II. Epidemiology

  1. Community acquired Pneumonia affects >1 Million elderly per year in U.S,
    1. Hospitalization Relative Risk is 9 times higher for age 65-79 and 25 times higher for age >80 years
  2. Pneumonia is second most common Nursing Home acquired infection
    1. Incidence: 1 per 1000 patient-days

III. Pathophysiology

  1. Micro-aspiration is common in the elderly and likely contributes to Pneumonia pathophysiology
  2. Other factors
    1. Decreased cell mediated and humoral immunity
    2. Decreased lung compliance
    3. Decreased mucociliary clearance
    4. Comorbidities (COPD, CHF, Diabetes Mellitus, malnutrition)

IV. Risk Factors

  1. Community acquired Pneumonia (CAP) - uncomplicated approach
    1. Not in hospital or Nursing Home within prior 14 days
  2. Health-care associated Pneumonia (HCAP) - Atypical, multi-drug resistant (e.g. MRSA, DRSP, gram neg)
    1. Hospitalized for at least 2 days in the last 90 days
    2. Immunocompromised
    3. Nursing Home resident
    4. Patients with predisposing comorbidity
      1. Dialysis
      2. Chemotherapy
      3. Chronic wound
      4. Home intravenous antibiotics

V. Causes

  1. Most common (approach half of isolates in some centers)
    1. Gram Negative Pneumonia (associated with most serious cases)
    2. Pneumococcal Pneumonia (Streptococcus Pneumoniae, 5 times more prevalent in age >65 years)
  2. Common (approach one quarter to one third of isolates in some centers)
    1. Staphylococcal Pneumonia (associated with most serious cases, includes MRSA)
    2. Haemophilus Influenzae Pneumonia
    3. Chlamydophila pneumoniae (Chlamydia pneumoniae or TWAR, more common in Nursing Home)
  3. Less common (10% or less of isolates)
    1. Viral Pneumonia (especially Influenza A Virus, RSV)
    2. Pseudomonas aeruginosa Pneumonia
    3. Legionella pneumonia (more common in community than Nursing Home)
    4. Mycoplasma pneumoniae (more common in community than Nursing Home)

VI. Findings: Probable Pneumonia in elderly (>1)

  1. Precautions
    1. Pneumonia may present atypically in older patients (especially in Nursing Home)
      1. See Signs of Infection in the Nursing Home Resident
      2. Classic triad of fever, cough and Dyspnea is present in only one third of elderly with Pneumonia
    2. Even Nursing Home patients with Pneumonia have at least 1 respiratory symptom (92% cases)
      1. Mehr (2001) J Fam Pract 50(11): 931-7 [PubMed]
  2. New or worsening cough
  3. Newly Purulent Sputum
  4. Respiratory Rate >25 breaths per minute (bpm)
    1. Key Pneumonia indicator (Increased Test Sensitivity for Pneumonia in the Elderly)
  5. Tachycardia
  6. New or worsening Hypoxia
  7. Pleuritic Chest Pain
  8. Altered Mental Status or cognitive decline
  9. Functional decline
  10. Syncope or fall
  11. Change in Respiratory Exam (e.g. rales or rhonchi)
  12. Fatigue (common among presenting symptoms)
  13. Fever or Temperature instability (often absent in the elderly)
    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
  14. Oxygen Saturation (O2 Sat)
    1. O2 Sat <94% in Nursing Home residents with signs of infection predicts Pneumonia
      1. Test Sensitivity: 80%
      2. Test Specificity: 91%
      3. Kaye (2002) Am J Med Sci 324(5): 237-42 [PubMed]

VII. Imaging

  1. Chest XRay
    1. Less sensitive and specific in elderly
    2. Infiltrate frequently absent despite Pneumonia
      1. Decreased ability to mount inflammatory response
      2. Dehydration
    3. Infiltrate often obscured
      1. Congestive Heart Failure
      2. Chronic fibrotic changes (e.g. COPD)
  2. Chest CT
    1. Consider in unclear cases where Pneumonia suspected and definitive diagnosis will change management

VIII. Labs

  1. Complete Blood Count
  2. Sputum Gram Stain and Sputum Culture
    1. May be difficult to obtain in elderly
    2. Adequate samples (>25 PMNs/lpf) Test Sensitivity: 75%
  3. Consider urine antigen testing (Test Sensitivity 74%, Test Specificity 97-99%)
    1. Pneumococcal urine antigen test
    2. Legionella pneumophila urine antigen test
  4. Blood Culture indications
    1. Intensive care unit admission
    2. Cavitary lung infiltrates
    3. Leukopenia
    4. Active Alcohol Abuse
    5. Chronic severe liver disease
    6. Asplenia
    7. Pleural Effusion
  5. Other specific respiratory testing to consider
    1. Rapid Influenza Test (False Negative Rates approach 30%)
    2. FilmArray Respiratory Panel

IX. Evaluation: Disposition (outpatient versus hospitalization versus ICU admission)

  1. Severe Community Acquired Pneumonia Criteria (includes IDSA Minor Criteria)
    1. Indications for ICU admission
  2. Mortality Prediction Tool for Patients with Community Acquired Pneumonia (CURB-65)
    1. Consider as disposition triage tool used by both outpatient and emergency providers
      1. Clinic providers should consider transfer to ED, patient with Hypoxia or CURB-65 >=2
    2. Indications for outpatient, inpatient or ICU admission
    3. Caveats
      1. Over-emphasizes age as a risk factor, and therefore over-estimates mortality in the elderly
      2. Add Hypoxia as admission criteria (not included in CURB-65)
      3. Poor Test Sensitivity (use other prediction tools for low scores)
      4. High Test Specificity (strongly consider ICU admission for higher scores)
  3. Pneumonia Severity Index
    1. Indications for outpatient, observation or admission
    2. As with CURB-65, over-emphasizes age as an independent risk factor for mortality
  4. Pneumonia IRVS Prediction Tool (SMART-COP)
    1. Indications for ICU admission (predicts Mechanical Ventilation and pressor support)
  5. Pneumonia SOAR Score
    1. Disposition of Nursing Home resident with Pneumonia (outpatient, inpatient or ICU admission)

X. Criteria: Poor prognostic signs favoring hospitalization in Elderly overall (see below for Nursing Home dwelling elderly)

  1. See Pneumonia Management
  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

XI. Criteria: Hospitalization Indications in Nursing Home Residents

  1. SOAR Pneumonia Score is most predictive of 30 day mortality for Pneumonia in Nursing Home residents
    1. El-Solh (2010) Chest 138(6): 1371-6 [PubMed]
  2. Most nursing patients who meet stable criteria may be safely treated at Nursing Home
    1. Loeb (2006) JAMA 295(21): 2503-10 [PubMed]
    2. Kruse (2004) Med Care 42(9): 860-70 [PubMed]
  3. Determine if patient is willing to be hospitalized
    1. Review Advanced Directives, POLST form
    2. Confer with patient or their Durable Power of Attorney
  4. Indications for hospitalization (2 or more)
    1. Respiratory Rate >30 bpm or 10 bpm over baseline
    2. Heart Rate >100/min
    3. Oxygen Saturation <90% on room air
    4. Systolic BP <90 mmHg or 20 mm Hg below baseline
    5. Oxygen requirement >3 LPM over baseline
    6. Uncontrolled comorbidity
      1. Uncontrolled Chronic Obstructive Pulmonary Disease
      2. Uncontrolled Congestive Heart Failure
      3. Uncontrolled Diabetes Mellitus
    7. Altered Level of Consciousness
      1. New Somnolence
      2. New or increased agitation
    8. Facility unable to care for patient
      1. Vital Signs every 4 hours
      2. Lab access (not typically needed in uncomplicated cases)
      3. Parenteral hydration (patient unable to eat and drink)
      4. Licensed nursing available
  5. References
    1. Hutt (2002) J Fam Pract 51:709-16 [PubMed]

XII. Precautions

  1. SIRS negative Sepsis
    1. Elderly often do not mount fever response or Tachycardia despite serious infection
    2. SIRS criteria may therefore not be met despite Sepsis
    3. Pneumonia is the single most common cause of Sepsis in the elderly
    4. Err on the side of treating as Sepsis (even if SIRS negative), with early directed care and ICU admission
  2. Bacterial superinfection of Influenza is common (especially Staphylococcus aureus)
  3. Multi-drug resistance is common in the Nursing Home, especially
    1. Antibiotic use in the previous 3 months
    2. Hemodialysis or immunosuppresion
    3. Severe illness (Mechanical Ventilation, ICU admission, failure to improve after 72 hours)
    4. Airway Foreign Body
    5. Chronic wounds
    6. Very low functional status
  4. Avoid repeating antibiotics prescribed within the last 90 days
  5. MRSA colonization is common in Nursing Homes (Up to 75% in some centers)
  6. Pseudomonas is common in recently hospitalized patients and those with comorbidity
  7. Adverse Drug Reactions and drug interactions are common in Nursing Home residents
  8. Do not delay antibiotics after diagnosis
    1. Lower 30 day mortality when antibiotics are started within 4 hours of hospital diagnosis
    2. Houck (2004) Arch Intern Med 164(6): 637-44 [PubMed]

XIII. Management: Empiric Therapy

  1. See Pneumonia Management
  2. Antibiotic course
    1. Continue antibiotics for 7-10 days (7-8 days is sufficient in most cases) AND
    2. Affebrile and improving for at least 48-72 hours
  3. Additional antibiotic coverage
    1. Aspiration Pneumonia
    2. Legionella coverage
      1. Azithromycin
    3. Influenza management (within first 48 hours, consider empiric management despite negative Rapid Influenza Test)
      1. Oseltamivir (Tamiflu) or Zanamavir and
      2. Cover MRSA for staphycoccal Pneumonia superinfection
  4. Mild to moderate cases: Oral antibiotics
    1. Fluoroquinolone (e.g. Levofloxacin, Moxifloxacin) or
    2. Amoxicillin-clavulanate (Augmentin) and Azithromycin (Zithromax) or
    3. Cephalosporin (e.g. Cefuroxime, Cefpodoxime) and Azithromycin (Zithromax)
  5. Moderate cases: Initial Intramuscular Injections for 48-72 hours followed by oral therapy above
    1. Ceftriaxone (Rocephin) IM every 24 hours or
    2. Cefepime (Maxipime) IM every 24 hours
  6. Hospitalized cases: Moderate
    1. High risk patients for multi-drug resistance (see above) should be treated as below
    2. Nursing Home residents
      1. May be initially treated as community acquired Pneumonia
      2. Start with parenteral antibiotics with early transition to oral antibiotics
      3. Transition to broader coverage based if poor response to antibiotics at 72 hours
  7. Hospitalized cases: Severe (Triple antibiotic coverage)
    1. Antibiotic 1: Broad-spectrum antibiotic with antipseudomonal coverage
      1. Cefepime or Ceftazidime 2 grams IV every 8 hours or
      2. Imipenem or Meropenem 1 gram IV every 8 hours or
      3. Piperacillin-tazobactam 4.5 grams IV every 6 hours
    2. Antibiotic 2: Gram-Negative and antipseudomonal coverage
      1. Levofloxacin 750 mg every 24 hours or
      2. Ciprofloxacin 400 mg IV every 8 hours or
      3. Aminoglycoside (Gentamicin, Tobramycin, Amikacin)
        1. Exercise caution with Aminoglycoside use to higher renal injury risk and higher mortality
    3. Antibiotic 3: MRSA coverage
      1. Vancomycin or
      2. Linezolid

XIV. Prevention

  1. See Influenza Vaccine
  2. See Pneumococcal Vaccine
    1. Give both Prevnar and Pneumovax to over age 65 years
  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 PneumoniaIncidence and Pneumonia mortality
    3. References
      1. Yoneyama (2002) J Am Geriatr Soc 50:430-3 [PubMed]

XV. Prognosis

  1. Mortality rate over ensuing month: 10-30%
  2. Pneumonia in over 65 years old is responsible for 90% of Pneumonia fatalities

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