymphocyte Ratio: An Emerging Marker Predicting Prognosis in Elderly Adults with Community-Acquired Pneumonia. J. Am. Geriatr. Soc. 2017, 65, 1796–1801. [Google Scholar] [CrossRef] [PubMed]
- Thiem, U.; Niklaus, D.; Sehlhoff, B.; Stückle, C.; Heppner, H.J.; Endres, H.G.; Pientka, L. C-Reactive Protein, Severity of Pneumonia and Mortality in Elderly, Hospitalised Patients with Community-Acquired Pneumonia. Age Ageing 2009, 38, 693–697. [Google Scholar] [CrossRef] [PubMed]
- Neupane, B.; Walter, S.D.; Krueger, P.; Marrie, T.; Loeb, M. Predictors of Inhospital Mortality and Re-Hospitalization in Older Adults with Community-Acquired Pneumonia: A Prospective Cohort Study. BMC Geriatr. 2010, 10, 22. [Google Scholar] [CrossRef] [PubMed]
- Luna, CM.; Palma, I.; Niederman, M.S.; Membriani, E.; Giovini, V.; Wiemken, T.L.; Peyrani, P.; Ramirez, J. The Impact of Age and Comorbidities on the Mortality of Patients of Different Age Groups Admitted with Community-Acquired Pneumonia. Ann. Am. Thorac. Soc. 2016, 13, 1519–1526. [Google Scholar] [CrossRef] [PubMed]
- Fine, M.J.; Auble, T.E.; Yealy, D.M.; Hanusa, B.H.; Weissfeld, LA.; Singer, D.E.; Coley, C.M.; Marrie, T.J.; Kapoor, W.N. A Prediction Rule to Identify Low-Risk Patients with Community-Acquired Pneumonia. N. Engl. J. Med. 1997, 336, 243–250. [Google Scholar] [CrossRef] [PubMed]
- Lim, W.S.; Van der Eerden, M.M.; Laing, R.; Boersma, W.G.; Karalus, N.; Town, G.I.; Lewis, S.A.; Macfarlane, J.T. Defining Community Acquired Pneumonia Severity on Presentation to Hospital: An International Derivation and Validation Study. Thorax 2003, 58, 377–382. [Google Scholar] [CrossRef] [PubMed]
- Chen, J.H.; Chang, S.S.; Liu, J.J.; Chan, R.C.; Wu, J.Y.; Wang, W.C.; Lee, S.H.; Lee, C.C. Comparison of Clinical Characteristics and Performance of Pneumonia Severity Score and CURB-65 Among Younger Adults, Elderly and Very Old Subjects. Thorax 2010, 65, 971–977. [Google Scholar] [CrossRef] [PubMed]
- Sanz, F.; Morales-Suárez-Varela, M.; Fernández, E.; Force, L.; Pérez-Lozano, M.J.; Martín, V.; Egurrola, M.; Castilla, J.; Astray, J.; Toledo, D.; et al. A Composite of Functional Status and Pneumonia Severity Index Improves the Prediction of Pneumonia Mortality in Older Patients. J. Gen. Intern. Med. 2018, 33, 437–444. [Google Scholar] [CrossRef] [PubMed]
- Pieralli, F.; Vannucchi, V.; De Marzi, G.; Mancini, A.; Bacci, F.; Para, O.; Nozzoli, C.; Falcone, M. Performance Status and In-Hospital Mortality of Elderly Patients with Community Acquired Pneumonia. Intern. Emerg. Med. 2018. [CrossRef] [PubMed]
- Oken, M.M.; Creech, R.H; Tormey, D.C.; Horton, J.; Davis, T.E.; McFadden, E.T.; Carbone, P.P. Toxicity and Response Criteria of the Eastern Cooperative Oncology Group. Am. J. Clin. Oncol. 1982, 5, 649–655. [Google Scholar] [CrossRef] [PubMed]
- Charles, P.G.P.; Wolfe, R.; Whitby, M.; Fine, M.J.; Fuller, A.J.; Stirling, R.; Wright, A.A.; Rapierz, J.A.; Christiansen, K.J.; Waterer, G.W.; et al. SMART-COP: A Tool for Predicting the Need for Intensive Respiratory or Vasopressor Support in Community-Acquired Pneumonia. Clin. Infect. Dis. 2008, 47, 375–384. [Google Scholar] [CrossRef] [PubMed]
- Al-Dorzi, H.M.; Tamim, H.M.; Mundekkadan, S.; Sohail, M.R.; Arabi, Y.M. Characteristics, Management and Outcomes of Critically Ill Patients who are 80 Years and Older: A Retrospective Comparative Cohort Study. BMC Anesthesiol. 2014, 14, 126. [Google Scholar] [CrossRef] [PubMed]
- Houck, P.M.; Bratzler, D.W.; Nsa, W.; Ma, A.; Bartlett, J.G. Timing of Antibiotic Administration and Outcomes for Medicare Patients Hospitalized with Community-Acquired Pneumonia. Arch. Intern. Med. 2004, 164, 637–644. [Google Scholar] [CrossRef] [PubMed]
- Daniel, P.; Rodrigo, C.; Mckeever, T.M.; Woodhead, M.; Welham, S.; Lim, W.S. Time to First Antibiotic and Mortality in Adults Hospitalised with Community-Acquired Pneumonia: A Matched-Propensity Analysis. Thorax 2016, 71, 568–570. [Google Scholar] [CrossRef] [PubMed]
- Lee, J.S.; Nsa, W.; Hausmann, L.R.M.; Trivedi, A.N.; Bratzler, D.W.; Auden, D.; Mor, M.K.; Baus, K.; Larbi, F.M.; Fine, M.J. Quality of Care for Elderly Patients Hospitalized for Pneumonia in the United States, 2006 to 2010. JAMA Intern. Med. 2014, 174, 1806–1814. [Google Scholar] [CrossRef] [PubMed]
- Lim, W.S.; Baudouin, S.V.; George, R.C.; Hill, A.T.; Jamieson, C.; Le Jeune, I.; Macfarlane, J.T.; Read, R.C.; Roberts, H.J.; Levy, M.L.; et al. BTS Guidelines for the Management of Community Acquired Pneumonia in Adults: Update 2009. Thorax 2009, 64 Suppl 3:iii, 1–55. [Google Scholar] [CrossRef]
- Woodhead, M.; Blasi, F.; Ewig, S.; Garau, J.; Huchon, G.; Ieven, M.; Ortgvist, A.; Schaberg, T.; Torres, A.; van der Heijden, G.; et al. Guidelines for the Management of Adult Lower Respiratory Tract Infections--Full Version. Clin. Microbiol. 2011, 17, E1–59. [Google Scholar] [CrossRef] [PubMed]
- Arnold, F.W.; LaJoie, A.S.; Brock, G.N.; Peyrani, P.; Rello, J.; Menéndez, R.; Lopardo, G.; Torres, A.; Rossi, P.; Ramirez, J.A.; et al. Improving Outcomes in Elderly Patients with Community-Acquired Pneumonia by Adhering to National Guidelines: Community-Acquired Pneumonia Organization International Cohort Study Results. Arch Intern. Med. 2009, 169, 1515–1524. [Google Scholar] [CrossRef] [PubMed]
- Torres, A.; Cillóniz, C.; Blasi, F.; Chalmers, J.D.; Gaillat, J.; Dartois, N.; Schmitt, H.J.; Welte, T. Burden of Pneumococcal Community-Acquired Pneumonia in Adults Across Europe: A Literature Review. Respir. Med. 2018, 137, 6–13. [Google Scholar] [CrossRef] [PubMed]
- Feldman, C.; Anderson, R. Recent Advances in our Understanding of Streptococcus Pneumoniae Infection. F1000Prime Rep. 2014, 6, 82. [Google Scholar] [CrossRef] [PubMed]
- Bonten, M.; Huijts, S.M.; Bolkenbaas, M.; Webber, C.; Patterson, S.; Gault, S.; van Werkhoven, C.H.; van Deursen, A.M.; Sanders, E.A.; Verheij, T.J.; et al. Polysaccharide Conjugate Vaccine against Pneumococcal Pneumonia in Adults. N. Engl. J. Med. 2015, 372, 1114–1125. [Google Scholar] [CrossRef] [PubMed]
- Kobayashi, M.; Bennett, N.M.; Gierke, R.; Almendares, O.; Moore, M.R.; Whitney, C.G.; Pilishvili, T. Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb. Mortal Wkly Rep. 2015, 64, 944–947. [Google Scholar] [CrossRef] [PubMed]
- Kim, D.K.; Bridges, C.B.; Harriman, K.H. Advisory Committee on Immunization Practices (ACIP), ACIP Adult Immunization Work Group. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2016. Morb. Mortal Wkly Rep. 2016, 16, 1930–1932. [Google Scholar]
- Egger, M.E.; Myers, J.A.; Arnold, F.W.; Pass, L.A.; Ramirez, J.A.; Brock, G.N. Cost Effectiveness of Adherence to IDSA/ATS Guidelines in Elderly Patients Hospitalized for Community-Aquired Pneumonia. BMC Med. Inform. Decis. Mak. 2016, 16. [Google Scholar] [CrossRef] [PubMed]
- Brown, P.D. Adherence to Guidelines for Community-Acquired Pneumonia: Does It Decrease Cost of Care? PharmacoEconomics 2004, 22, 413–420. [Google Scholar] [CrossRef] [PubMed]
- Torres, A.; Peetermans, W.E.; Viegi, G.; Blasi, F. Risk Factors for Community-Acquired Pneumonia in Adults in Europe: A Literature Review. Thorax 2013, 68, 1057–1065. [Google Scholar] [CrossRef] [PubMed]
Signs and Symptoms |
---|
Delirium/acute confusional status |
Decreased appetite |
Urinary incontinence |
Pleuritic pain |
Leukocytosis |
Shortness of breath |
Fever |
Cough |
Microorganism | Risk Factor |
---|---|
Streptococcus pneumoniae | Dementia, seizure disorders, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, HIV infection, black race, overcrowded living conditions, and smoking |
S. pneumoniae resistant to ß- lactam | Use of ß- lactam (prior 3-6 months), Prior hospitalization (3 months), Aspiration, Previous episodes of pneumonia in the last year, Non-invasive disease, >65 years old Attendance in day care, COPD |
S. pneumoniae resistant to macrolide | Recent macrolide use (prior 1-3 months), >65 years old, Attendance in day care centers, Recent hospitalization |
S. pneumoniae resistant to fluoroquinolones | Prior exposition to fluoroquinolones, Nursing home, Nosocomial infection, Penicillin resistance, COPD |
Staphylococcus aureus | Advanced age, underlying lung disease, and previous antibiotic use |
Methicillin-resistant Staphyloccus aureus (MRSA) | Previous MRSA infection or colonization, residence in a nursing home or extended-care facility, cerebrovascular disease, diabetes, chronic renal failure, hospitalization for ≥2 days in the preceding 90 days, prior intravenous antibiotic therapy within the last 30 days |
Community-acquired Methicillin-resistant Staphyloccus aureus (CA-MRSA) | History of viral upper respiratory infection, smoking, recent hospitalization, and chronic pulmonary disease |
Haemophilus influenzae | Chronic obstructive pulmonary disease treated with antibiotics or oral steroids within the previous 3 months |
Pseudomonas aeruginosa | Pulmonary comorbidity is the major risk factor |
Multidrug-resistant Pseudomonas aeruginosa | Prior antibiotic treatment (1 month) |
Microorganism | Frequency |
---|---|
Streptococcus pneumoniae | 10%–50% |
Intracellular bacteria | 2%–15% |
Haemophilus influenzae | 1%–10% |
Respiratory viruses | 2%–20% |
Pseudomonas aeruginosa | 1%–15% |
Staphylococcus aureus | 1%–7% |
Polymicrobial etiology | 2%–13% |
Enterobacteriaceae | 1%–3% |
Aspiration | 10% |
BTS Guidelines [64] |
Outpatients/Low Severity CURB-65 score of 0 to 1. Empirical therapy is primarily directed at S. pneumoniae. Treat with oral amoxicillin (preferred agent, dose of 500 mg, three times daily), or doxycycline, or clarithromycin for patients hypersensitive to penicillin. |
Inpatients Moderate Severity CURB-65 score of 2.Treat with oral amoxicillin plus clarithromycin. When oral therapy is contraindicated, the preferred parenteral choices include intravenous amoxicillin or benzylpenicillin, together with clarithromycin. Alternative for patients intolerant to penicillins or macrolides: doxycycline, moxifloxacin, or levofloxacin. IV recommendations include levofloxacin monotherapy, a second generation (e.g., cefuroxime), or a third-generation (e.g., cefotaxime or ceftriaxone) cephalosporin together with clarithromycin. |
Inpatients High Severity CURB-65 score of 3 to 5. Treat immediately after diagnosis. Treat with an intravenous combination of a broad-spectrum β-lactamase stable antibiotic such as co-amoxiclav, together with a macrolide, such as clarithromycin is preferred. In patients allergic to penicillin, a second-generation (e.g., cefuroxime) or third-generation (e.g., cefotaxime or ceftriaxone) cephalosporin can be used instead of co-amoxiclav, together with clarithromycin. Patients with Pseudomonas infection: ceftazidime plus gentamicin or tobramycin (dose monitored). Alternatively, ciprofloxacin or piperacillin, plus gentamicin or tobramycin (dose monitored). |
ATS/IDSA Guidelines [5] |
---|
Outpatients/low severity: PSI OR CURB-65 score to guide outpatient treatment. Treat previously healthy patients with low risk of drug-resistant pneumococci with a macrolide (azithromycin, clarithromycin, or erythromycin) (strong recommendation; level I evidence) or doxycycline (weak recommendation; level III evidence). Treat patients with a high risk of drug-resistant pneumococci with a fluoroquinolone or β-lactam plus macrolide. Presence of comorbidities, use of immunosuppressing drugs, use of antimicrobials within the previous three months, or other risks of DRSP infection: Treat with respiratory fluoroquinolone (moxifloxacin or levofloxacin [750 mg]) (strong recommendation; level I evidence). β-lactam plus a macrolide (high-dose amoxicillin [e.g., 1 g, three times daily] or amoxicillin-clavulanate [2 g, twice daily] is preferred; alternatives include ceftriaxone, cefpodoxime, and cefuroxime [500 mg, twice daily]; doxycycline [level II evidence] is an alternative to the macrolide) (strong recommendation; level I evidence). In regions with a high rate (>25%) of infection with high-level (MIC, ≥16 mg/mL) macrolide-resistant Streptococcus pneumoniae: Consider the use of alternative agents listed above for any patient, including those without comorbidities (moderate recommendation; level III evidence). |
Patients directly admitted to hospital: Treat with a respiratory fluoroquinolone (strong recommendation; level I evidence) or a β-lactam plus a macrolide (strong recommendation; level I evidence). Preferred β-lactam agents include cefotaxime, ceftriaxone, and ampicillin; ertapenem for selected patients; with doxycycline [level III evidence] as an alternative to the macrolide. A respiratory fluoroquinolone should be used for penicillin-allergic patients. |
Patients who require ICU admission: Treat with β-lactam (e.g., cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus either azithromycin (level II evidence) or a fluoroquinolone (level I evidence) (strong recommendation). Alternatively, a respiratory fluoroquinolone and aztreonam are recommended for penicillin-allergic patients. |
Patients with Pseudomonas infection: Treat with either an antipneumococcal, antipseudomonal β-lactam (e.g., piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750 mg dose are recommended), or the above β-lactam plus an aminoglycoside and azithromycin, or the above β-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone. For patients allergic to penicillin the above β-lactam should be substituted with aztreonam (moderate recommendation; level III evidence). Patients with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection: Add vancomycin or linezolid to standard CAP therapy (moderate recommendation; level III evidence). |
Low Severity | Moderate—High Severity |
---|---|
CURB-65 to guide outpatient treatment Treatment: * Aminopenicillin ± macrolide * Aminopenicillin/ß-lactamase inhibitora ± macrolide * Non-antipseudomonal cephalosporin II or III + macrolide * Cefotaxime or ceftriaxone ± macrolide * Penicillin G ± macrolide | ICU admission: acute respiratory failure, severe sepsis or septic shock and radiographic extension of infiltrates/ severely decompensated comorbidities No risk factors for Pseudomonas aeruginosa: Non-antipseudomonal cephalosporin III + macrolide or non-antipseudomonal cephalosporin III + moxifloxacin or levofloxacin Risk factors for P. aeruginosa: Antipseudomonal cephalosporin or acyl-ureido-penicillin/ß-lactamase inhibitor or carbapenem (meropenem preferred) plus ciprofloxacin or plus macrolide + aminoglycoside (gentamicin, tobramycin or amikacin) |
© 2018 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Cillóniz, C.; Rodríguez-Hurtado, D.; Torres, A. Characteristics and Management of Community-Acquired Pneumonia in the Era of Global Aging. Med. Sci. 2018, 6, 35. https://doi.org/10.3390/medsci6020035
Cillóniz C, Rodríguez-Hurtado D, Torres A. Characteristics and Management of Community-Acquired Pneumonia in the Era of Global Aging. Medical Sciences. 2018; 6(2):35. https://doi.org/10.3390/medsci6020035
Chicago/Turabian StyleCillóniz, Catia, Diana Rodríguez-Hurtado, and Antoni Torres. 2018. "Characteristics and Management of Community-Acquired Pneumonia in the Era of Global Aging" Medical Sciences 6, no. 2: 35. https://doi.org/10.3390/medsci6020035
APA StyleCillóniz, C., Rodríguez-Hurtado, D., & Torres, A. (2018). Characteristics and Management of Community-Acquired Pneumonia in the Era of Global Aging. Medical Sciences, 6(2), 35. https://doi.org/10.3390/medsci6020035