referat : pneumonia in elderly
DESCRIPTION
This referat is submitted to fulfill one of the requirements of internship at Internal Medicine Department, RSPAD Gatot Soebroto. It describes about definition of geriatric and also about definition, epidemiology, clinical presentation, laboratories findings, therapy, prevention, and prognostic of pneumonia in elderly.TRANSCRIPT
REFERAT
Diagnostic Procedures and Treatment Of
PNEUMONIA IN ELDERLY
Lecturer :dr. Alex Ginting S. Sp.P
Created by :Athieqah Asy –Syahidah
110. 2007. 051FK - YARSI
INTERNAL MEDICINE DEPARTMENTRUMAH SAKIT PUSAT ANGKATAN DARAT GATOT SOEBROTO
JAKARTA2012
1
Foreword
All praise be to Allah SWT, the Cherisher and Sustainer of the world; God whohas been giving His blessing to the writer to complete this referat entitled ”Diagnostic Procedures and Treatment of Pneumonia in Elderly”. This referat is submitted to fulfill one of the requirements of internship at Internal Medicine Department, RSPAD Gatot Soebroto.
In finishing this referat, the writer really gives his regards and thanks for people who has given guidance and help, especially for dr. Alex Ginting, Sp. P as the supervisor who has given his best guidance to write a quality content of this referat. Another great thanks also send to writer’s parent who always give their best supports.
Finally the writer realizes there are unintended errors in writing this referat. The writer really allows all readers to give their suggestions to improve its content in order to be made as one of the good examples for the next referat. Hopefully this referat is useful for the wirter and all the readers.
Jakarta, Desember 2012
Writer
2
RATIFICATION SHEET
REFERAT
Diagnostic Procedures and Treatment of Pneumonia in Elderly
Created by :Athieqah Asy-Syahidah
(110.2007.051)UNIVERSITAS YARSI
Corrected and Confirmed by :
________________________________ Pembimbing : dr. Alex Ginting, Sp.P Tanggal : Desember 2012
INTERNAL MEDICINE DEPARTMENTRUMAH SAKIT PUSAT ANGKATAN DARAT GATOT SOEBROTO
JAKARTA2012
3
Table of Contents
Cover i
Foreword ii
Ratification Sheet iii
Table of Contents iv
Chapter I 1
Introduction 1
Chapter II 2
Review of the Literature 2
I. Geriatric 2
II.Pneumonia in Elderly 7
a. Definition 7
b. Epidemiology 7
c. Classification 10
d. Etiology 12
e. Symptoms and Findings of Pneumonia in Elderly 14
f. Diagnostic Procedures 16
g. Severity Assessment 20
h. Treatment of Pneumonia Among the Elderly 23
i. Prevention 32
j. Conclusion 34
References
4
CHAPTER 1
Introduction
The world's population has increased significantly from year to year, it
directly increase the number of elderly (geriatric). The same thing also
happened in Indonesia, according to the International Demographic Data from
the Bureau of the Census USA, the enhancement number of elderly in
Indonesia is the highest in the world (41,4%), with an estimated length of time
between 1990-2025. However, the enhancement number of elderly in
Indonesia is inversely proportional to life expectancy of Indonesia’s
population.
That will be followed by greater number of elderly patients who may
demand health care services as they are more vulnerable to various
conditions of acute illness. One of the diseases that become a main focus in
elderly is pneumonia, in which morbidity and mortality in elderly patients due
to pneumonia is still high.
In elderly, their health status is determined by several comorbidities
factors, such as diabetes mellitus, renal insufficiency, hepatic insufficiency,
Alzheimer's and etc. Thus the special health care needs for elderly, it requires
an holistic approach and a total care.
5
CHAPTER 2
Review of the Literature
I. GERIATRIC
Geriatric is a term consisting of the word Geros (elderly) and iatreia (care
/ merumat), geriatrics itself refers to the branch of medicine that focuses on
providing health care for seniors. (Ignas Vascher Leo, 1909). Someone said
elderly, if it has reached the age of 60. (1)
a. DEP.KES RI
1. 60 – 69 y’o : elderly
2. ≥ 70 y’o : high risk elderly
b. WHO
1. Middle age = 45 – 59 y’o
2. Elderly = 60 – 74 y’o
3. Old = 75 – 90 y’o
4. Very old = > 90 y’o
To deal with geriatric diseases requires an holistic approach and a total
care to patients in an integrated way by considering the state of the
6
environment, socio-economic, lifestyle, diagnosis and therapy in treating
patients with the disease.
Total care is when a resident or patient requires a caregiver in order to
have all their survival needs met, including ambulation, respiration, bathing,
dressing, feeding, and toileting. The term "total care" is sometimes incorrectly
used in nursing homes and other similar facilities to refer to a patient who
simply needs diaper changes, but is able to provide other care on his/her own.
Total care is where long term care facilities for residents are responsible for
meeting all the needs of a resident. While some residents receiving so-called
total care may be able to independently meet all or some of their needs for
their activities of daily living without the assistance of a caregiver, the facility
and its staff have the duty of monitoring the resident to be sure s/he is having
those needs met.
The term "total care" is also used within long term care facilities to refer
to residents who need actual assistance in meeting all their needs in their
activities of daily living. Those who need little or no assistance are referred to
as "self care." Some facilities have special units reserved for those dependent
on total care. Others specialize specifically in residents in need of total care.
Some facilities cannot handle total care residents, and when one becomes
needy of such care, the facility will transfer the resident to another facility.
Holistic health is a concept in medical practice upholding that all
aspects of people’s needs including : psychological, physical, social and
spiritual should be taken into account and seen as whole. As defined before,
holistic approach is widely accepted in medicine.
7
Many elderly suffering from diseases that can lead to complications if
not handled properly, such as bone fractures that can lead to osteoporosis, or
if someone has high cholesterol numbers during aging, it may become
coronary heart disease (CHD), hypertension, heart failure and myocardia
infarc, diabetes mellitus, and kidney or liver dysfunction.
Some of the problems that often arise in old age called as a series of
I's, ie immobility, instability, incontinence, intellectual impairment, infection,
impairment of vision and hearing, isolation, Inanition, insomnia and immune
deficiency. (Kane and Ouslander)
Disease Characteristics of the Elderly in Indonesia `
- Joint and bone diseases, such as rheumatic, and osteoporosis.
- Cardiovascular diseases, such as hypertension, cholesterolemia,
angina, cardiac attack, stroke, high triglycerides, anemia, and CHD.
- Digestive diseases such as gastritis and ulcer pepticum.
- Urogenital Diseases, such as Urinary Tract Infection (UTI), Acute
Kidney Injury/ Chronic and Benigna Prostate Hyperplasia.
- Disease Metabolic / Endocrine, such as diabetes mellitus, and obesity.
- Respiratory diseases, such as pneumonia, influenza, asthma, and
pulmonary tuberculosis.
- Disease malignancies, such as carcinoma or cancer.
- Other diseases, such as senility / dementia, Alzheimer, and Parkinson's
8
The growth of the number of elderly in Indonesia was recorded as the
most rapid in the world in the period 1990-2025. In 2005 there were
17,767,709 people or 7.97% of the total population, and it will become 25.5
million in 2020, or around 11.37 percent of the total population. That means
the number of elderly in Indonesia will be ranked fourth in the world, under
China, India, and the United States. (2)
While in Jakarta, based on data from a national health survey of 2001,
there were 641,124 elderly or around 8.64% of the total population of Jakarta,
amounting to 7,423,379 people. (3)
According to the international demographic data from the Bureau of the
Census USA (1993), the increase in the number of elderly Indonesia between
the years 1990-2025 reached 41.4%, the highest in the world. The rapid
increase is related to the life expectancy of Indonesia's population. From
Badan Pusat Statistik (BPS) 1998, the life expectancy of Indonesia’s
population approximately is 63 years for men and 67 years for women. But
according to the WHO study (1999) the life expectancy of Indonesia’s
population is 59.7 years, ranked the world 103. Number one is Japan (74.5
years).
Increasing number of the elderly will be followed by greater number of
geriatric patients who may demand health care services as they are more
vulnerable to various conditions of acute illness. One of illnesses includes
respiratory tract infection, which is the leading cause of death and the most
significant cause that impairs quality of life the elderly. The elderly is more
9
vulnerable to infection as they own impaired physiological immune system
and reduced lung function, i.e. suppression of the cough reflex and decreased
function of mucocilliary epithelial in the respiratory tract, therefore, the risk of
pneumonia in the elderly increases. Decreased cell-mediated immunity as
shown by increasing annergic reaction, slower response of lymphocyte
proliferation, as well as reduced function of helper T-cells and B- lymphocytes
in the elderly will cause lower immune response against infections. (3)
Upper respiratory tract infections and influenza are common in the
elderly and may develop into pneumonia. The prevalence of influenza may
reach 5-20% of population each year along with high mortality rate, especially
among neonates and the elderly population. (4)
In 2003, the mortality rate related to pneumonia is still as high as
30.3% of all hospitalized elderly patients. In 2000, a proportion of 54%
hospitalization and 90% of death in the elderly over 65 years in the United
States were caused by pneumonia. Until 2002, many elderly patients have
died from pneumonia (200 out of 100,000 elderly) .(5,6)
Considering the high morbidity and mortality rates related to
pneumonia in the elderly, it’s important to diagnose early and to treat the
elderly patients carefully.
10
II. PNEUMONIA IN ELDERLY
a. Definition
Pneumonia can be generally defined as inflammation of the lung
parenchyma, in which consolidation of the affected part and a filling of the
alveolar air spaces with exudate, inflammatory cells, and fibrin is
characteristic.(7) It may be caused by bacteria, viruses, or parasites. Clinically
pneumonia is characterized by a variety of symptoms and signs. Cough
(which may be productive of purulent, mucopurulent, or “rust-colored”
sputum), fever, chills, and pleuritic chest pain are among its manifestations.
Extra- pulmonary symptoms such as nausea, vomiting, or diarrhea may occur.
There is a spectrum of physical findings, the most common of which is
crackles or rales in the lungs. Other findings in the lungs may include dullness
to percussion, increased tactile and vocal fremitus, bronchial breathing, and a
pleural friction rub.
b. Epidemiology
Until now, pneumonia is the leading cause of death in hospitalized
geriatric patient. The prevalence of pneumonia at acute geriatric ward of Cipto
Mangunkusumo Hospital in 2000 was 54.8% with mortality rate reached
32.5%. In2001, the prevalence increased to 61.6% with mortality rate of
32.9%. In 2003, the prevalence of pneumonia in geriatric patients decreased
into 52.2%, with mortality rate that remained high of 30.3%. (5,6)
In terms of patient statistics in Japan, as indicated by the figures in
Table 1 which were excerpted from “Kokumin Eisei no doukou (Trends in
National Public Health in Japan),” both the physician treatment rate and the
11
mortality rate show an abrupt and accelerating increase among pneumonia
patients over 65. It can be stated that pneumonia is a disease of the eld- erly
rather than a disease frequently observed among them.
Pneumococcal resistance to antibiotic is one of the other important
issues. Parsons (2002) reported that the incidence of pneumococcal
resistance to penicillin varied from country to country: Spain 65.6% (1999-
2000), United States 23% (1998), England 9% (1998), and Australia 9%
(1994). (8)
The resistance contributes to high mortality rate and the development of
complications related to pneumonia such as meningitis and sepsis (invasive
pneumococcal pneumonia = IPD). In Europe and United States, the incidence
of invasive pneumococcal disease ranges between 25 and 100 per 100,000
cases with the highest age- specific incidence rate in the elderly. Mortality
rate related to IPD may reach 40% in patients aged >85 years and 20% in
patients aged >65 years. The issue of antimicrobial resistance apparently may
12
not only restricted to penicillin, but also macrolides, chloramphenicol,
trimetoprim-sulfametoxazol, and cephalosporin. (9)
The transmission of pneumonia in the elderly patients is similar to the
young adults. It is important to remember that pneumonia in the elderly may
present with few respiratory symptoms and signs (data given below) and
instead may be manifest as delirium, worsening of chronic confusion, and
falls. Delirium or acute confusion was found in 45 [44.5%] of 101 elderly
patients with pneumonia studied by Riqueleme et al.(10), compared with 29
(28.7%) of 101 age- and sex-matched control subjects. Falls are usually an
indication that the person is ill. Among the healthy elderly, rough or slippery
ground accounted for 54% of falls, but in the sick elderly this factor accounted
for only 14% of falls (11). Dizziness, syncope, cardiac and neurological disease,
poor health status, and functional disability are more likely to account for falls
among the sick elderly (11)
However, several aspects need to be concerned. First, oropharynx is the
common site of microbial colonization that may increase the risk for
pneumonia. Malnutrition, poor oral and dental hygiene also contribute as risk
factors for recurrent pneumonia. (6)
Pneumonia is a major medical problem in the elderly. The increased
frequency and severity of pneumonia in the elderly is largely explained by the
ageing of organ systems (in particular the respiratory tract, immune system,
and digestive tract) and the presence of comorbidities due to age-associated
diseases. The most striking characteristic of pneumonia in the very old is its
13
clinical presentation: falls and confusion are frequently encountered, while
classic symptoms of pneumonia are often absent. Community acquired
pneumonia (CAP) and nursing-home acquired pneumonia (NHAP) have to be
distinguished. Although there are no fundamental differences in
pathophysiology and microbiology of the two entities, NHAP tends to be much
more severe, because milder cases are not referred to the hospital, and
residents of nursing homes often suffer from dementia, multiple comorbidities,
and decreased functional status.
c. Classification
Classification of anatomy
Based on the anatomical part of the lung parenchyma involved, traditionally,
pneumonia are classified into following three types:
1. Lobar pneumonia:
Occurs due to acute bacterial infection of part of a lobe or complete
lobe. Whole lobe is often affected as the inflammation spreads through
the pores of Khon and Lambert channels. Commonly Streptococcus
pneumoniae, Staphylococcus aureus, beta Haemolytic streptococci
and less commonly Haemophilus influenzae, Klebsiella pneumoniae
are responsible for lobar pneumonia.
2. Lobular pneumonia:
Acute bacterial infection of the terminal bronchioles characterized by
purulent exudates which extends into surrounding alveoli through
endobronchial route resulting into patchy consolidation. It is usually
seen in extremes of age and in association with chronic debilitating
14
conditions.Commonly Streptococci, Staphylococcus aureus, beta
Haemolytic streptococci, Haemophilus influenzae, Klebsiella
pneumonia and Pseudomonas are responsible for Bronchopneumonia.
3. Interstitial pneumonia:
Patchy inflammatory changes, caused by Viral or mycoplasma
infection, mostly confined to the interstitial tissue of the lung without
alveolar exudates. It is characterised by alveolar septal oedema and
mononuclear infiltrates. Commonly Mycoplasma pneumoniae,
Respiratory syncytial virus, Influenza virus, adenoviruses,
cytomegaloviruses and uncommonly Chlamydia and Coxiella are
responsible for Interstitial pneumonia.
Classification of pathogen
Pathogen classification is the most useful to treat the patients by choosing
effective antimicrobial agents :
1. Bacterial Pneumonia
(a) Aerobic Gram-positive bacteria,such as streptococcus
pneumoniae, staphylococcus aureus, Group A hemolytic
streptococci
(b) Aerobic Gram-negative bacteria, such as klebsiella pneumoniae,
Hemophilus influenzae, Escherichia coli
(c) Anaerobic bacteria
15
2. Atypical Pneumonia
Including Legionnaies pneumonia, Mycoplasmal pneumonia, chlamydia
pneumonia. Usually show the systemic manifestations such as
cephalgia, myalgia and confusion in elderly.
3. Fungal Pneumonia
Commonly caused by candid sp. and aspergilosis. Fungal pneumonia
is also caused by Pneumocystis Jiroveci
4. Viral Pneumonia
May be caused by adenoviruses, respiratory syncytial virus, influenza,
cytomegaloviruses
5. Pneumonia caused by other pathogen
Rickettsias, parasites, protozoa
Classification of acquired environment
a. Community acquired pneumonia (CAP)
b. Hospital acquired pneumonia (HAP)
c. Nursing home acquired pneumonia (NHAP)
d. Immuno compromised host pneumonia (ICAP)
d. Etiology
The main pathogens causing pneumonia in the elderly is a bacteria.
Pathogenic microbes for pneumonia may differ between the elderly and the
16
younger population. Mycoplasma pneumonia is found overwhelmingly among
the younger population, but rarely seen among the elderly. Bacterial
pneumonia, on the other hand, is a kind of pneu- monia frequently observed
among the elderly. Chlamydia pneumonia has been reported to be much
more common among the elderly than the younger population.(12). However,
chlamydia pneumonia has also been reported to be fre- quently seen in the
younger population, and the disease, including mixed infection with bacterial
pneumonia, needs to be further examined.
Figure 1 shows comparisons of pathogenic microbes for pneumonia
between the elderly and the younger population.(13) Overall, no major
differences seem to exist regarding pathogenic microbes, and there are at
least no critical differences.
17
e. Symptoms and Findings of Pneumonia in the Elderly
Since the contrast between the elderly and the younger population can
be ascribed to the difference in abilities of the infected host to fend off
infections, differences in symptoms and findings are presumed to exist, which
draws the most attention. Table 2 shows the comparisons of symptoms and
findings in community-acquired respiratory infections between the elderly and
adults complied by Suga.(14)
Although the elderly with community-acquired respiratory infections are
likely to exhibit mild symptoms, atypical physical findings, and mild laboratory
findings, their dis- ease is resistant to treatment and is often intractable. On
the other hand, the diseases develop abruptly in adults with severe symptoms
and severe abnormal laboratory findings, but they respond well to treatment.
While these are classical examples that are generally observed, not all cases
18
present such trends, and that is what makes clinical medicine complicated.
In a period of five years between April 1985 and March 1990, there
was a research about 406 cases of pneumonia at Kawasaki Medical School,
Kawasaki Hospital, Okayama, Japan. Fifty-seven cases were found among
patients aged 80 and above, and 51 cases among patients under 50 years of
age.
Table 3 shows the comparisons of their cardinal symptoms (at most up to the top three chief complaints) and laboratory findings.
Although chest pain and bloody sputum seem to be more common
among the younger population, and disturbed consciousness, dehydration,
loss of appetite, and general malaise among the elderly, no obvious
differences are seen in cardinal symptoms of pneumonia such as fever,
cough, and sputum.
19
In view of laboratory findings, no obvious differences are observed in
variables important in pneumonia patients including body temperature (fever),
white blood cell count (WBC) in peripheral blood, and C-reactive protein
(CRP). Differences exist in serum protein and a tuberculin skin test, though it
is unknown if they are the result of or basis of pneumonia.
One of the characteristics of pneumonia among the elderly that is
frequently noted is that they do not often run a fever. However, despite
normothermia at the first consultation or hospital admission, all of the above-
mentioned pneumonia patients, except those in shock, showed body
temperatures of 37 °C or greater when a careful thermometry was performed
after admission.
As these examples suggest, despite the fact that there are certain
severity patterns in symptoms and findings of pneumonia among the elderly,
no definitive differences exist between the elderly and the younger population.
Furthermore, since there are individual differences among pneumonia
patients, the regular treatment approach should be applied even to the
elderly.
f. Diagnostic Procedures
(a) Radiology
Although often difficult to perform in optimum conditions, plain chest
radiographs are important for confirming the clinical suspicion of pneumonia,
assessing extension of the disease, detecting potential complications such as
cavitation, parapneumonic effusion, or empyema, and documenting signs of
pre-existing pulmonary disorders such as COPD, sequelae of tuberculosis,
20
interstitial lung disease, bronchiectasis, or possible carcinoma. Computed
tomography scan is helpful when seeking an underlying cause such as airway
obstruction by a proximal tumour, documenting location and extension of a
pleural effusion, or when considering alternative diagnoses
(b) Laboratory data
Leucocyte count and inflammatory parameters
Leucocytosis and increase in band forms develop less frequently in
elderly patients and are thus less sensitive in the detection of pneumonia.
Fortunately, CRP, although not specific for bacterial infection, is highly
sensitive for detecting pneumonia: a normal CRP value virtually excludes
pneumonia, even in the very old. A persistent increase in CRP concentrations
under antibiotherapy is an adverse prognostic factor and suggests inadequate
antibiotic coverage, parapneumonic effusion, or empyema.(15,16,17) Procalcitonin
has a much lower sensitivity for the detection of pneumonia (54% in patients
aged 50–85).(18) Increased white-blood-cell counts, a higher percentage of
band forms, leucopenia, and lymphopenia have been described as adverse
prognostic factors.
Blood gas analysis
American Thoracic Society guidelines recommend that arterial blood
gases (ABG) be obtained on admission in patients who are hospitalised with
severe illness, or in any patient with chronic lung disease, not only for
detection of hypoxaemia (for which pulse oximetry is sufficient), but also for
that of hypercapnia, which occurs at a much higher frequency in the elderly
21
because of a lesser functional reserve.(19) This recommendation also pertains
to HAP. A reasonable limit is to suggest measuring ABG when pulse oximetry
readings for pulse oximetry are below 94%. For patients who are not admitted
to an ICU or intermediate- care unit, pulse oximetry is adequate for
subsequent monitoring of oxygenation with CAP, NHAP, or HAP.
Blood chemistry
Hyponatraemia and elevations of hepatic enzymes (alanine
aminotransferase and aspartate aminotransferase) are frequent, non-specific,
and are not reported as adverse prognostic factors. Conversely, low serum
albumine, and renal failure are associated with an increased mortality
( c) Microbiology
Although there is no doubt that a causative diagnosis of pneumonia in
the elderly is desirable, the question of whether sputum analysis should be
done is controversial (recommended by the Infectious Diseases Society of
America, but not by the American Thoracic Society).(20,21) Indeed, the elderly
are often too weak to provide an adequate sputum specimen, or too confused
to cooperate and the diagnostic yield of sputum analysis is relatively low.
Blood cultures and test for urinary legionella antigen are unanimously
recommended in elderly patients hospitalized for CAP or NHAP.(20,21) PCR
testing for Chlamydia spp, M pneumoniae, and common respiratory viruses
are now available, but their clinical usefulness has not yet been established.
Recent studies suggest that a search for urinary S pneumoniae
capsular antigen (common to all serotypes) may be useful in the diagnosis of
22
pneumococcal pneumonia. For non-bacteraemic pneumonia, reported
sensitivity ranges from 64–69%; and from 77–100% for bacteraemic
pneumococcal pneumonia.(22) Specificity of urinary S pneumoniae capsular
antigen is 82–97%. Potential drawbacks of the method are its rather low
sensitivity for non-bacteraemic pneumococcal pneumonia, and a high
positivity rate 1 month after an acute pneumococcal infection. (22)
(d) Bronchoscopy
Bronchoscopy is well tolerated in the very old(23-25),and should be done
when pneumonia responds poorly to treatment, or in immunocompromised
patients. In severe pneumonia, complications of bronchoscopy consist mainly
of transient worsening hypoxaemia (11%), postbronchoscopy fever (5%), and
transient cardiac arrhythmia (2%). In one study, about two-thirds of
bronchoalveolar lavage (BAL) yielded significant microbiological results,
leading to a change of therapy in 55% of the patients. Bronchoscopy may also
contribute to a diagnosis of unsuspected mycobacterial disease or unusual
organisms, as well as non-infectious causes of pulmonary infiltrates.
(e) Serological studies
Serological studies are not recommended initially on a routine basis in
available guidelines but may be contributive either in poorly responsive
patients, for retrospective confirmation of a suspected diagnosis, or in
epidemiological studies.
However, if certain etiologic agents such as Coxiella burnetii, M. pneu-
moniae, C. pneumoniae, or a virus are suspected, serological tests of acute
23
and convalescent serum samples can aid in the diagnosis. Unfortunately, the
results of these studies are not available for 3–4 weeks, by which time the
clinical situation has been resolved.
These studies are helpful for public health purposes and should always
be performed in workups during an outbreak of pneumonia. A urine specimen
for detection of Legionella antigen is useful in all cases of severe pneumonia.
Currently available tests detect only Legionella pneumophila serogroup 1
antigen (which accounts for ∼80% of cases of legionnaires disease) (26-27)
g. Severity Assessment
Severity assessment and site-of-care decisions are critical when
managing elderly patients who present with CAP. Severity assessment tools
can help predict mortality and determine the optimal setting in which to
provide care for patients with CAP. Nowadays, we can use PSI (Pneumonia
Severity Index) or CURB-65 for severity assessment test.
PSI is a prediction rule to calculate the severity of a person with CAP. It
is based on data that are commonly available upon presentation and divide
patients into 5 different classes, according to the severity of the disease.
Higher scores mean higher risk of death, admission to ICU and longer length
of stay in the hospital. The patient may need to be treated as an inpatient.
24
Patients in risk classes 1, 2 and 3 are regarded as at low risk of death
and are mostly treated as outpatients unless there are other risk factors. The
low risk patients in class 3 who look sick or needed further care can stay in
the hospital for another 23 hours and monitored for deterioration. After the
patient’s condition is better, patient will be allowed to leave the hospital.
As for patients grouped in class 4 (moderate risk) and 5 (high risk),
they should be hospitalized due to their higher risks of death and
complications.
25
There is an exception for patients with hypoxemia or PaO2 of >60mm
Hg. These patients must be hospitalized regardless of their PSI score. This
also applies to patients with metastatic disease (endocarditis, meningitis,
osteomyelitis) or those infected with high risk pathogens such as Staph.
aureus.
For all patients, clinical judgement supported by the CRB65 score
should be applied when deciding whether to treat at home or refer to hospital.
Patients who have a CRB65 score of 0 are at low risk of death and do
not normally require hospitalisation for clinical reasons. Patients who have a
CRB65 score of 1 or 2 are at increased risk of death (moderate risk of death),
particularly with a score of 2, and hospital referral and assessment should be
considered. Patients who have a CRB65 score of 3 or more are at high risk of
death and require urgent hospital admission. These patients should be
reviewed by a senior physician at the earliest opportunity to refine disease
severity assessment and should usually be managed as having high severity
pneumonia. Patients with CURB65 scores of 4 and 5 should be assessed with
specific consideration to the need for transfer to a critical care unit (high
dependency unit or intensive care unit).
26
Although severity assessment criteria (CURB-65) are useful to help
identify patients who may need hospitalization in the ward service or ICU, they
are not meant to replace clinical judgment.
h. Treatment of Pneumonia Among the Elderly
The most important treatment of pneumonia is antibiotic chemotherapy.
Although there are no specific choice regarding the selection of drugs
according to pathogenic bacteria, careful attention should be given to
administration and dosage. Table 4 lists precautions in introducing antibiotic
therapy on elderly pneumonia patients.(28-29) They are well summarized and
provide sufficient information.
Of these precautions, the most important point to notice is underlying
renal dysfunction in the elderly. Table 5 shows the dosage and administration
27
for using antibacterial agents in such a case.Treatment should be planned on
the basis of this table.
As the therapies other than chemotherapy, managements of
dehydration, diet, or body temperature are needed. Also, expectoration of
bronchial secretion are required to subside pneumonia.
In addition, some nonantibiotic strategies may be important when
treating pneumonia in elderly populations. In older patients, the pneumonia
process often extends beyond the lung parenchyma, presenting as a systemic
disease with higher severity of illness. This is supported by the finding that
many elderly pneumonia patients present with primarily nonpulmonary
symptoms, such as mental status changes or renal dysfunction.
28
1. Antibiotic therapy for CAP
For patients treated in the community, amoxicillin remains the preferred
agent at a dose of 500 mg three times daily. Either doxycycline or
clarithromycin are appropriate as an alternative choice, and for those patients
who are hypersensitive to penicillins. Those with features of moderate or high
severity infection should be admitted urgently to hospital.
For those patients referred to hospital with suspected CAP and where
the illness is considered to be life- threatening, general practitioners should
administer antibiotics in the community. Penicillin G 1.2 g intravenously or
amoxicillin 1 g orally are the preferred agents.
For those patients referred to hospital with suspected high severity
CAP and where there are likely to be delays of over 6 h in the patient being
admitted and treated in hospital, general practitioners should consider
administering antibiotics in the community. A diagnosis of CAP should be
confirmed by chest radiography before the commencement of antibiotics in
the majority of patients. Selected patients with life- threatening disease should
be treated based on a presumptive clinical diagnosis of CAP. In such
instances, an immediate chest radiograph to confirm the diagnosis or to
indicate an alternative diagnosis is indicated.
All patients should receive antibiotics as soon as the diagnosis of CAP
is confirmed. This should be before they leave the initial assessment area
(emergency department or medical assessment unit). The objective for any
service should be to confirm a diagnosis of pneumonia with chest radiography
and initiate antibiotic therapy for the majority of patients with CAP within 4 h of
presentation to hospital.
29
Most patients with low severity CAP can be adequately treated with
oral antibiotics. Oral therapy with amoxicillin is preferred for patients with low
severity CAP who require hospital admission for other reasons such as
unstable comorbid illnesses or social needs. When oral therapy is
contraindicated, recommended parenteral choices include intravenous
amoxicillin or benzylpenicillin, or clarithromycin.
Most patients with moderate severity CAP can be adequately treated
with oral antibiotics. Oral therapy with amoxicillin and a macrolide is preferred
for patients with moderate severity CAP who require hospital admission.
Mono therapy with a macrolide may be suitable for patients who have
failed to respond to an adequate course of amoxicillin prior to admission.
Deciding on the adequacy of prior therapy is difficult and is a matter of
individual clinical judgement. It is therefore recommended that combination
antibiotic therapy is the preferred choice in this situation and that the decision
to adopt mono therapy is reviewed on the ‘‘post take’’ round within the first 24
h of admission.
When oral therapy is contraindicated, the preferred parenteral choices
include intravenous amoxicillin or benzylpenicillin, together with
clarithromycin. For those intolerant of penicillins or macrolides, oral doxycyline
is the main alternative agent. Oral levo- floxacin and oral moxifloxacin are
other alternative choices.
When oral therapy is contraindicated in those intolerant of penicillins,
recommended parenteral choices include levofloxacin mono therapy or a
second-generation (eg, cefuroxime) or third-generation (eg, cefotaxime or
ceftriaxone) cephalosporin together with clarithromycin.
30
Patients with high severity pneumonia should be treated immediately
after diagnosis with parenteral antibiotics. An intravenous combination of a
broad-spectrum b- lactamase stable antibiotic such as co-amoxiclav together
with a macrolide such as clarithromycin is preferred. In patients allergic to
penicillin, a second-generation (eg, cefuroxime) or third-generation (eg,
cefotaxime or ceftriaxone) cephalosporin can be used instead of co-
amoxiclav, together with clarithromycin.
Table 6. Initial empirical treatment regimens for pneumonia
source : British Thoracic Society : Guidelines for the management of community acquired
pneumonia, update 2009
The oral route is recommended in those with low and moderate
severity CAP admitted to hospital provided there are no contraindications to
31
oral therapy. Patients treated initially with parenteral antibiotics should be
transferred to an oral regimen as soon as clinical improvement occurs and the
temperature has been normal for 24 h, providing there is no contraindication
to the oral route.
For community managed and for most patients admitted to hospital
with low or moderate severity and uncomplicated pneumonia, 7 days of
appropriate antibiotics is recommended.
For those with high severity microbiologically-undefined pneumonia, 7–
10 days treatment is proposed. This may need to be extended to 14 or 21
days according to clinical judgment; for example, where S aureus or Gram-
negative enteric bacilli pneumonia is suspected or confirmed.
This following algorithm made by IDSA (Infectious Diseases Society of
America) and ATS (American Thoracic Society) for the steps of CAP
treatment :
32
Table 7. Antibiotic therapy (choices in order of preference) for community-acquired pneumonia when the etiology is unknown
source: American Thoracic Society and the Infectious Diseases Society of America
From PDPI (Perhimpunan Dokter Paru Indonesia) 2004, treatment for
CAP is divided into three categories by where the patient treated, the
ambulatory basis patients (without modification factors, with modification
factors, atypical pneumonia suspected), hospital ward patient (without
modification factors, with modification factors, atypical pneumonia suspected),
and intensive care unit patients (risk factors for pseudomonas infections +/-).
33
The ambulatory basis patients without modification factors could be
treated by β-lactam or β-lactam +anti β-lactamase. The ambulatory basis
patients with modification factors treated by β-lactam or β-lactam +anti β-
lactamase or respiratory fluoroquinolone (levofloxacin, moxifloxacin), and
atypical pneumonia patiens treated by macrolide (azithromycin).
For patients to be treated in hospital ward without modification factors :
β-lactam or β-lactam +anti β-lactamase iv, or, cephalosporin 3rd generation iv,
or, flouroquinolone iv. If modification factors detected, we can choose
cephalosporin 3rd generation iv, or, respiratory flouroquinolone. Atypical
pneumonia patients treated by macrolide (azithromycin).
Intensive care unit-patients divided by the risk of pseudomonas
infections. If the risk is high, we can give cephalosporin 3rd generation iv and
macrolide or fluoroquinolon.
Table 8. Recommended treatment of microbiologically documented
pneumonia and
34
source : British Thoracic Society : Guidelines for the management of community acquired
pneumonia, update 2009
2. Antibiotic Therapy for HAP
Table 9. Initial Empiric AB therapy for HAP or VAP in patients with no known risk factors for multidrug-resistant pathogens, early onset, and any disease
severity.
Source : American Journal of Respiratory and Critical Care Medicine Vol 171
35
Table 10. Initial IV, adult doses of antibiotics for empiric therapy of HAP or
VAP in patients with late onset disease or risk factors for multidrug-resistant
pathogens
Source : American Journal of Respiratory and Critical Care Medicine Vol 171
i. Prevention
Vaccination is the mainstay for prevention of CAP. All persons aged
65 years and over should receive the pneumococcal polysaccharides vaccine.
The efficacy of revaccination is unknown. All persons aged 50 years and over
should receive inactivated influenza vaccine during the autumn and winter.
Chemoprophylaxis for influenza infection with oseltamivir or zanamivir for
those who have household exposure or are at high risk for influenza
36
complications in the setting of an outbreak. A smoking cessation plan should
be offered to all elderly smoker patients, since nearly a third of pneumonia
episodes could be attributed to smoking.
Table 11. Pneumonia vaccination
37
j. Conclusion
The growth of the number of elderly in Indonesia was recorded as the
most rapid in the world in the period 1990-2025, and it made the number of
elderly in Indonesia will be ranked fourth in the world, under China, India, and
the United States. While in Jakarta, based on data from a national health
survey of 2001, there were 641,124 elderly or around 8.64% of the total
population of Jakarta, amounting to 7,423,379 people.
Increasing number of the elderly will be followed by greater number of
geriatric patients who may demand health care services. To deal with geriatric
diseases requires an holistic approach and a total care to patients in an
integrated way. Total care is when a patient requires a caregiver in order to
have all their survival needs met, including ambulation, respiration, bathing,
dressing, feeding, and toileting. Holistic health is a concept in medical practice
upholding that all aspects of people’s needs including : psychological,
physical, social and spiritual should be taken into account and seen as whole.
Until now, pneumonia is the leading cause of death in hospitalized
geriatric patient. Pneumonia can be generally defined as inflammation of the
lung parenchyma, in which consolidation of the affected part and a filling of
the alveolar air spaces with exudate, inflammatory cells, and fibrin is
characteristic, caused by bacteria, viruses, or parasites. There are no critical
differences in pneumonia between the elderly and the younger population.
The most striking characteristic of pneumonia in the very old is its clinical
presentation: falls and confusion are frequently encountered, while classic
symptoms of pneumonia are often absent. Severity assessment tools can
help predict mortality and determine the optimal setting in which to provide
38
care for patients with CAP. Empiric antimicrobial regiment should cover
S.Pneumoniae with β-lactam medications or new respiratory flouroquinolones,
and atypical pathogens should be treated with macrolides or respiratory
fouroquinolones.
Vaccination is the mainstay for prevention of CAP. All elderly should
receive the pneumococcal polysaccharides vaccine. The efficacy of
revaccination is unknown.
39
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