Dr Asmaa fathy abdellah hassan Infection in Elderly Dr Asmaa fathy abdellah hassan Lecturer of Geriatric Medicine Department of Geriatric and Gerontology Ain Shams University

PNEUMONIA There are three types of pneumonia in the elderly: community-acquired, nursing home-acquired, and nosocomial pneumonia. healthcare-associated pneumonia (HCAP) was defined as pneumonia in non hospitalized patients who had significant experience with the healthcare system.

RISK FACTORS Chronic obstructive pulmonary disease and smoking are the most pervasive risk factors for CAP. Smoking cessation for 5 years may reduce excess risk of CAP by almost half. 2. Congestive heart failure 3. Diabetes 4. lung cancer 5. immunosuppression 6. Previous pneumonia 7. other malignancies

SYMPTOMS AND SIGNS OF CAP • Classical: • Cough with or without sputum production, dyspnea, pleurisy chest pain, fever, and chills are blunted or nonexistent in elderly patients who have pneumonia. • Elderly patients are almost twice as likely to have tachypnea as younger patients. • Delirium, dizziness, falls • Sepsis up to septic shock or ARDS

Signs of bacterial pneumonia may include the following: Hyperthermia (fever, typically >38°C) or hypothermia (< 35°C) Tachypnea (>18 respirations/min) Use of accessory respiratory muscles Tachycardia (>100 bpm) or bradycardia (< 60 bpm) Central cyanosis Altered mental status

Local Physical findings may include the following: Adventitious breath sounds, such as rales/crackles, rhonchi, or wheezes Decreased intensity of breath sounds Dullness to percussion Tracheal deviation Lymphadenopathy Pleural friction rub

ORGANISMS CAP: Streptococcus pneumoniae, Haemophilus influenzae Staphylococcus aureus, Moraxella catarrhalis, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae , Atypical: Legionella pneumophilia, Chlamydia pneumoniae, Coxiella burnetti, Mycoplasma pneumoniae Viruses: Influenza A, Parainfluenza HAP: resistant organisms such as Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae , MRSA. NHAP: Streptococcus pneumoniae, haemophilus influenzae,Moraxella catarrhalis

SEVERITY OF PNEUMONIA: There are a variety of assessment tools that can assist in determining the severity of pneumonia. CURB-65 The modified American Thoracic Society (ATS) guidelines. Pneumonia severity index scoring the CURB-65 score can stratify patients into 3 different management options: group 1 (score 0 or 1) was found to have a low mortality of 1.5% and can be considered for outpatient management group 2 (score of 2, mortality intermediate 9.2%, can be considered for hospital supervised treatment; group 3 (score 3or more, mortality high at 22%,) should be considered for intensive care management if appropriate.

CRITERIA: HOSPITALIZATION INDICATIONS IN NURSING HOME RESIDENTS Indications for hospitalization (2 or more) : Respiratory Rate >30 bpm or 10 bpm over baseline Oxygen Saturation <90% on room air Systolic BP <90 mmhg or 20 mm Hg below baseline Oxygen requirement >3 LPM over baseline Uncontrolled comorbidity (Uncontrolled Chronic Obstructive Pulmonary Disease ,Uncontrolled Congestive Heart Failure, Uncontrolled Diabetes Mellitus). Altered Level of Consciousness (New Somnolence , New or increased agitation). Facility unable to care for patient ( Vital Signs every 4 hours , Lab access, Parenteral hydration , Licensed nursing available).

INVESTIGATIONS • Leucocytosis and increase in band forms develop less frequently in elderly patients and are thus less sensitive in the detection of pneumonia. • a normal CRP value virtually excludes pneumonia, even in the very old. • Blood gas analysis • Microbiology: sputum analysis • Blood cultures twice • TEST for urinary legionella antigen ,PCR testing for Chlamydia spp, M pneumoniae, and common respiratory viruses are now available, but their clinical usefulness has not yet been established. • BUN, electrolytes, glucose prognostic value

MANAGEMENT: Supportive ttt: 1. Chest percussion 2. Rehydration 3. Bronchodilators 4. Oxygen therapy or mechanical ventilation

INSTITUTIONALLY ACQUIRED PNEUMONIA Initial regimens should be broadly inclusive, followed by step-down therapy to narrower coverage if the causative agent is identified • For MRSA-colonized patients or patients in units with high rates of MRSA, initial regimens should include vancomycin or linezolid until MRSA is excluded. • Patients with improving hospital-acquired pneumonia not caused by nonfermenting gram-negative bacilli (eg, Pseudomonas, Stenotrophomonas) can receive short courses of antibiotics (8 days).

DURATION OF ANTIBIOTIC THERAPY Patients with CAP should be treated for: a minimum of 5 days . 2. should be afebrile for 48–72 h. Most patients with CAP have been treated for 7–10 days longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infection, such as meningitis or endocarditis

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