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DOI: 10.1177/20499361135180412014 2: 3Therapeutic Advances in Infectious Disease

Antonella F. Simonetti, Diego Viasus, Carolina Garcia-Vidal and Jordi CarratalManagement of community-acquired pneumonia in older adults

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Management of community-acquired

pneumonia in older adults

Antonella F. Simonetti, Diego Viasus, Carolina Garcia-Vidal and Jordi Carratala

Abstract:Community-acquired pneumonia (CAP) is an increasing problem among the elderly.Multiple factors related to ageing, such as comorbidities, nutritional status and swallowingdysfunction have been implicated in the increased incidence of CAP in the older population.Moreover, mortality in patients with CAP rises dramatically with increasing age. Streptococcuspneumoniaeis still the most common pathogen among the elderly, although CAP may also becaused by drug-resistant microorganisms and aspiration pneumonia. Furthermore, in theelderly CAP has a different clinical presentation, often lacking the typical acute symptomsobserved in younger adults, due to the lower local and systemic inflammatory response.

Several independent prognostic factors for mortality in the elderly have been identified,including factors related to pneumonia severity, inadequate response to infection, and lowfunctional status. CAP scores and biomarkers have lower prognostic value in the elderly, andso there is a need to find new scales or to set new cut-off points for current scores in thispopulation. Adherence to the current guidelines for CAP has a significant beneficial impact onclinical outcomes in elderly patients. Particular attention should also be paid to nutritionalstatus, fluid administration, functional status, and comorbidity stabilizing therapy in this groupof frail patients. This article presents an up-to-date review of the main aspects of CAP inelderly patients, including epidemiology, causative organisms, clinical features, and prognosis,and assesses key points for best practices for the management of the disease.

Keywords: clinical features, community-acquired pneumonia, elderly, etiology, management,

prognosis, treatment

What is the magnitude of the problem?Community-acquired pneumonia (CAP) is

among the most common infectious diseases

and causes significant morbidity and mortality

[Mandell et al. 2007]. CAP is an increasing prob-

lem among the elderly. CAP rates in older adults

are rising as a consequence of an overall increase

in the elderly population [Centers for Disease

Control and Prevention, 2003]. It has been

reported that CAP is the third most common

reason for hospitalization for persons aged 65

years and over [May et al. 1991], and in fact

nearly 50% of hospitalized patients with CAP

are in this age group [Niederman et al. 1998].

Interestingly, in a prospective cohort of 4534 hos-

pitalized patients with CAP (19952012), we

found that the number of patients aged 80 and

over has increased significantly in the last 17

years (Figure 1).

The incidence of hospitalized CAP is much

higher among elderly patients. In a US

Medicare cohort of patients 65 years, the inci-

dence was 18.3/1000 population and rose more

than fivefold, from 8.4/1000 in those aged 6569

years to 48.5/1000 in those aged 90 years or older

[Kaplanet al.2002]. In a Spanish cohort study of

11,240 inhabitants aged 65 years conducted

from 2002 to 2005, the annual incidence rate of

CAP was 13.9/1000 elderly persons/year [Vila-

Corcoles et al. 2009]. As in the US cohort, the

incidence also increased with age in this popula-

tion (from 9.9% in those aged 6574 years to

16.9% in those aged 7584 years, and to

29.4% in the over 85s) [Ochoa-Gondar et al.

2008].

Furthermore, mortality in hospitalized CAP

patients ranges between 10% and 25%, being

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Therapeutic Advances in Infectious Disease Review

Ther Adv Infect Dis

(2014) 2(1) 316

DOI: 10.1177/2049936113518041

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Correspondence to:Jordi Carratala, MD, PhD

Department of InfectiousDiseases, HospitalUniversitari de Bellvitge -IDIBELL, LHospitalet deLlobregat, Feixa Llarga

s/n, 08907, LHospitalet deLlobregat, Barcelona,[email protected]

Antonella F. Simonetti,

MD

Department of InfectiousDiseases, HospitalUniversitari de Bellvitge -IDIBELL, LHospitalet deLlobregat, Barcelona,Spain

Diego Viasus, MD, PhD

Department of InfectiousDiseases, HospitalUniversitari de Bellvitge -IDIBELL, LHospitalet deLlobregat, Barcelona,Spain and Spanish

Network for Research inInfectious Diseases(REIPI), Madrid, Spain

Carolina Garcia-Vidal,MD, PhD

Department of InfectiousDiseases, HospitalUniversitari de Bellvitge -IDIBELL, LHospitalet deLlobregat, Barcelona,Spain and SpanishNetwork for Research inInfectious Diseases(REIPI), Madrid, Spain

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particularly high in older adults and in patients

with comorbidities [Fernandez-Sabeet al. 2003].

In the Spanish cohort study just mentioned the

30-day case-fatality rate rose dramatically with

increasing age (7.2% in those aged 6574

years, 13.5% in those aged 7584 years and

23.5% in the over-85 s) [Ochoa-Gondar et al.

2008].

Key points

The elderly population is at an increased risk

for acquiring CAP and is more likely to suffer

from severe disease.

In the coming years, rates of CAP in older

adults will rise due to the overall increase in

the elderly population.

CAP in elderly patients is associated with

high morbidity and mortality. The risk of

poor outcome increases with age.

What are the predisposing factors for CAPin older patients?Several factors have been linked with an

increased risk of CAP in the elderly. Even in

healthy ageing without comorbidity, immunity

and lung function may be impaired. In older

patients, nasal mucociliary clearance has been

shown to be less efficient [Ho et al. 2001]. Age-

related effects on pulmonary host defenses have

been reported, such as mechanical barriers,

phagocytic activity, humoral and T-cell immun-

ity, in animal and human models [Meyer, 2001].

Similarly, changes in the immune system asso-

ciated with ageing involve, in particular, a decline

in peripheral antigen-specific T- and B-cell func-

tion. Finally, the function of natural killer cells,

macrophages, and neutrophils also decreases inthe elderly [Meyer, 2001; Renshaw et al. 2002;

Janssens and Krause, 2004].

A variety of methodological approaches have

been tested in attempts to identify independent

risk factors for CAP in the elderly. Jackson and

colleagues identified lung diseases, heart dis-

eases, weight loss, poor functional status,

and smoking as independent predictors for CAP

in older patients [Jackson et al. 2009].

Riquelme and colleagues found that suspicion

of swallowing disorders, large volume aspiration,

malnutrition, hypoproteinemia (7 mmol/l, Respiratory rate

(RR) 30/min, Blood pressure (systolic blood

pressure (BP)


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cancer, stroke) performed better than both

CURB-65 and PSI for predicting mortality

[Abisheganaden et al. 2012]. Moreover, it is

known that in advancing age both confusion

and increased urea are common and may be

affected by multiple confounding factors. For

this reason, Myint and colleagues also proposed

a new set of criteria named SOAR (Systolic BP,

Oxygenation, Age and Respiratory rate), for use

in older patients with CAP instead of CURB[Myint et al. 2006]. However, most authors

favor modifying existing scores in order to

improve their prognostic value rather than creat-

ing new tools for elderly patients [Brito and

Niederman, 2010].

Are biomarkers useful for predicting prognosis

in older patients?

Markers such as C-reactive protein (CRP) level,

white blood cell (WBC) count, procalcitonin

level, proadrenomedullin, and natriuretic pep-

tides are increasingly being used to assess the

prognosis of patients with CAP. However, few

studies have explored the value of biomarkers in

the elderly.

Ahkee and colleagues found an inverse relation

between mortality and WBC. In elderly patients

with CAP, the mortality rate was seven times

higher in those without leukocytosis on hospitaladmission than in the group with the condition.

The authors suggest that the lack of a systemic

inflammatory response may be seen as a marker

of an abnormal immune system [Ahkee et al.

1997]. However, a prospective study of 897

patients admitted with CAP found no difference

in interleukin (IL)-6 or in IL-10 levels between

younger patients and those older than 65 years.

This study presents further data rejecting the

Figure 2. Area under receiver operating characteristic curve (95% confidence interval) for predicting mortalityof PSI and CURB-65 scores by age group in 4534 hospitalized cases with community-acquired pneumonia in atertiary teaching hospital in Barcelona, Spain.

PSI, Pneumonia Severity Index; CURB-65, Confusion, Urea >7 mmol/l, Respiratory rate30/min, Blood pres-sure (systolic blood pressure


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view that older patients display a muted response

to pneumonia [Kelly et al. 2009].

More recently, the usefulness of other biomarkers

such as CRP and procalcitonin in elderly patients

has been evaluated. An analysis of a retrospectivecohort of 438 patients65 years with CAP did not

reveal any association between CRP or WBC and

mortality, or between CRP or WBC and pneumo-

nia severity [Thiemet al. 2009]. The investigators

stress that the same phenomenon has been iden-

tified for the prognostic value of risk scores. On

the other hand, a recent study [Kim et al. 2013]

reported a good correlation between procalcitonin

level and both PSI and CURB-65 in elderly

patients. However, no relationship was found

between procalcitonin and mortality.

What factors are associated with mortalityin older patients?

Several studies of CAP [Riquelme et al. 1996;

Rello et al. 1996; Garcia-Ordonez et al. 2001]

have failed to associate age alone with a higher

risk of mortality. In a cohort of patients with

severe CAP admitted to the ICU, no difference

in mortality rate was found between patients aged

6575 years and those over 75. This finding

stresses how inappropriate it is to withhold inten-

sive care from elderly patients on account of age,

because more than half may survive the respira-

tory infection and may return to their previous

lifestyle [Rello et al. 1996].

The data regarding the impact of comorbidities

in the outcome of elderly population with CAP

are controversial. Some researchers identify

comorbid illness as one of the most important

prognostic factors [Conte et al. 1999; Ma et al.

2011]. An association has also been found

between certain specific comorbid conditions

and mortality, such as chronic obstructive pul-

monary disease (COPD), cerebrovascular disease

[Neupane et al . 2010], renal disease, and

immunosuppression [Skull et al . 2009].

Nevertheless, many other studies of CAP in theelderly have not found an association between

comorbid illness and mortality [Lim and

Macfarlane, 2001; Janssens et al. 1996; Rello

et al. 1996; Riquelme et al. 1996].

Moreover, several independent prognostic factors

for mortality in the elderly have been identified

(Table 3). Many studies have reported the associ-

ation between mortality and the severity of

pneumonia, as expressed by its extension and

consequent respiratory failure [Riquelme et al.

1997; Garca-Ordonez et al. 2001; Naito et al.2006; Skull et al. 2009]. Another group of prog-

nostic factors for poor outcome is related to an

inadequate response to infection, such as septic

shock at admission, apyrexia, and altered mental

status [Riquelme et al. 1997; Garca-Ordonez

et al. 2001; Fernandez-Sabe et al. 2003]. The

third group of factors related to mortality includes

host characteristics: low functional status, bedrid-

den status, poor nutritional status, and passive or

active smoking have all been related to poor out-

come in elderly patients with CAP [Skull et al.

2009; Naito et al. 2006; Riquelme et al. 1997;

Maet al. 2011; Vecchiarino et al. 2004].

Key points

The accuracy of CURB-65 and PSI for pre-

dicting outcome in CAP decreases with

advancing age.

There are insufficient data to sustain the use-

fulness of biomarkers in older patients.

Severity and extension of pneumonia, inad-

equate response to infection, and low func-

tional status are the principal factors

associated with mortality in older patients.

What treatment should elderly patientswith CAP receive?Antimicrobials are the cornerstone of therapy for

CAP in any population, including the elderly.

The most recently published clinical practice

guidelines for CAP do not recommend different

treatments for elderly patients [Mandell et al.

2007; Woodhead et al. 2011].

Table 3. Factors associated with poor outcome forcommunity-acquired pneumonia in elderly patients.

Severity of pneumonia:3 lobes affectedtachypneasevere hypoxemia

hypercapniaInadequate response to infection:

shock at admissionapyrexiaaltered mental status

Factors related with the host:comorbiditieslow functional statusbedridden statuspoor nutritional statuspassive or active smokers

Therapeutic Advances in Infectious Disease2 (1)

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According to the IDSA/ATS guidelines, in the

outpatient setting, the recommended empirical

treatment is a macrolide for previously healthy

patients who have not used antimicrobials

within the previous 3 months. However, in

some countries macrolide-resistantS. pneumoniaeare frequent [Jones et al. 2010; European Centre

for Disease Prevention and Control,

20052013]. A respiratory fluoroquinolone or a

beta-lactam plus a macrolide are recommended

for patients with comorbidities. In hospitalized

patients with nonsevere CAP, the recommen-

dation is a respiratory fluoroquinolone or a

beta-lactam plus a macrolide. In severe CAP, a

combination of antibiotics is usually recom-

mended. A beta-lactam plus either azithromycin

or a respiratory fluoroquinolone are preferred. In

patients with predisposing factors for P. aerugi-

nosa or other Gram-negative bacilli an antipneu-mococcal, antipseudomonal beta-lactam plus

either a quinolone or an aminoglycoside and

azithromycin should be considered [Mandell

et al. 2007]. If MRSA is considered as a possible

causative organism, guidelines recommend

adding vancomycin or linezolid.

Importantly, it has been demonstrated that good

adherence to the 2007 IDSA/ATS guidelines for

CAP has a significant beneficial impact on clin-

ical outcomes in elderly patients. In a cohort of

1649 hospitalized CAP patients aged 65 years,

adherence to guidelines was associated with asignificantly shorter time taken to achieve clinical

stability compared with nonadherence.

Adherence to guidelines was also associated

with shorter length of stay (8 days versus 10

days) and decreased overall in-hospital mortality

(8%versus 17%) [Arnoldet al.2009]. Recently, a

Danish study in older patients with CAP

reported that the CAP guidelines were mainly

applied with regard to diagnostic tests and treat-

ment initiation whereas nutrition and mobiliza-

tion were neglected or only sporadically

addressed [Lindhardt et al. 2013].

Several studies have shown that elderly persons

hospitalized for CAP may be at increased risk of

functional loss during hospitalization and after

discharge. A lack of recovery in the first 3

months is associated with an increased risk of

hospital readmission and 1-year mortality [El

Solh et al. 2006]. For this reason, rehabilitation

of elderly patients during hospitalization and

post-discharge should be encouraged [Klausen

et al. 2012]. In addition, in elderly patients

special attention should also be paid to the

global assessment, including aspects such as

nutritional status, fluid therapy, comorbidity sta-

bilizing therapy, and patient information. A ran-

domized, controlled trial demonstrated that

nutritional supplementation in older patientsadmitted for pneumonia achieved a faster and

greater physical recovery [Woo et al. 1994].

Similarly, the use of a three-step critical pathway,

including early mobilization, was safe and effect-

ive in reducing the length of hospital stay for CAP

and did not adversely affect patient outcomes

[Carratala et al. 2012].

Importantly, a recent study showed that in elderly

patients with CAP, the decision to use a do not

resuscitate (DNR) order was taken in nearly 30%

of hospitalized patients [Oshitani et al. 2013]. In

this study physicians were more inclined to pro-pose DNR orders when CAP patients demon-

strated older in age (more than 75 years), poor

performance status, dementia, aspiration, low

albumin, extensive consolidation, and respiratory

failure. The decision to use DNR orders did not

make physicians choose less-intense antimicro-

bial treatments. Nevertheless effort to detect bac-

teria was not made in the DNR group as

elaborately as in the non-DNR g roup.

They also found that the DNR group has

higher 30-day mortality.

Key points

Adherence to guidelines for treatment of

CAP is highly recommended in the elderly.

Risk factors for P. aeruginosa, MRSA, and

other Gram-negative bacilli have to be con-

sidered when selecting antibiotic treatment.

Physicians should pay special attention to

nutrition, early mobilization, and comorbid-

ity-stabilizing therapy in older patients.

Which vaccines should be administered to

elderly patients in order to prevent CAP?Vaccination remains the primary preventive strat-egy for CAP in the elderly. Guidelines recom-

mend immunization against both influenza virus

andS. pneumoniaein patients above the age of 65.

Nevertheless, both vaccinations are substantially

underused in this vulnerable population.

Recent meta-analyses provide evidence support-

ing the recommendation of pneumococcal poly-

saccharide vaccine (PPV) to prevent invasive

AF Simonetti, D Viasus et al.




11/15

pneumococcal disease in adults, but, with regard

to adults with chronic illness, do not find compel-

ling evidence to support the routine use of PPV

to prevent all-cause pneumonia or mortality

[Moberley et al. 2013; Huss et al. 2009].

However, the 23-valent vaccine preventedpneumococcal pneumonia and reduced mortality

due to pneumococcal pneumonia in nursing-

home residents in a randomized trial

[Maruyamaet al. 2010]. Moreover, in a matched

casecontrol study in patients aged 65 years

and hospitalized with CAP, Domnguez and col-

leagues found an effectiveness of 23.6% for the

PPV for preventing hospitalizations due to pneu-

monia [Domnguezet al. 2010].

Recently, randomized trials have showed that 13-

valent pneumococcal conjugate vaccine (PCV13)

induces a greater functional immune responsethan PPSV23 for the majority of serotypes cov-

ered by PCV13 in adults [Jackson et al. 2013].

Consequently, the United States Food and Drug

Administration approved the use of the PCV13 in

this population. However, studies evaluating the

clinical effectiveness of PCV vaccination in adults

are lacking. Similarly, recently it was suggested

that there is no epidemiological reason to vaccin-

ate older adults with PCV due to the fact that

PCV vaccination of children has also reduced

the incidence of conjugate vaccine-serotype dis-

ease in older adults.

Regarding the impact of influenza vaccination on

CAP, a Cochrane meta-analysis did not find any

effect on hospital admissions, incidence of pneu-

monia, or complication rates between vaccinated

and unvaccinated patients [Jefferson et al. 2010].

However, in the elderly, vaccinations against

influenza and pneumococcus are associated

with reduced risk of hospitalization for heart dis-

ease and acute cardiovascular events. These find-

ings highlight the benefits of vaccination and

support efforts to increase vaccination rates

among the elderly [Nichol et al. 2003;

Lamontagne et al. 2008].

Key points

Current guidelines recommend vaccination

against S. pneumoniae and influenza in all

patients 65 years.

Nevertheless, coverage of both vaccinations

remains low; physicians should promote

their implementation.

ConclusionsThe elderly population is at an increased risk of

acquiring CAP and is more likely to suffer from

severe disease. In the coming years, CAP cases in

older adults will increase as a consequence of the

overall increase in the elderly population. Thespectrum of etiological pathogens in elderly

patients with CAP is diverse and shows substan-

tial variations between studies, butS. pneumoniae

is still the most common pathogen. Moreover,

drug-resistant microorganisms and aspiration

pneumonia should also be borne in mind.

Significantly, the clinical presentation in elderly

patients may be subtle and may lack the typical

acute symptoms, due to the lower local and sys-

temic inflammatory response. This suggests the

need to maintain a high suspicion of CAP in eld-

erly patients, even if they present with atypical

symptoms such as falls, altered mental statusand/or worsening of underlying diseases. The

usefulness of CAP-specific scores and biomarkers

to predict outcomes in elderly population is con-

troversial; we probably need to set different cutoff

points for current scores. New scales developed

recently for assessing severity in elderly patients

with CAP need further evaluation. Antimicrobial

selection for elderly patients with CAP is the

same as for younger adult populations; however,

when choosing the correct treatment, physicians

must carefully check for possible risk factors for

resistant microorganisms and evaluate the possi-

bility of aspiration pneumonia. In addition toantibiotic treatment, special attention should be

paid to the management of older patients, includ-

ing nutrition, rehabilitation, comorbidity stabil-

ization, and early mobilization. Preventive steps

such as pneumococcal and influenza vaccination

and measures aimed at improving nutritional

status may help to reduce CAP incidence.

FundingThis work was supported by the Fondo de

Investigacion Sanitaria de la Seguridad Social

(g rant number 11/01106) and Spains

Ministerio de Economia y Competitividad,

Instituto de Salud Carlos III, cofinanced by the

European Regional Development Fund A way to

achieve Europe and Spanish Network for

Research in Infectious Diseases (grant number

REIPI RD12/0015). Dr Simonetti is the recipient

of a research grant from the IDIBELL, Bellvitge

Biomedical Research Institute. Dr Viasus is the

recipient of a research grant from the REIPI. Dr

Garcia-Vidal is the recipient of a Juan de la





12/15

Cierva research grant from the Instituto de Salud

Carlos III, Madrid, Spain.

Conflict of interest statementNo authors have any conflicts of interest to

disclose.

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