Community-acquired pneumonia in the elderly - A practical guide to treatment

The incidence of community-acquired pneumonia (CAP), an infectious disease, sharply increases among the elderly and the main risk factor for CAP in th is age group is chronic comorbidity. The use of the term CAP in the elderly population should be reserved for pneumonia acquired outside of the nursin g home setting, since nursing home-acquired pneumonia differs from CAP in t erms of its aetiology and clinical manifestations. The main aetiology for CAP is Streptococcus pneumoniae, but atypical pathog ens also play an important role as causative agents. The clinical presentat ions of CAP in the elderly can be different from those in younger patients, and therefore it is important to be aware of and familiar with these diffe rences to avoid unnecessary delays in reaching the correct diagnosis. Imagi ng is essential to diagnose CAP and to assess its severity. Clinical and la boratory indices can be used to identify elderly patients with CAP who are at low risk for mortality and who can be treated as outpatients. The decisi on not to hospitalise elderly patients with CAP is contingent on a good cli nical condition and the existence of home support systems. The aetiology of CAP cannot be determined on the basis of clinical manifestations, imaging or routine laboratory test results, and the initial antibiotic therapy for elderly patients with CAP should be empirical, based on accepted guidelines . In the light of developments in recent years, elderly patients with CAP, ex cept those who are severely ill, can be treated empirically with once-daily antibiotic monotherapy in the initial phase, using a third-generation fluo roquinolone preparation, such as sparfloxacin, levofloxacin or moxifloxacin , or a new macrolide such as clarithromycin, azithromycin or dirithromycin. In addition to antibiotic therapy, it is critically important to identify and treat the physiological disturbances that accompany CAP as well as deco mpensation of chronic comorbid conditions. As soon as the patient's conditi on permits, oral antibiotic therapy should replace intravenous therapy and early discharge from the hospital should be considered. Since influenza and pneumococcus immunisation can reduce morbidity and mortality from CAP, it is important to implement regular immunisation programmes in the primary ca re setting.