Pulmonology Book

Bacterial Infections

  • Pneumonia in the Elderly

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Pneumonia in the ElderlyAka: Pneumonia Hospitalization Criteria in the Elderly, Pneumonia Prognostic Factors in Older Patients, Pneumonia Prevention in the Elderly, Pneumonia Management in the Nursing Home Resident

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  1. See Also
    1. Pneumonia
    2. Pneumonia Causes
    3. Pneumonia Management
  2. Causes in the Elderly
    1. Streptococcus Pneumoniae
    2. Haemophilus Influenzae
    3. Gram Negative Bacteria
    4. Staphylococcus aureus
    5. Chlamydia pneumoniae (less common in nursing home)
    6. Mycoplasma pneumoniae (less common in nursing home)
    7. Legionella (less common in nursing home)
  3. Signs and Symptoms: Probable Pneumonia in elderly (>1)
    1. New or worsening cough
    2. Newly Purulent Sputum
    3. Respiratory Rate >25 breaths per minute (bpm)
    4. Tachycardia
    5. New or worsening Hypoxia
    6. Pleuritic Chest Pain
    7. Cognitive or functional decline
    8. Change in respiratory exam (e.g. rales or rhonchi)
    9. Fever or temperature instability
      1. Temperature >100.5 F (38.1 C) or
      2. Temperature <96 F (35.6 C) or
      3. Temperature >2 F (1.1 C) over baseline
  4. Poor prognostic signs favoring hospitalization in Elderly
    1. Nursing home resident
    2. Comorbid conditions
      1. Neoplasm
      2. Chronic Renal Failure
      3. Liver Failure
      4. Congestive Heart Failure
      5. Prior Cerebrovascular Accident
    3. Vital Sign Changes
      1. Tachycardia over 124 beats per minute
      2. Tachypnea over 29 breaths per minute
      3. Hypotension with systolic Blood Pressure <90 mmHg
      4. Temperature under 35 C (95 F) or over 40 C (104 F)
    4. Diagnostic Changes
      1. Arterial Blood Gas (ABG)
        1. PaO2 <60 mmHg or Oxygen Saturation below 90%
      2. Complete Blood Count (CBC)
        1. White Blood Cell count <4000/mm3 or >13000/mm3
        2. Hematocrit under 30%
      3. Electrolytes
        1. Blood Urea Nitrogen (BUN) over 29 mg/dl
        2. Serum Glucose over 250 mg/dl
        3. Serum Sodium under 130 mEq/L
      4. Chest XRay Changes
        1. Multilobar infiltrates
        2. Infiltrate progression
        3. Pleural Effusion
  5. Hospitalization Indications in Nursing Home Residents
    1. Assumes that patient is willing to be hospitalized
    2. Indications for hospitalization (2 or more)
      1. Respiratory Rate >30 bpm or 10 bpm over baseline
      2. Oxygen Saturation <90% on room air
      3. Systolic BP <90 mmhg or 20 mm Hg below baseline
      4. Oxygen requirement >3 LPM over baseline
      5. Uncontrolled comorbidity
        1. Uncontrolled Chronic Obstructive Pulmonary Disease
        2. Uncontrolled Congestive Heart Failure
        3. Uncontrolled Diabetes Mellitus
      6. Altered Level of Consciousness
        1. New somnolence
        2. New or increased agitation
      7. Facility unable to care for patient
        1. Vital signs every 4 hours
        2. Lab access
        3. Parenteral hydration
        4. Licensed nursing available
    3. References
      1. Hutt (2002) J Fam Pract 51:709
  6. Management: Non-hospitalized nursing-home patients
    1. Amoxicillin-Clavulanate (Augmentin) 500 mg PO tid
    2. Levofloxacin (Levaquin) 500 mg PO daily
    3. Gatifloxacin (Tequin) 400 mg PO daily
    4. Moxifloxacin (Avelox) 400 mg PO daily
    5. Ceftriaxone 1000 mg IM daily
    6. Cefotaxime 500 mg IM q12 hours
    7. Marrie (2000) Clin Infect Dis 31:1066
  7. Prevention
    1. See Influenza Vaccine
    2. See Pneumococcal Vaccine
    3. Oral care in institutionalized elderly
      1. Toothbrushing for five minutes after each meal
        1. Brush teeth and Tongue dorsum
        2. Brush palate and mandibular mucosa
        3. Betadine applied to oropharynx if unable to brush
      2. Reduces Pneumonia Incidence and Pneumonia mortality
      3. References
        1. Yoneyama (2002) J Am Geriatr Soc 50:430
  8. References
    1. Furman (2004) Am Fam Physician 70:1495
    2. Muder (1998) Am J Med 105:319

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