What is the management of pneumonia in the elderly?

Management of Pneumonia in the Elderly Based on Australian Guidelines

The management of pneumonia in the elderly should follow a structured approach with oral amoxicillin as first-line therapy for non-severe community-acquired pneumonia, combined with a macrolide (erythromycin or clarithromycin) for hospitalized patients, and more aggressive combination therapy for severe cases. 1

Assessment and Diagnosis

• Use CURB-65 score to assess severity (Confusion, Urea >7 mmol/L, Respiratory rate ≥30/min, Blood pressure <90 mmHg systolic or ≤60 mmHg diastolic, Age ≥65 years)
• Chest radiograph is essential for diagnosis but need not be repeated prior to hospital discharge if clinical recovery is satisfactory 1
• Consider CT scan or chest ultrasound in uncertain cases, especially in the elderly where presentation may be atypical 2
• Laboratory tests should include complete blood count, C-reactive protein, and blood cultures if the patient is febrile 3

Antibiotic Management

For Community-Managed Patients

• First-line: Amoxicillin at higher doses than previously recommended 1
• Alternative: Macrolide (erythromycin or clarithromycin) for those with penicillin hypersensitivity 1
• Consider immediate antibiotic administration by GPs when illness is life-threatening or hospital admission will be delayed 1

For Hospitalized Non-Severe CAP

• First-line: Combined oral therapy with amoxicillin and a macrolide (erythromycin or clarithromycin) 1
• When oral treatment is contraindicated: IV ampicillin or benzylpenicillin, together with erythromycin or clarithromycin 1
• Alternative: Fluoroquinolone with pneumococcal activity (e.g., levofloxacin) for those intolerant to penicillins or macrolides, or where Clostridium difficile is a concern 1

For Severe CAP

• First-line: IV combination of a broad-spectrum β-lactamase stable antibiotic (co-amoxiclav, cefuroxime, or ceftriaxone) plus a macrolide (clarithromycin or erythromycin) 1
• Alternative: Fluoroquinolone with enhanced pneumococcal activity plus IV benzylpenicillin 1

For Aspiration Pneumonia

• First-line: Beta-lactam/beta-lactamase inhibitor (ampicillin/sulbactam or amoxicillin-clavulanate) 3
• Routine anaerobic coverage is not recommended unless lung abscess or empyema is suspected 3

Duration of Treatment

• For non-severe and uncomplicated pneumonia: 7 days of appropriate antibiotics 1
• For aspiration pneumonia: 7-14 days for uncomplicated cases; 4-6 weeks for lung abscesses 3
• Transfer from parenteral to oral antibiotics as soon as clinical improvement occurs and temperature has been normal for 24 hours 1

Monitoring and Follow-up

• Clinical review should be arranged for all patients at around 6 weeks, either with their GP or in a hospital clinic 1
• Chest radiograph at follow-up is indicated for patients with:
  • Persistent symptoms or physical signs
  • Higher risk of underlying malignancy (especially smokers and those over 50 years) 1
• Monitor clinical stability using parameters such as:
  • Body temperature ≤ 37.8°C
  • Heart rate ≤ 100 beats/min
  • Respiratory rate ≤ 24 breaths/min
  • Systolic blood pressure ≥ 90 mmHg 3

Prevention Strategies

• Influenza vaccination is recommended for all elderly people (over 65 years) and those with chronic diseases 1
• Pneumococcal vaccination is recommended for those aged 2 years or older in whom pneumococcal infection is likely to be more common or serious 1
• Both vaccines can be administered together at different sites 1

Special Considerations for Elderly Patients

• Be aware of atypical presentations in the elderly, which may include confusion without respiratory symptoms 2
• Consider swallowing evaluation before resuming oral intake in patients with suspected aspiration 3
• Implement preventive measures:
  • Swallowing rehabilitation
  • Oral health care
  • Head-up position during the night
  • Management of gastroesophageal reflux 4
• Always consider tuberculosis in the differential diagnosis of pneumonia in elderly patients 4

Common Pitfalls to Avoid

• Delaying antibiotic treatment while waiting for diagnostic confirmation
• Failing to recognize atypical presentations in the elderly
• Inadequate dose adjustment for renal function
• Not switching from IV to oral antibiotics when appropriate
• Overuse of broad-spectrum antibiotics when narrow-spectrum would suffice
• Neglecting supportive care (hydration, oxygenation, nutritional support)
• Missing the opportunity for vaccination at discharge

By following these guidelines, clinicians can optimize the management of pneumonia in elderly patients, improving outcomes and reducing complications.