Elderly patients with community-acquired pneumonia - the optimal treatment strategy
The review discusses certain characteristics of the management of community-acquired pneumonia in elderly patients.
Community-acquired pneumonia (CAP) remains one of the most common infectious diseases, causing, despite continuous improvement in medical and preventive measures, significant levels of morbidity and mortality. Elderly patients are particularly often affected by community-acquired pneumonia, and in this review, certain characteristics of the management of this disease in elderly patients are taken into account.
Streptococcus pneumoniae remains the most important pathogen in the CAP, less often Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella spp. Antibiotic resistance is a growing problem, especially in Western Europe, the resistance of pneumococci to macrolides, as well as the emergence and spread of strains resistant to fluoroquinolones S, are relevant. pneumoniae. As for β-lactam antibiotics, there is a problem of H. resistance for European countries influenzae and Moraxella catarrhalis to aminopenicillins, as well as the spread of multidrug-resistant strains of Staphylococcus aureus.
Key decisions about patient management should be based on the severity of the disease, which is assessed using validated disease severity scales, such as CURB-65, which is a tool for determining the severity of pneumonia based on patient's state of consciousness, serum urea, respiratory rate and blood pressure. in patients over 65 years of age.
For the treatment of patients at low risk of death, aminopenicillins (amoxicillin) with or without a β lactamase inhibitor are most often recommended. It is also possible to make an appointment for monotherapy with macrolides. If there are factors predisposing to the isolation of resistant strains or any specific pathogen (for example, Gram-negative pathogens), an β-lactam protected by an inhibitor or, preferably, a combination of β- lactam resistant to an inhibitor with macrolide, should be prescribed.
If possible, patients who have received antibiotic therapy in the past 1 to 1.5 months should be given a class of antibiotics that has not been used before.
For hospitalized patients with mild pneumonia, routine empirical treatment involves the use of β-lactams protected by an inhibitor or monotherapy with fluoroquinolones.
With the proven etiology of legionellosis of pneumonia, it is recommended to use β lactams in combination with fluoroquinolones or macrolides.
In severe pneumonia, generation II-III cephalosporins, macrolides and fluoroquinolones should be prescribed. The most commonly recommended combination is β lactam (cefotaxime or ceftriaxone) or piperacillin / tazobactam with macrolide.
In patients at risk for Pseudomonas aeruginosa, a combination of piperacillin / tazobactam, cefepime, imipenem or meropenem with levofloxacin or ciprofloxacin is preferred. Usually a treatment duration of more than 7 days is not recommended, except for a proven infection caused by Pseudomonas aeruginosa - in this case, the duration of administration of antibiotics is 15 days.
In addition, all inpatients, in addition to prescribing antibiotics, may require oxygen support for hypoxemia, administration of intravenous fluids and, in some cases, dose adjustment. antibacterial drugs based on kidney function.
In order to further optimize the management of elderly patients with community-acquired pneumonia, studies are needed to identify various pathogens in the elderly, determine the optimal antibiotic regimen and clarify the necessary duration of treatment.