From the Guidelines
For a 73-year-old patient with potential pneumonia, I recommend starting with empiric therapy using amoxicillin-clavulanate 875/125 mg orally twice daily for 5-7 days, or if more severe, ceftriaxone 1-2 g IV once daily plus azithromycin 500 mg IV/orally daily. The choice of antibiotic depends on several factors including severity of illness, setting (community vs. hospital-acquired), and patient's comorbidities. For hospitalized patients, respiratory fluoroquinolones like levofloxacin 750 mg daily may be appropriate 1. Before starting antibiotics, obtain sputum cultures and blood cultures if possible. Consider age-related changes in drug metabolism and potential drug interactions in elderly patients, which may necessitate dose adjustments 1. Assess kidney function before prescribing, as many elderly patients have reduced renal clearance. Ensure adequate hydration and monitor for improvement within 48-72 hours. If the patient has risk factors for drug-resistant pathogens such as recent hospitalization or nursing home residence, broader coverage may be needed 1. Treatment should be reassessed and potentially narrowed once culture results are available. It is essential to note that the patient's residence in a skilled nursing facility may increase the risk of drug-resistant pathogens, and therefore, broader coverage may be necessary 1. In addition, the patient's age and potential comorbidities should be taken into consideration when selecting an antibiotic regimen, as they may affect the patient's response to treatment and increase the risk of adverse effects 1. Overall, the goal of treatment is to improve the patient's symptoms, reduce morbidity and mortality, and enhance quality of life.
From the FDA Drug Label
The recommended dose of Azithromycin for Injection for the treatment of adult patients with community-acquired pneumonia due to the indicated organisms is: 500 mg as a single daily dose by the intravenous route for at least two days Intravenous therapy should be followed by azithromycin by the oral route at a single, daily dose of 500 mg, administered as two 250 mg tablets to complete a 7 to 10 day course of therapy.
Azithromycin (IV) should be used for a 73-year-old patient with potential pneumonia, with a dose of 500 mg as a single daily dose by the intravenous route for at least two days, followed by oral therapy to complete a 7 to 10 day course of therapy 2.
- The patient's age does not require a dosage adjustment.
- However, caution should be exercised when azithromycin is administered to subjects with severe renal impairment.
- It is also important to note that elderly patients may be more susceptible to development of torsades de pointes arrhythmia than younger patients.
From the Research
Antibiotic Treatment for Pneumonia
The choice of antibiotic for a 73-year-old patient with potential pneumonia should be based on the likely causative pathogen, the presence of risk factors for infection with resistant bacteria, and local resistance patterns 3.
Recommended Antibiotics
- Ceftriaxone, a third-generation cephalosporin, has been shown to be effective in the treatment of community-acquired pneumonia, including cases caused by Streptococcus pneumoniae 4, 5.
- The combination of a macrolide (such as azithromycin) and a third-generation cephalosporin (such as ceftriaxone) may be preferred over fluoroquinolones as first-line therapy for hospitalized patients with community-acquired pneumonia to minimize the development of multiresistant nosocomial Gram-negative bacilli 4.
- Levofloxacin, a fluoroquinolone, is also an option, but its use may be limited by the presence of resistant bacteria 4, 3.
Considerations for Older Patients
- Older patients, such as those residing in skilled nursing facilities, may be at higher risk for health care-associated pneumonia, which requires management similar to nosocomial pneumonia 6.
- The presentation of pneumonia in older patients may be atypical, with symptoms such as headache, nausea, abdominal pain, and absence of one or more of the prototypical symptoms 7, 6.
- Knowledge of local bacterial pathogens and their antibiotic susceptibility and resistance profiles is crucial for effective pharmacologic selection and treatment of pneumonia in older patients 3, 7.