Community-Acquired Pneumonia in the Elderly 2010

H.B. Fung and M.O. Monteagudo-Chu The American Journal of Geriatric Pharmacotherapy

Volume 8 • Number 1 February 2010 47

Accepted for publication December 22, 2009. doi:10.1016/j.amjopharm.2010.01.003© 2010 Excerpta Medica Inc. All rights reserved. 1543-5946/$ - see front matter

Community-Acquired Pneumonia in the Elderly

Horatio B. Fung, PharmD1; and Maricelle O. Monteagudo-Chu, PharmD2

1Pharmacy Service, James J. Peters Veterans Affairs Medical Center, Bronx, New York; and 2Department of Pharmacy, Kingsbrook Jewish Medical Center, Brooklyn, New York

AbstrActBackground: Community-acquired pneumonia (CAP) is a frequent cause of hospitalization and death among the

elderly.Objective: This article reviews information on CAP among the elderly, including age-related changes, predispos-

ing risk factors, causes, treatment strategies, and prevention.Methods: Searches of MEDLINE (January 1990–November 2009), International Pharmaceutical Abstracts

(January 1990–November 2009), and Google Scholar were conducted using the terms community-acquired pneu-monia, pneumonia, treatment guidelines, and elderly. Additional publications were found by searching the reference lists of the identified articles. Studies that reported diagnostic criteria as well as the treatment outcomes achieved in adult patients with CAP were selected for this review.

Results: Three practice guidelines, 5 reviews, and 43 studies on CAP in the elderly were identified in the literature search. Based on those publications, risk factors that predispose the elderly to pneumonia include comorbid condi-tions, poor functional and nutritional status, consumption of alcohol, and smoking. The clinical presentation of pneumonia in the elderly (≥65 years of age) may be subtle, lacking the typical acute symptoms (fever, cough, dysp-nea, and purulent sputum) observed in younger adults. Pneumonia should be suspected in all elderly patients who have fever, altered mental status, or a sudden decline in functional status, with or without lower respiratory tract symptoms such as cough, purulent sputum, and dyspnea. Treatment of CAP in the elderly should be guided by the latest recommendations of the Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS), along with consideration of local rates and patterns of antimicrobial resistance, as well as individual patient risk fac-tors for acquiring less common or more resistant pathogens. Recommended empiric antimicrobial regimens gener-ally consist of either a β-lactam plus a macrolide or a respiratory fluoroquinolone alone. Adherence to the IDSA/ATS guidelines has been found to improve in-hospital mortality (adherence vs nonadherence, 8%; 95% CI, 7%–10% vs 17%; 95% CI, 14%–20%; P < 0.01), length of hospital stay (8 days; interquartile range [IQR], 5–15 vs 10 days; IQR, 6–24 days, respectively; P < 0.01), and time to clinical stability in elderly patients with CAP (percentage of stable patients by day 7, 71%; 95% CI, 68%–74% vs 57%; 95% CI, 53%–61%, respectively; P < 0.01). All elderly patients should be vaccinated against pneumococcal disease and influenza based on recommendations from the Centers for Disease Control and Prevention. Lifestyle modifications and nutritional support are also important elements in the prevention of pneumonia in the elderly.

Conclusion: Adherence to established guidelines, along with customization of antimicrobial therapy based on local rates and patterns of resistance and patient-specific risk factors, likely will improve the treatment outcome of elderly patients with CAP. (Am J Geriatr Pharmacother. 2010;8:47–62) © 2010 Excerpta Medica Inc.

Key words: community-acquired pneumonia, pneumonia, pneumonia prevention, elderly.

The American Journal of Geriatric Pharmacotherapy H.B. Fung and M.O. Monteagudo-Chu

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IntroductIonPneumonia is the most frequent cause of infectious disease–related mortality among patients of all ages and the eighth leading cause of death in the United States.1 Along with influenza, pneumonia accounted for 56,326 deaths, with a crude death rate of 2.3% in 2006. Pneumonia in patients who have not been hospitalized or a resident of a long-term care facility for >14 days before the onset of symptoms is considered community-acquired pneumonia (CAP).2

CAP is a common disease and a frequent cause of hospitalization and death among the elderly.3–5 (Through-out this review, the term elderly is defined as persons ≥65 years of age unless otherwise specified.) The inci-dence of CAP increases substantially with age, with pa-tients >60 years of age accounting for 81.2% of all cases. The rate of hospitalization due to CAP increases with every decade of life until the eighth decade.3 According to a retrospective cohort study that included 46,237 el-derly patients of a health maintenance organization in Washington state, the rate of CAP rose from 18.2 cases/1000 person-years among patients aged 65 to 69 years to 52.3 cases/1000 person-years among patients aged ≥85 years.4 In the United States, ~915,900 episodes of CAP occurred each year between March 1, 1998, and February 28, 2001 in the elderly, 40.1% of which re-quired admission to a hospital. In 1997, CAP accounted for 623,718 hospital admissions among Medicare re-cipients (18.3 per 1000 population >65 years of age), with an overall mortality rate of 10.6%. The mortality rate roughly doubled as age increased from 65 to 69 years to >90 years.5 In fact, age was the most important prog-nostic factor in 30-day mortality outcome according to an analysis of 14,199 adult inpatients with CAP.6 The mean length of stay (LOS) per hospital admission was 7.6 days, with a mean cost of US $6949 per person (1997 value).5 This is consistent with the results of a retrospective analysis by Niederman et al,7 which report-ed that the mean hospital LOS and costs were 7.8 days and US $7166 per person (1995 value) in patients >65 years of age. In these 2 studies,5,7 the overall annual hospital costs for CAP in elderly patients in the United States ranged from $4.4 to $4.8 billion, posing a tre-mendous burden on the health care system.

This article reviews information on CAP in the el-derly, including age-related changes, predisposing risk factors, causes, treatment strategies, and prevention.

MethodsRelevant information was identified through a search of MEDLINE (January 1990–November 2009), Inter-

national Pharmaceutical Abstracts (January 1990–November 2009), and Google Scholar, using the terms community-acquired pneumonia, pneumonia, treatment guidelines, and elderly. National treatment guidelines were obtained through the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) Web sites.8,9 Additional publications were found by searching the reference lists of the identified articles. Studies that reported diagnostic criteria as well as the treatment outcomes achieved in adult patients with CAP were selected for this review.

resuLtsLimited prospective clinical data are available for el-derly patients with CAP. Of the 3 practice guidelines, 5 reviews, and 43 clinical studies on CAP that were iden-tified in the literature search, only 6 prospective trials or subgroup analyses of prospective trials evaluated the efficacy of an antimicrobial agent for the treatment of CAP exclusively in the elderly. Principal findings of those 6 clinical trials are summarized in Table I.10–15

Age-related changesAdvanced age was found to be one of the most im-

portant risk factors for pneumonia. A 3-year multi-center surveillance study16 that included 254 nursing home residents (mean age, 86.1 years; 75.6% female; mean length of residence, 3.2 years) was designed to determine whether age was an independent risk factor for CAP. The study reported 272 episodes of health care–associated pneumonia and other lower respiratory tract infections. Age was found to be an independent risk factor for pneumonia (odds ratio [OR] = 1.7; 95% CI, 1.1–2.6 per 10-year interval; P = 0.01), after con-trolling for confounding variables such as comorbid conditions, immobility, and the use of tranquilizers. El-derly persons are more susceptible to pneumonia be-cause of anatomic and physiologic changes that occur in the lungs with age.17,18 Aging is associated with a progressive decrease in pulmonary function, including declines in elastic recoil of the lungs, chest wall compli-ance, and respiratory muscle strength.18 In addition, with age, a gradual enlargement of the alveoli leads to an increase in residual volume, which further increases the workload on respiratory muscles. All these changes contribute to a diminished cough reflex in the elderly. The gag reflex is decreased along with the altered cough reflex, leading to ineffective mucociliary clear-ance of respiratory secretions.17,18

Increased colonization of the oropharynx with respi-ratory pathogens was found to be a common phenom-

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Table I. Selected clinical trials conducted exclusively in subjects aged ≥65 years with community-acquired pneumonia.10–15

Principal Findings

StudyStudy

DesignSample

Size InterventionClinical Cure, % P

Bacterial Eradication, % P Comments

Woods et al, 200310

P, R, DB, MC, C

148 Ertapenem 1 g IV QD x 7–14 d

93.9 0.34 92.8 NA Combined data analyses on patients aged >65 y from 2 CAP trials

125 Ceftriaxone 1 g IV QD x 7–14 d

90.4 93.2

Anzueto et al, 200611

P, R, DB, C 141 Moxifloxacin 400 mg IV/PO QD x 7–14 d

92.9 0.2 81.0 0.9 No difference in efficacy or tolerability

140 Levofloxacin 500 mg IV/PO QD x 7–14 d

87.9 75.0

Shorr et al, 200512

R, DB, MC 80 Levofloxacin 750 mg IV/PO QD x 5 d

89.0 0.78 90.3 NA Retrospective subgroup analysis of a CAP trial on patients aged >65 y

97 Levofloxacin 500 mg IV/PO QD x 10 d

91.9 87.5

Grossman et al, 199913

P, R, DB, C 67 Cefepime 2 g IV BID x 3–14 d

79.1 0.62 98.5 NA No difference in efficacy or tolerability

71 Ceftriaxone 1 g IV BID x 3–14 d

75.4 100.0

Yanagihara et al, 200614

P, R, C 35 Ampicillin/sulbactam 3 g IV BID x 7–14 d

91.4 NA 84.0 NA Mild to moderate CAP treated according to Japanese Respiratory Society Guideline

32 Imipenem/cilastatin 500 mg IV BID x 7–14 d

87.5 80.0

Okimoto et al, 200515

P 30 Gatifloxacin 100 mg PO BID x 4–14 d

96.7 NA 93.3 NA Mild to moderate CAP treated as outpatients

P = prospective; R = randomized; DB = double blind; MC = multicenter; C = comparative; NA = not available; CAP = community-acquired pneumonia.


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Environmental risk factors for CAP were studied in 717 elderly patients who presented to emergency de-partments in Ontario and Alberta, Canada.25 They were compared with 867 elderly controls randomly se-lected from the same communities. Exposure to sec-ondhand smoke, gases, fumes, or chemicals were found to be risk factors for CAP by multivariate logistic re-gression analyses. Patients who were receiving immu-nosuppressants, had poor nutritional status, used alco-hol (amount not quantified but risk presented as per 5-g increase in consumption/month during the previ-ous 12 months), or smoked were also at risk for CAP. Dysphagia and renal disease also were found to be in-dependent risk factors for CAP after adjusting for po-tential confounders.25 Independent risk factors for CAP in the elderly are summarized in Table III.24,25

Other independent risk factors for CAP have also been identified: contact with children, sudden changes in temperature at work, inhalation therapy, oxygen

enon in the elderly that has been attributed to a decrease in salivary clearance and abnormalities in swallowing.19

A progressive decline in host defenses also contributes to the increase in bacterial colonization. Changes in the immune system associated with aging involve, in par-ticular, a decline in peripheral antigen-specific T- and B-cell function, with decreased activation to presenting antigens. Functions of natural killer cells, macrophages, and neutrophils are also decreased in the elderly.20 Fur-thermore, elderly persons tend to have physiologic or drug-associated achlorhydria, which allows survival and proliferation of bacteria that would otherwise be de-stroyed in the stomach.

Silent aspiration of gastric and oropharyngeal con-tents into the respiratory tract is an important mecha-nism in the pathogenesis of pneumonia among older adults (≥65 years).17 Five of 10 healthy men 22 to 55 years of age aspirated a small amount of oropharyn-geal content during sleep in a study in which radioac-tive tracer was introduced into the nasopharynx.21 Force-ful coughing, active mucociliary transport, and a normal immune system in younger adults result in clearance of the inoculum without any sequelae.17 Kikuchi et al22

investigated the occurrence of silent aspiration during sleep in 14 elderly patients (mean age not available) with an acute episode of pneumonia. Aspiration con-firmed by an indium111 marker was documented in 10 of the 14 patients. In a multicenter prospective study, the incidence of aspiration pneumonia was 80.1% (306/382) among hospitalized Japanese patients aged ≥70 years.23 The high rate of aspiration in the elderly presumably is related to an increased incidence of dys-phagia due to strokes and other degenerative neuro-logic diseases.17 Chronic comorbidities, tube-feeding, tracheostomy, and the use of sedatives could also impair swallowing and cough reflex, increasing the risk of aspiration.17,18 Table II summarizes the age-related changes that predispose the elderly to pneumonia.17–20

risk FactorsMany investigators have attempted to identify inde-

pendent risk factors for CAP in the elderly.24,25 Jackson et al24 analyzed 1173 immunocompetent patients 65 to 94 years of age with CAP and 2346 age- and sex-matched controls without CAP enrolled in a health mainte-nance organization in western Washington state. The in-dependent predictors for CAP included lung disease (chronic obstructive pulmonary disease and/or asth-ma), congestive heart failure (CHF), non-CHF heart disease, a >10% weight loss from baseline (time frame not specified), poor functional status, and smoking.

Table II. Age-related changes that predispose the elderly to pneumonia.17–20

Predisposing Factor Age-Related Change

Decreased mucociliary Decline in pulmonary functionclearance ↓ Chest wall compliance (stiff chest wall) ↓ Elastic recoil of lungs ↓ Respiratory muscle strength ↑ Residual volume Decreased cough reflex Decreased gag reflex

Increased colonization Impaired immunityof oropharynx with ↓ Adaptive immune respiratory pathogens function ↓ Antigen-specific T- and B-cell activity ↓Antigen-presenting function ↓ Innate immune function ↓ Natural killer cells ↓ Macrophages ↓ Neutrophils Decreased salivary clearance

Proliferation of bacteria Achlorhydriain gastric contents Physiologic Drugs (histamine [H2] blockers, proton-pump inhibitors)

Increased aspiration Dysphagia


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derly Medicare recipients with CAP,5 a microbiologic etiology was not identified in more than two thirds of the patients. Even in prospective studies in which the microbiologic etiology of CAP was systematically sought in the elderly, a definite or presumptive patho-gen was often reported in <60% of the patients.10,32–34

Streptococcus pneumoniae is the most common etiol-ogy of CAP in the elderly.10,32–35 Other common patho-gens include Haemophilus influenzae, enteric gram-negative bacilli, respiratory viruses, the atypical organisms, Staphylococcus aureus, Pseudomonas aeruginosa, and Mo-raxella catarrhalis, although the relative prevalence of each tends to vary among studies.10,32–35

The incidence of pneumococcal pneumonia generally increases with age.36,37 In a 2-year, population-based, prospective cohort study36 conducted in 3 municipali-ties on the Mediterranean coast of Spain, the rate of pneumococcal pneumonia among patients ≥75 years of age (n = 12,921; 60.5% female) was double that of patients 65 to 74 years of age (n = 18,329; 53.4% fe-male) (10.06 cases; 95% CI, 6.72–14.98 per 10,000 pa-tients vs 4.64 cases; 95% CI, 2.80–7.61 per 10,000 pa-tients; P < 0.001, respectively).36

The prevalence of CAP due to influenza viruses also was higher in German patients ≥65 years of age (n = 1349) than in those <65 years (n = 1298) in a multi-

therapy, asthma, chronic bronchitis, and the use of gas-tric acid-suppressants.26–28 Of note, the risk of CAP was reported to decrease with the use of statins (adjust-ed OR = 0.78; 95% CI, 0.65–0.94; P < 0.05) and angiotensin-converting enzyme inhibitors (ACEIs; ad-justed OR = 0.75; 95% CI, 0.65–0.86; P < 0.05).28

Nevertheless, those risk factors have not been specifi-cally studied in the elderly population.

etiologyDespite extensive diagnostic procedures and testing,

identification of the exact etiology of CAP remains problematic. This is particularly true in the elderly, be-cause they may not produce sputum, and even if they do, the amount may not be sufficient for examination and culture.29 Moreover, given the high rate of bacte-rial colonization of the oropharynx in the elderly, it is a challenge to distinguish causative pathogens from colo-nized organisms with specimens obtained from the upper respiratory tract. In clinical practice, invasive di-agnostic procedures such as flexible fiberoptic bron-choscopy for protected specimen brush sampling and bronchoalveolar lavage are used to obtain specimens for etiologic testing, but these procedures are not per-formed routinely in this patient population.29–31 In an observational cohort study of 623,718 hospitalized el-

Table III. Independent risk factors for community-acquired pneumonia in the elderly.24,25

Risk Factor Odds Ratio (95% CI) P

Patient characteristic/lifestyle Smoking 2.01 (1.26–3.36) 0.004 Alcohol use* 1.69 (1.08–2.61) 0.006 Dysphagia 3.76 (1.60–8.88) 0.002 Poor functional status 7.94 (3.77–16.69) <0.001 Poor nutritional status 1.83 (1.19–2.80) 0.006 >10% Weight loss from baseline† 1.9 (1.3–2.6) <0.05 Use of immunosuppressants 15.13 (4.74–48.29) <0.001Comorbid condition CHF 2.07 (1.22–3.49) 0.007 Non-CHF heart disease 1.2 (1.1–1.4) <0.05 Renal disease 4.05 (1.98–8.35) <0.001 Chronic obstructive pulmonary disease 13.53 (7.80–23.48) <0.001Environmental exposure Secondhand smoke 1.76 (1.04–2.90) 0.04 Gases, fumes, or chemicals 3.69 (2.37–5.75) <0.001

CHF = congestive heart failure.*Odds ratio is per 5-g increase in consumption/month during the previous 12 months.†Time frame not specified.


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for all comparisons). After controlling for patient de-mographics, comorbidities, and severity of illness, el-derly patients exhibited significantly fewer respiratory symptoms than did younger patients (respiratory symp-tom score, 7.21 vs 9.79, respectively; P < 0.01).

In an analysis of observational data from 1474 adult patients hospitalized with CAP in Barcelona, Spain, al-tered mental status and the absence of fever were ob-served more frequently in patients ≥80 years of age than in those <80 years of age (21.0% vs 10.7%; P < 0.001 and 32.1% vs 21.9%; P < 0.001, respectively). Other adverse effects also were significantly less com-mon in patients ≥80 years of age than in younger coun-terparts (pleuritic chest pain: 36.4% vs 45.2%; P = 0.007; myalgia: 7.9% vs 22.5%; P < 0.001; and headache: 6.6% vs 21.0%; P < 0.001).42 These findings are consistent with the results of a CAP study of 59 patients >65 years of age and 21 patients <65 years of age conducted by Kelly et al,43 which reported a higher incidence of con-fusion but a lower incidence of pleuritic chest pain in the older patients (27.1% vs 4.8%; P = 0.03 and 23.7% vs 66.7%; P < 0.001, respectively). In another study,44

17 of 64 elderly patients (mean age, 72.1 years) hospi-talized with CAP had no fever or leukocytosis.

It appears that the manifestations of CAP are atypical in the elderly. The classic symptoms of cough, purulent sputum, dyspnea, and fever may be absent. Further-more, it has been suggested that the local inflammatory response to infection of the lungs is decreased in the elderly, resulting in less cough and sputum produc-tion.44 The systemic inflammatory response (ie, fever, leukocytosis) is also reduced secondary to decreased production of cytokines. Nevertheless, the decrease in interleukin-6 (IL-6), the most prevalent mediator of fever, did not reach statistical significance in a study that measured IL-6 levels in 59 elderly patients (≥65 years) and 21 younger patients with CAP (211.6 vs 284.5 pg/mL, respectively).43 In contrast, tachypnea remains prevalent and appears to be a sensitive indicator of lower respira-tory tract infection in the elderly.30 Altered mental sta-tus, confusion, a sudden decline in functional physical capacity, and decompensation of the underlying illness may be the only symptoms of an infection (including pneumonia) in the elderly.39 Clinicians should be cog-nizant of those symptoms to avoid delay in establishing the diagnosis and initiating antibiotic therapy.

Prognostic rules for severity AssessmentCAP encompasses a spectrum of illnesses ranging

from mild, self-limiting ailments to life-threatening diseases. Severity assessment is therefore crucial in de-

center prospective study (14.8% vs 5.9%, respectively; P = 0.001).37 In contrast, the incidence of CAP due to Mycoplasma pneumoniae is generally lower in the older adults (≥60 years of age) than in their younger counter-parts (0.7% vs 14.0%, respectively; P < 0.001; OR for Mycoplasma CAP in young adults = 5.3; 95% CI, 1.7–16.8).38

Among elderly individuals who aspirated and devel-oped pneumonia subsequently, gram-negative bacilli were the predominate organisms (49%), followed by anaerobic bacteria (16%) and S aureus (12%), based on a prospective study of aspiration pneumonia in institution-alized elderly subjects (n = 95; mean age, 80.0 years).34

However, it must be noted that results from this study, which was conducted in an institutionalized setting, cannot be applied directly to elderly patients who de-velop aspiration pneumonia while at home.

clinical PresentationThe clinical presentation of pneumonia in the elderly

may be subtle, lacking the typical acute symptoms ob-served in younger adults. Riquelme et al39 reported the initial clinical presentation of 101 elderly patients with CAP (mean age, 78 years; 66.3% men) who were ad-mitted to a 1000-bed teaching hospital in Barcelona, Spain. The most frequently observed symptoms were dyspnea (72.3%), cough (66.3%), fever (63.4%), asthe-nia (57.4%), purulent sputum (51.5%), anorexia (49.5%), altered mental status (44.6%), and pleuritic chest pain (33.7%). The classic triad of symptoms of pneumonia—cough, dyspnea, and fever—was observed in only 30.7% of these elderly patients. Nineteen patients (18.8%) did not have cough, purulent sputum, or pleuritic chest pain.

In a prospective study40 designed to assess the clini-cal characteristics of 503 elderly patients (mean age, 76.3 years; 63.4% men) admitted to 16 hospitals lo-cated in 10 cities across Spain (Bilbao, Valencia, Ma-drid, Barcelona, Huesca, Oviedo, Logrono, Albacete, Zaragoza, and Santa Cruz) for CAP, the most frequently observed symptoms were cough (80.9%), fever (75.5%), dyspnea (69.8%), sputum production (65.8%), chills (53.1%), pleural pain (43.3%), asthenia (38.6%), and altered mental status (25.8%). The typical constellation of symptoms of CAP (cough, purulent sputum, and pleural pain) was noted in only 152 patients (30.2%).

Metlay et al41 studied the influence of age on symp-toms at presentation in 1812 patients with CAP. Cough, dyspnea, and pleuritic chest pain were signifi-cantly less common among patients ≥65 years of age than among younger patients (81.7% vs 87.8%, 68.8% vs 73.9%, and 31.6% vs 53.3%, respectively; P < 0.05


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currently established guidelines for treatment were not specifically developed for the elderly. Unless otherwise specified, some of the studies discussed in the following sections may have been conducted in adults in general.

Diagnostic EvaluationsBecause the classic symptoms may not be present,

diagnosing pneumonia in the elderly remains a chal-lenge to clinicians. Pneumonia should be suspected in all elderly patients who have fever, altered mental sta-tus, and a sudden decline in functional status, with or without lower respiratory tract symptoms such as cough, purulent sputum, and dyspnea.39 A chest radio-graph is recommended as part of the routine evalua-tions to establish the diagnosis for all patients, to iden-tify complications such as pleural effusion and multilobar disease, and to differentiate CAP from other common causes of cough and fever such as bronchitis.30,50 El-derly patients admitted to the hospital generally should have blood and sputum samples collected for Gram staining and cultures. Urinary antigen tests for Legion-ella and pneumococcus are usually reserved for patients who fail outpatient antibiotic therapy, have pleural ef-fusion or other comorbidities, or are treated in an in-tensive care unit.50 Because the yield from sputum Gram staining and cultures is greatly affected by the quality of the specimen, obtaining a good sample from the patient is essential.51 This may be extremely chal-lenging among the frail elderly, who usually have more difficulty in producing sputum. The etiology of CAP, however, is valuable in the critically ill, especially when it reveals unusual or drug-resistant pathogens, leading to a change in the initial empiric antibiotic regimen.50

Antimicrobial Treatment StrategiesControversy exists concerning the ideal approach to

antibiotic management of CAP. Because of the lack of sensitivity and specificity of current diagnostic meth-ods, recommendations for the treatment of CAP vary from a pathogen-directed approach to an empiric strate-gy with broad-spectrum antibiotics. In one prospec-tive study,52 262 patients with CAP were randomized to receive either pathogen-directed treatment (PDT; n = 134; mean age, 62.0 years; 55.2% men) or empiric, broad-spectrum antibiotic treatment (EAT; n = 128; mean age, 66.7 years; 52.3% men). Patients in the PDT group were given antibiotics based on the results of microbiologic evaluations (sputum Gram stain and cul-ture, blood and pleural fluid culture, urinary antigen test, bronchoalveolar lavage, and protected specimen brush sampling culture) if the patient did not produce

ciding the level of care needed, including hospitaliza-tion, admission to an intensive care unit, various levels of diagnostic and microbiologic testing, and initial an-timicrobial therapy.30 Subsequently, many investiga-tors have attempted to develop a prognostic severity-assessment scoring system on the basis of the risk for mortality to guide those decisions.6,45–49 To date, the 2 most rigorously tested assessment tools for CAP are the Pneumonia Severity Index (PSI) and the CURB-65 criteria, both of which are endorsed by the IDSA and the ATS.50 It is important to point out, however, that although both assessment tools have been validated in a heterogeneous adult population, they have not been studied specifically in the elderly.51

The PSI relies on the identification of preexisting patient characteristics (age, sex, nursing home resi-dence status, and comorbidities), physical examination findings (altered mental status, respiratory rate, blood pressure, temperature, and heart rate), and a variety of laboratory and radiographic abnormalities (arterial pH; partial pressure of oxygen; blood urea nitrogen, serum sodium, and glucose levels; and pleural effusion). Ac-cording to the PSI score, patients are categorized into 5 risk classes, with the lowest mortality rate in class I (0.1%–0.4%) and the highest mortality rate in class V (27.0%–31.1%). This stratification is then extrapolated to define the level of care needed (eg, hospital ad-mission).6 The PSI risk stratification is complex and extensive, involving 20 different variables. The score often requires cumbersome calculation, which can be time consuming.

In contrast, the CURB-65 criteria include 5 easy-to-remember variables: confusion (new disorientation to person, time, or place), urea (blood urea nitrogen >20 mg/dL), respiratory rate (≥30 breaths/min), blood pressure (systolic <90 mm Hg or diastolic ≤60 mm Hg), and age ≥65 years. Each criterion is assigned 1 point. The investigators proposed that patients with a CURB-65 score of 0 or 1 (low mortality, 1.5%) can be treated as outpatients, those with a score of 2 (intermediate mor-tality, 9.2%) should be admitted to the hospital, and patients with a score ≥3 (high mortality, 22.0%) should be considered for management in an intensive care unit.45

This recommendation has been included in the latest IDSA/ATS consensus guidelines on the management of CAP in adults.50

ManagementAlthough there is no reason to believe that individu-

als ≥65 years of age with CAP should be managed dif-ferently than younger adults, it should be noted that


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[IQR], 5–15 vs 10 days; IQR, 6–24 days, respectively; P < 0.01), as well as a reduction in overall in-hospital mortality (8%; 95% CI, 7%–10% vs 17%; 95% CI, 14%–20%; P < 0.01) and a higher proportion of patients reaching clinical stability by day 7 (71%; 95% CI, 68%–74% vs 57%; 95% CI, 53%–61%; P < 0.01).54 It appears that empiric therapy, when implemented in ac-cordance with guideline-recommended treatment strate-gies (eg, IDSA/ATS guidelines), has the potential to improve mortality, hospital LOS, and time to clinical stability in elderly patients with CAP.

A multicenter retrospective cohort study55 evaluated 14,069 elderly patients (84.0% white; 50.6% women; ages 65–74 years, 30.3%; 75–84 years, 41.8%; ≥85 years, 27.8%) hospitalized with pneumonia in the United States for associations between 30-day mortality rate, time from hospital arrival to initial antibiotic administra-tion, and performance of blood cultures within 24 hours of hospital admission. After adjusting for the patient’s risk status and performance of other processes of care, antibiotic administration within 8 hours of hospital ar-rival and performance of blood cultures within 24 hours of hospital admission were associated with a signifi-cantly lower 30-day mortality rate (OR = 0.86; 95% CI, 0.75–0.96; P < 0.05 and OR = 0.90; 95% CI, 0.81–1.0, respectively; P < 0.05).

As with other infectious diseases, switching from in-travenous to oral antibiotic therapy for CAP has been reported to be safe, efficacious, and cost-effective.56,57

The respiratory fluoroquinolones (moxifloxacin, gemi-floxacin, and levofloxacin, in particular) may play an important role in switch therapy for CAP. Their excel-lent oral bioavailability, favorable pharmacokinetic properties, and broad spectrum of activity, which covers pathogens such as the atypical organisms and penicillin- and macrolide-resistant S pneumoniae, make them ideal candidates for this treatment strategy.58

Overall, treatment of CAP in the elderly with antimi-crobial agents commonly recommended for adults ap-peared to be effective, with clinical cure rates ranging from 75% to 97%.

Empiric Antibiotic SelectionSelection of empiric antibiotic therapy for the treat-

ment of CAP in the elderly is complicated by concern over drug-resistant S pneumoniae. Studies have re-ported that age >65 years is an independent risk factor for CAP caused by this pathogen.30,51,59 Nevertheless, in the absence of meningitis, clinical failure is highly unlikely with the high dose of β-lactam recommended by the current IDSA/ATS guidelines (eg, amoxicillin

sputum within 24 hours. Patients in the EAT group were given antibiotics based on the 1993 ATS guidelines. Despite a rigorous workup for the etiology of CAP in the PDT group, no significant differences were observed between the PDT and EAT groups in the hospital LOS (14.3 vs 13.2 days, respectively), 30-day mortality (7.9% vs 14.6%), or clinical failure (21.1% vs 23.2%).

Currently, empiric initial antibiotic therapy for CAP is recommended by the IDSA and the ATS.50 Ideally, empiric therapy for CAP should provide coverage for the most likely pathogens, while considering local rates and patterns of resistance of the suspected organisms. Clinicians should also be aware of risk factors for ac-quiring less common pathogens or more resistant or-ganisms based on the patient’s age, lifestyle, residence status, exposure, contact, and comorbid conditions, as well as events preceding or triggering the current episode of pneumonia. An empiric antibiotic regimen should then be customized based on careful consideration of those risk factors and events. Once the microbiologic etiology and susceptibility of the pathogen are known, antibiotic therapy should be deescalated and directed at the iden-tified pathogen. This strategy is considered the stan-dard of care for the treatment of CAP.29,51

In a controlled before-and-after intervention study, Capelastegui et al53 investigated the impact of imple-menting the guideline for the management of CAP issued by the Spanish Society of Pneumology and Tho-racic Surgery in 5 public hospitals in Spain. Implemen-tation of the guideline resulted in a shorter duration of antibiotic treatment (11.4 vs 12.9 days; P < 0.001) and a decrease in hospital LOS (5.7 vs 7.3 days; P < 0.001) compared with treatment during the preguideline pe-riod. Moreover, adjusted analyses revealed a decrease in 30-day mortality (OR = 2.14; 95% CI, 1.23–3.72; P < 0.01) in the intervention cohort (n = 417; mean age, 71.0 years; 65.2% men) compared with the pre-intervention cohort (n = 377; mean age, 67.1 years; 62.3% men).

Arnold et al54 performed a secondary analysis on data from an international observational study of hos-pitalized patients in 13 countries worldwide, including the United States and Canada, from June 1, 2001, to January 1, 2007; the study included 1649 patients ≥65 years of age hospitalized for CAP. Their initial em-piric antimicrobial therapy was evaluated retrospective-ly for adherence to the 2007 IDSA/ATS consensus guidelines on the management of CAP in adults. Ad-herence to the guidelines was associated with a shorter median hospital LOS in the adherence group than in the nonadherence group (8 days; interquartile range


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(eg, azithromycin). CAP in an elderly patient with co-morbid conditions such as chronic heart, lung, liver, or kidney disease; diabetes mellitus; alcoholism; malignan-cies; asplenia; immunosuppression or use of immuno-suppressants; and a CURB-65 score of 1 should be treated with either a respiratory fluoroquinolone or a combination of a macrolide and a high dose of a β-lactam such as amoxicillin 1 g 3 times daily or amoxicillin/clavulanate 2 g/125 mg twice daily.50

Based on the IDSA/ATS guidelines,50 elderly pa-tients with CAP who have a CURB-65 score ≥2 should be hospitalized for treatment. Patients who have a CURB-65 score of ≥3 should be considered for man-agement in an intensive care unit, especially when they show signs of sepsis or are intubated. In addition to the previously mentioned pathogens, elderly patients with CAP who need hospital care are at risk for Legionellaspecies, enteric gram-negative rods, and S aureus. For patients with moderate CAP who are admitted to a general ward (CURB-65 score ≥2), the recommended empiric treatment is either a respiratory fluoroquino-lone or a combination of a macrolide and a β-lactam (eg, ceftriaxone, cefotaxime). Elderly patients with se-vere CAP treated in an intensive care unit (CURB-65 score ≥3; sepsis requiring vasopressors; respiratory fail-ure requiring intubation) should receive a β-lactam

1 g orally 3 times daily).30,50,51,59 The following recom-mendations are based mainly on the 2007 IDSA/ATS consensus guidelines for the management of CAP in adults, which are evidence based and derived from mul-tiple large retrospective cohort studies.50 A schematic of the treatment of CAP in the elderly is depicted in the figure.

It should be noted that simply adhering to the guide-lines and administering a recommended broad-spectrum agent do not equate to safe and effective treatment. Clinicians must also consider local rates and patterns of antimicrobial resistance as well as individual patient risk factors when selecting an initial empiric antibiotic regi-men. Recommended empiric antimicrobial regimens generally consist of either a β-lactam plus a macrolide or a respiratory fluoroquinolone alone. Initial empiric antimicrobial regimens for the treatment of CAP based on the 2007 IDSA/ATS consensus guidelines (level I evidence, strong recommendation) are summarized in Table IV.50,60,61

Common pathogens responsible for CAP among el-derly outpatients include S pneumoniae, H influenzae, Chlamydophila pneumoniae, and respiratory viruses. In otherwise healthy elderly individuals with CAP, who took no antibiotics within the previous 3 months, the recommended choice for empiric therapy is a macrolide

Patients aged ≥65 years with signs and symptoms of pneumonia

Outpatient treatment Hospitalization

CURB-65 score ≥2

CURB-65 score ≥3,sepsis, intubated

Non-ICU management ICU managementOtherwise healthyand no antibiotic use

within previous 3 months

Patients withcomorbidconditions

β-lactam+

fluoroquinolone or azithromycin

Respiratory fluoroquinolone

OR

β-lactam + macrolide

Macrolide Respiratory fluoroquinolone

OR

β-lactam +macrolide

Figure. Treatment of community-acquired pneumonia in the elderly.50 CURB-65 = confusion, urea nitrogen, respiratory rate, blood pressure, and age ≥65 years; ICU = intensive care unit.


56

Overall, all recommended empiric antibiotic regi-mens for CAP in the elderly provide adequate cover-age for S pneumonia, including the penicillin-resistant strains.62 A macrolide or a fluoroquinolone is included in all recommended regimens to cover the atypical or-

such as ceftriaxone, cefotaxime, or ampicillin/sulbactam plus either a fluoroquinolone or azithromycin. In addi-tion, antipseudomonal and methicillin-resistant S aureus (MRSA) coverage should be considered if risk factors for those pathogens exist.

Table IV. Initial empiric antimicrobial regimens for the treatment of community-acquired pneumonia (CAP).50,60,61

Site of Care/Patient Characteristic Empiric Regimens*

Outpatient treatmentPreviously healthy patients who used no antibiotics within the previous 3 months; CURB-65 score, 1

Azithromycin 500 mg PO on day 1 followed by 250 mg PO QD on days 2–5 ORClarithromycin 500 mg PO BID ORErythromycin 500 mg PO QID

Patients with comorbid conditions (eg, chronic heart, lung, liver, or kidney disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppression or use of immunosuppressants; use of antimicrobials within the previous 3 months; CURB-65 score, 1

Levofloxacin 750 mg PO QD x 5 days ORMoxifloxacin 400 mg PO QD ORGemifloxacin 320 mg PO QD ORAmoxicillin 1 g PO TID plus a macrolide†

ORAmoxicillin/clavulanate 2 g/125 mg PO BID plus a macrolide†

Inpatient treatmentPatients with moderate CAP (CURB-65 score, ≥2); non-ICU admission

Levofloxacin 750 mg PO/IV QD ORMoxifloxacin 400 mg PO QD ORGemifloxacin 320 mg PO QD ORCeftriaxone 1 g IV QD plus a macrolide‡

ORCefotaxime 1 g IV q6h plus a macrolide‡

ORAmpicillin 1–2 g IV q6h plus a macrolide‡

Patients with severe CAP (CURB-65 score, ≥3), sepsis requiring vasopressors; respiratory failure requiring intubation; ICU admission

Ceftriaxone 1 g IV QD plus either azithromycin 500 mg IV QD or levofloxacin 750 mg IV QD ORCefotaxime 1 g IV q6h plus either azithromycin 500 mg IV QD or levofloxacin 750 mg IV QD ORAmpicillin/sulbactam 1.5–3 g IV q6h plus either azithromycin 500 mg IV QD or levofloxacin 750 mg IV QD

CURB-65 = confusion, urea nitrogen, respiratory rate, blood pressure, and age ≥65 years; ICU = intensive care unit.*For adults with normal renal function; duration is 7 to 14 days unless otherwise stated. † Azithromycin 500 mg PO on day 1 followed by 250 mg PO QD on days 2 to 5 or clarithromycin 500 mg PO BID. ‡ Azithromycin 500 mg PO/IV QD, clarithromycin 500 mg PO BID, or erythromycin 1 g IV q6h.


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(n = 141; mean age, 77.9 years; 51.1% women) and 87.9% in the levofloxacin arm (n = 140; mean age, 77.4 years; 50.7% men; P = NS).11 However, in a retrospective subgroup analysis of patients aged >65 years with CAP, a 5-day course of levofloxacin 750 mg daily resulted in a clinical cure rate of 89.0% (n = 80; mean age, 73.1 years; 53.8% men; 80.0% white).12 It appears that elderly pa-tients with CAP should be treated for a minimum of 5 days and generally for 7 to 14 days. A longer duration (14–21 days) may be necessary if pneumonia is caused by atypical organisms.29 Until more clinical data be-come available, the duration of treatment for CAP in the elderly should be guided by the clinical response of the patient. Antibiotic therapy should be continued for 72 hours after the elderly patient becomes afebrile and meets criteria for clinical stability (heart rate ≤100 beats/min, respiratory rate ≤24 breaths/min, systolic blood pressure ≥90 mm Hg, arterial oxygen saturation ≥90%, ability to maintain oral intake, normal mental status).50

Recurrent HospitalizationReadmission for CAP is a common problem among

the elderly, occurring at a rate of 5% to 29%.69 To iden-tify modifiable risk factors for recurrent hospitalization among elderly patients with CAP, El Solh et al69 con-ducted a case–control study using data from 204 pa-tients aged ≥65 years who were readmitted to 3 tertiary-care hospitals associated with the University of Buffalo (Buffalo, New York) with a clinical diagnosis of pneu-monia over a period of 1 year from the first episode. Control subjects were matched for age, admission date, and nursing home residence status. The independent predictors for readmission were swallowing dysfunction (hazard ratio [HR] = 2.15; 95% CI, 1.46–2.97; P < 0.05), current smoker (HR = 2.04; 95% CI, 1.48–2.82; P < 0.05 ), use of tranquilizers (HR = 1.5; 95% CI, 1.02–2.22; P < 0.05), and low activities of daily living scores (HR = 1.06; 95% CI, 1.02–1.10; P < 0.05) by Cox regression analyses. Pneumococcal vaccination was found to be protective (HR = 0.59; 95% CI, 0.42–0.82; P < 0.05). Although effective measures to improve swallowing dysfunction and functional status are limit-ed, smoking cessation and pneumococcal vaccination should be actively pursued in this patient population. The use of tranquilizers should be discouraged unless no alternative exists.

PreventionVaccination is probably the most cost-effective means

of preventing pneumonia in the elderly. Despite the perceived concern over reduced efficacy of vaccinations

ganisms.50 Studies have shown that the addition of a macrolide or a fluoroquinolone to a β-lactam for the treatment of hospitalized patients with CAP was associ-ated with decreased 30-day mortality compared with a β-lactam alone (β-lactam plus macrolide or fluoroquino-lone vs β-lactam alone: OR = 0.4; 95% CI, 0.2–0.8; P < 0.009).63–66 Antipseudomonal coverage should be considered for elderly patients with structural lung dis-ease, previous antibiotic treatment, or previous hospi-talization.62 Empiric treatment for those patients should include an antipneumococcal, antipseudomonal β-lactam (eg, piperacillin/tazobactam 4.5 g intravenously 4 times daily) in combination with either an antipseudomonal fluoroquinolone (eg, levofloxacin 750 mg intravenous-ly once daily) or an aminoglycoside (eg, gentamicin 1 mg/kg intravenously 3 times daily) and azithromycin (500 mg intravenously once daily).50 In elderly patients with dysphagia or other risk factors for aspiration, en-teric gram-negative and anaerobic coverage should be included in the initial empiric regimen (eg, ampicillin/sulbactam 1.5–3 g intravenously 4 times daily).62

Community-acquired MRSA (CA-MRSA) is an emerg-ing pathogen. Cases of necrotizing community-onset pneumonia caused by this pathogen have been reported in the literature.67 To date, risk factors for CAP second-ary to CA-MRSA have not been identified, although it may be reasonable to include previous influenza infec-tion, previous CA-MRSA skin and soft-tissue infection, and close contact with someone with CA-MRSA infec-tion. If CA-MRSA is suspected, vancomycin 1 g given intravenously twice daily, or linezolid 600 mg given orally or intravenously twice daily should be added to the empiric regimen.50

CAP among elderly residents of long-term care facilities has been reclassified as health care–associated pneumonia and should be treated in the same way as hospital-acquired pneumonia. A discussion of the treatment of health care–associated pneumonia is be-yond the scope of this review. Readers are referred to the latest IDSA/ATS guidelines for the management of adults with hospital-acquired, ventilator-associated, and health care–associated pneumonia for treatment recommendations.68

Duration of TherapyIn a prospective, double-blind, randomized CAP

clinical trial that only included elderly subjects,11 281 pa-tients were treated with moxifloxacin (400 mg intrave-nously or orally once daily) or levofloxacin (500 mg intravenously or orally once daily) for 7 to 14 days. The clinical cure rates were 92.9% in the moxifloxacin arm


58

Aspiration of stomach contents into the respiratory tract is another cause of pneumonia. Many elderly pa-tients receive gastric-acid suppressants such as proton-pump inhibitors or histamine (H2) blockers. Theoreti-cally, those medications may induce achlorhydria, which allows proliferation of bacteria that would otherwise be destroyed in the stomach.17 In a population-based case–control study, Myles et al28 reported a 55% increase in the risk of pneumonia in patients who received a proton-pump inhibitor (OR = 1.55; 95% CI, 1.38–1.77; P < 0.05). Based on these findings, we recom-mend that elderly persons not take a proton-pump in-hibitor routinely unless clearly indicated.

Poor nutritional status and a >10% weight loss from baseline are known risk factors for CAP in the elderly (OR = 1.83; 95% CI, 1.19–2.80; P = 0.006 and OR = 1.9; 95% CI, 1.3–2.6; P < 0.05, respectively).24,25 We recommend that elderly persons, especially those with low body weight or difficulty swallowing, have a well-balanced diet with frequent input from a dietitian.

Among individuals ≥65 years of age, smoking is not only a risk factor for CAP (OR = 2.01; 95% CI, 1.26–3.36; P = 0.004)25 but also a risk factor for recurrent hospital admission due to CAP (HR = 2.04; 95% CI, 1.48–2.82; P < 0.05).69 Based on these findings, we believe that smoking cessation must be actively pursued in this patient population. The use of alcohol is also associated with an increased risk for CAP in the elderly (OR = 1.69; 95% CI, 1.08–2.61; P = 0.006).25 Life-style modification appears to be an important element in the prevention of CAP.

Few effective measures are available to improve swal-lowing dysfunction, a known risk factor for CAP in the elderly (OR = 3.76; 95% CI, 1.60–8.88; P = 0.002).24,69

Recently, the use of ACEIs has been associated with a reduced risk for CAP (adjusted OR = 0.75; 95% CI, 0.65–0.86; P < 0.05).28 The theory is that ACEIs pre-vent the breakdown of substance P, leading to an en-hanced coughing reflex.17 Sekizawa et al75 studied the incidence of pneumonia in 127 patients with stroke. In a 2-year period, pneumonia was diagnosed in 7% of patients who received ACEIs compared with 18% of patients who received other antihypertensive agents (relative risk = 2.65; 95% CI, 1.3–5.3; P = 0.007). Al-though clinical data supporting the role of ACEIs in improving dysphagia are preliminary, elderly hyperten-sive patients may benefit from the use of an ACEI.

dIscussIonIn the United States, the elderly population increased 11-fold, from 3 million in 1900 to 33 million in 1994.76

in adults ≥60 years of age, vaccination against pneumo-coccal disease and influenza is currently recommended by the Centers for Disease Control and Prevention (CDC) in all adults >65 years of age.70,71

In a prospective cohort study72 that included 11,241 in-dividuals ≥65 years of age, pneumococcal vaccination did not reduce the risk of hospitalization for pneumo-nia (HR = 0.80; 95% CI, 0.50–1.28) or the incidence of pneumonia (HR = 0.86; 95% CI, 0.56–1.31). Pneu-mococcal vaccination, however, was associated with a significant reduction in death from pneumonia (HR = 0.28; 95% CI, 0.09–0.83; P < 0.05).72 In a similar study,73

in which 1298 elderly patients (ages 65–74 years, 58.4%; 75–84 years, 33.2%; ≥85 years, 8.4%) with chronic bron-chitis, emphysema, or asthma were followed for 3 years (2002–2004), pneumococcal vaccination did not alter the overall risk for CAP (HR = 0.77; 95% CI, 0.56–1.07) or the 30-day mortality from CAP (HR = 0.87; 95% CI, 0.33–2.28) after adjustment for age and co-morbidity.73 The protective effect of pneumococcal vaccine against CAP appears to be marginal. However, in a case–control study,69 pneumococcal vaccination was found to be associated with a 41% reduction in recurrent hospitalization for CAP in patients ≥65 years of age (HR = 0.59; 95% CI, 0.42–0.82; P < 0.05). The exact beneficial effect of pneumococcal vaccination re-mains to be elucidated.

In contrast, the role of influenza vaccination in pre-venting CAP is well defined. To determine the effec-tiveness of influenza vaccine, Nichol et al74 analyzed data extracted from the administrative and clinical da-tabases of 3 participating health management organiza-tions (HealthPartners, Kaiser Permanente, and Oxford Health Plus) for 10 seasons. Influenza vaccination was associated with a 27% reduction in risk of hospitaliza-tion (HR = 0.73; 95% CI, 0.68–0.77; P < 0.05) and a 48% reduction in risk of death (HR = 0.52; 95% CI, 0.50–0.55; P < 0.05) for CAP or influenza among per-sons ≥65 years of age. According to the CDC, all el-derly persons should be vaccinated against influenza annually.70

Pneumonia in the elderly is often associated with aspiration of upper respiratory tract secretions. For bedridden elderly individuals, aspiration may be mini-mized by placing the patient in a semirecumbent posi-tion.62 Another approach is to reduce bacterial coloni-zation of the oropharynx through proper oral care. Oral hygiene in the elderly is frequently poor. Imple-mentation of a protocol of oral care might decrease the bacterial load, thereby lowering the risk of pneumonia in the elderly.17,62


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It has been estimated that by the year 2030, 1 in 5 Ameri-cans will be >65 years of age.76 CAP is a major cause of mortality in the elderly, yet few clinical trials on CAP conducted in this population have been published. More studies performed exclusively in the elderly are needed to adequately assess the effects of age-related changes on treatment outcomes for CAP in this popu-lation. Nonetheless, a growing body of evidence has suggested that antimicrobial therapy, when implement-ed in accordance with IDSA/ATS guidelines, has the potential to reduce hospital LOS and mortality, as well as shorten the time to clinical stability in elderly pa-tients with CAP.

S pneumoniae is the most common etiology of CAP in the elderly. Current treatment regimens recom-mended by the IDSA/ATS provide adequate coverage for most of the pathogens involved in CAP in persons >65 years of age. Recommended empiric antibiotic regi-mens generally consist of either a β-lactam plus a mac-rolide or a respiratory fluoroquinolone alone. When se-lecting an appropriate initial empiric antibiotic regimen for an elderly patient, clinicians must also consider local rates and patterns of antimicrobial resistance as well as individual patient risk factors for acquiring less com-mon pathogens or more resistant organisms. Empiric antibiotic therapy for CAP, once selected, should be initiated as soon as possible. When a microbiologic etiology is available based on reliable diagnostic tests, antimicrobial therapy should be deescalated and tar-geted at the identified pathogen.

We recommend that all elderly patients be vaccin-ated against pneumococcal disease and influenza and that modifiable risk factors for CAP in the elderly (eg, smoking, alcohol use, poor nutritional status) be corrected with proper lifestyle changes and a well-balanced diet. Proper positioning of the body and aggressive oral hygiene to reduce bacterial coloniza-tion of the oropharynx may also be associated with re-ductions in the risk of aspiration pneumonia in the elderly.

concLusIonAdherence to established guidelines, along with cus-tomization of antimicrobial therapy based on local rates and patterns of resistance and patient-specific risk fac-tors, likely will improve the treatment outcome of el-derly patients with CAP.

AcknowLedgMentThe authors have indicated that they have no conflicts of interest regarding the content of this article.


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Address correspondence to: Horatio B. Fung, PharmD, Pharmacy Service, James J. Peters Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468. E-mail: [email protected]

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Community-Acquired Pneumonia in the Elderly 2010