2. Definition
• Pneumonia is an inflammatory condition of the lung affecting primarily the
alveoli. It is most commonly caused by bacteria, but the implication of viruses is
now recognized
• Pneumonia is often classified in relation to where it was acquired:
• Community-acquired pneumonia (CAP)
• Nursing home-acquired pneumonia (NHAP)
• Hospital-acquired pneumonia (HAP):
• HAP is defined as pneumonia which manifests 48 h or more after admission to hospital
• Ventilator-associated pneumonia (VAP):
• VAP generally occurs more than 48–72 h after endotracheal intubation
• Healthcare-acquired pneumonia (HCAP):
• Occurs in patients with frequent contact with the health system, numerous antibiotic intake and/or a
functional state of frailty
• Pneumonia is also classified by its physio-pathological mechanism (i.e.,
aspiration pneumonia) or, if identified, by the etiological pathogen
3. Pathogens of pneumonia in older patients
Gram-positive cocci Gram-negative
bacilli
Atypical pathogens Viral pathogens Other
Streptococcus
pneumoniae
Haemophilus
influenzae
Legionella species Influenza (e.g., H1N1
and seasonal flu)
Anaerobes
Drug-
resistant Streptococcus
pneumoniae
(penicillin and macrolide
resistant)
Escherichia coli Mycoplasma
pneumoniae
Parainfluenza Endemic and
opportunistic
Staphylococcus aureus Klebsiella species Chlamydophila
pneumoniae
Severe acute
respiratory syndrome
Mycobacterium
tuberculosis
Community-acquired
methicillin-resistant
Staphylococcus aureus
Pseudomonas
aeruginosa
Coxiella burnetii (rare) COVID 19 Nontuberculous
mycobacteria
4. Risk factors
• Physiological changes linked to the progressive decline of
the respiratory tree
• The mucociliary clearance and the coughing reflexes are
reduced leading to a poor airway clearance
• The immunosenescence involves alterations to the innate
and adaptive immune systems favoring infections after
broncho-aspirations
• Increased virulence of pathogenic microorganisms
• Influenza, latentic infections (eg tuberculosis)
• Severe comorbidities
• GERD
• Swallowing disorder:
• Oropharyngeal dysphagia (OD) is recognized as one of the
major pathophysiological mechanisms leading to aspiration
pneumonia
• Poor oral health
• Impaired consciousness, mental diseases
• Hypokynesis, coma
• Malnutrition, starvation:
• Malnutrition (evaluated by mini nutritional assessment, body
mass index (BMI) and serum albumin levels) is also highly
prevalent and strongly associated with OD and pneumonia in
older patients hospitalized for an acute disease
• Surgical interventions
• Prolonged hospitalization
• Invasive interventions (eg mechanical lung ventilation,
tracheostomy)
• Smoking, alcohol abuse
• Long-term drugs: anticholinergics, sedatives, hypnotics,
corticosteroids, antacids
• Presence in long - term care facilities
In older patients, special attention should be paid to patients with swallowing disorders, malnutrition,
high rate of comorbidities, poor functional and bedridden status as predisposing factors for pneumonia
5. Risk for pneumonia
Morbidities Risk of pneumonia
Chronic cardiovascular disease 3 × the risk
Chronic respiratory disease 2 to 4 × the risk
Neurological disease (cerebrovascular disease or
stroke, and neurodegenerative disease)
2 × the risk
Chronic renal disease 2 × the risk
Chronic liver disease 2 × the risk
Diabetes mellitus Moderate risk
Cancer Moderate risk
Immunosuppression: asplenia, HIV 2 × the risk
Rheumatoid arthritis Moderate risk
Previous pneumonia Moderate risk
Stupka JE, Mortensen EM, Anzueto A, Restrepo MI. Community-acquired pneumonia in elderly patients. Aging health. 2009;5(6):763-774. doi:10.2217/ahe.09.74
6. Clinical presentation of pneumonia in older
persons
• The classical diagnostic triad of cough, fever and dyspnea may only be present in fewer than
60% of patients:
• As a general rule, the older and frail patients, the more likely the classical pneumonia syndrome will
manifest incompletely
• Physicians should be alert to the diagnosis of pneumonia in older patients, even in the absence of the
classic symptoms
• Atypical presentations in which pneumonia must be considered include:
• Gradual onset
• Clinical presentation of pneumonia in the elderly may be subtle, and may be afebrile
• Falls
• Confusion/delirium
• New or worsening incontinence
• Worsening comorbidities (e.g. worsening cardiac failure) or deteriorating function in activities of daily living
• The cough nonproductive or may absent
• Other non-respiratory symptoms
• Normal sounds of lungs auscultation do not rule out a diagnosis of pneumonia:
• Auscultation findings are unremarkable in 35% of patients
• A respiratory rate >20 breaths per minute is the earliest and most sensitive sign and may precede other
signs by three to four days
Anita R. Modi, Christopher S. Kovacs. Cleveland Clinic Journal of Medicine March 2020, 87 (3) 145-151
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019
SA Fam Pract 2006;48(5): 24-28)
7. Complications of pneumonia
Complications:
• Pleuritis
• Lung abscess
• Empiema
• Respiratory failure
• Bacteremia (sepsis) and shock
• Damage of internal organs (meningitis, pericarditis,
endocarditis)
• Mortality:
• Mortality from pneumonia can reach 30-60 percent
• Mortality increases with delirium, immobility,
hypothermia, tachypnea, CRP> 100 mg / l,
hypoalbuminemia, dysphagia and possible aspiration
• The most common causes of death are respiratory
failure, shock, and multiorganic failure
Clinical features associated with a poor
prognosis of pneumonia and/or
mortality:
• Respiratory rate >30 breaths/ minute
• Heart rate >125 beats/ minute
• Altered mental status
• Hypotension (systolic BP <100 mm Hg )
• History of dementia
• CRP >100 mg/l
• Acute aggravation of comorbid chronic diseases,
especially diabetes, cardiac, renal and liver
Ther Adv Infect Dis. 2014 Feb; 2(1): 3–16
8. Diagnosis: laboratory tests
• The recommended blood tests include:
• CBC
• In 50 percent cases leukocytosis may absent,
note the deviation of the formula to the left (≥
90%)
• Measurement of renal parameters (urea,
creatinine, GFR)
• Electrolytes, glucosis
• C reactive protein (CRP) is a sensitive, age-
independent marker that decreases after a
favourable treatment response:
• A CRP level of 100 mg/l or higher has been
independently associated with mortality in
older patients with pneumonia
• Procalcitonin test is more sensitive
• Culture:
• Sputum:
• An older person produces less sputum and
coughs ineffectively, thus reliable sputum
samples are rarely obtained
• Indications for blood culture:
• Intensive care unit admission
• Cavitary infiltrates
• Leukopenia
• Active alcohol abuse
• Chronic liver failure
• Asplenia (anatomic or functional)
• Positive pneumococcal urine antigen test
• Pleural effusion
• Serological (SARS-CoV-2 RNA by RT-PCR,
SARS-CoV-2 antigen tests)
• Blood gas
Anita R. Modi, and Christopher S. Kovacs. Cleveland Clinic Journal of Medicine March 2020, 87 (3) 145-151
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care
Med 2019; 200(7):e45–e67
9. Diagnosis: X - ray
• The gold standard is a chest X-ray
• In the early stages uninformative in the
following cases:
• In dehydrated patients, infiltration and
consolidation are not seen on the X - ray,
infiltration becomes apparent after hydration
• Neutropenia and Gram-negative pneumonia or
endobronchial tuberculosis
• It is difficult to perform in patients with
dementia, agitation (delirium) or severe
dyspnea
• Absorption may take up to 3 months
• Other investigations: bronchoscopy, CT of
the lungs, pleural sonoscopy
Anita R. Modi, and Christopher S. Kovacs. Cleveland Clinic Journal of Medicine March 2020, 87 (3) 145-151
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care
Med 2019; 200(7):e45–e67
11. Diagnosis of aspirative pneumonia (1)
• Criteria:
• Big risk for aspiration due to dysphagia
• Infiltration in typical segments of the lungs
• Other investigations: videofluoroscopy , FEES, electromyography
12. Diagnosis of aspirative pneumonia (2)
Localization of infiltration:
• Lying down position - posterior
segments of the upper lobes
and upper segments of the
lower lobes
• Half lying down or vertical
position- basal segments of the
lower lobes, more often on the
right side
14. Common stratification scores to assess severity
and need for hospitalization in patients with
community-acquired pneumonia
• Pneumonia severity index score
• A total of 20 parameters are evaluated at the time of clinical presentation
and consist of:
• Three demographics (age [1 point per year of age], females [−10 points] and nursing-
home resident [+10 points]);
• Five comorbid conditions (neoplasia [+30 points], liver disease [+20 points],
congestive heart failure [+10 points], cerebrovascular disease [+10 points] and renal
disease [+10 points]);
• Five physical examination findings (confusion [+20 points], tachypnea [+20 points],
hypotension [+20 points], temperature [+15 points] and tachycardia [+15 points]);
• Seven laboratory/imaging variables (arterial pH [+30 points], elevated blood urea
[+20 points], hyponatremia [+20 points], hyperglycemia [+10 points], anemia by
hematocrit [+10 points], pleural effusion [+10 points] and poor oxygenation [+10
points])
Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N. Engl. J. Med. 1997;336(4):243–250
15. Common stratification scores to assess severity
and need for hospitalization in patients with
community-acquired pneumonia
• CURB-65:
• Confusion (altered mental status; 1 point)
• Urea nitrogen in serum >19.6 mg/dl (1 point)
• Respiratory rate >30 breaths per min (1 point)
• Blood pressure (BP minus systolic BP <90 mmHg or diastolic BP <60 mmHg; 1
point)
• Age of 65 years or older (1 point)
CURB: Confusion, urea nitrogen, respiratory rate, blood pressure and age of 65 years or older
Lim WS, Lewis S, Macfarlane JT. Severity prediction rules in community acquired pneumonia: a validation study. Thorax. 2000;55(3):219–223
Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international
derivation and validation study. Thorax. 2003;58(5):377–382
16. Assessment of severity and need for
hospitalization in patients with community-
acquired pneumonia
Pneumonia severity index score CURB-65
Risk class Points Mortality (%) Recommended site of
care
Risk class Mortality (%) Recommended site
of care
I –
*
0.1 Outpatient 0 0.7 Outpatient
II <70 0.6 Outpatient 1 2.1 Outpatient
III 71–90 2.8 Outpatient or brief
inpatient
2 9.2 Inpatient
IV 91–130 8.2 Inpatient 3 14.5 Inpatient
V >130 29.2 Inpatient 4–5 40–57 Inpatient (possible
need of
intensive care unit
care)
*Risk class I: age <50 years, no comorbidities and absence of vital-sign abnormalities
Stupka JE, Mortensen EM, Anzueto A, Restrepo MI. Community-acquired pneumonia in elderly patients. Aging health. 2009;5(6):763-774
17. Initial antibiotic therapy for pneumonia
Outpatients without comorbidities
Amoxicillin
Or doxycycline
Or a macrolide
Outpatients with comorbidities
Combination therapy:
Amoxicillin/clavulanate or a cephalosporin
Plus a macrolide or doxycycline
Or monotherapy with a fluoroquinolone
Patients on a medical floor
A fluoroquinolone
Or a combination of a beta-lactam plus a macrolide
Intensive care patients
A beta-lactam
Plus either a macrolide or a fluoroquinolone
Add coverage as needed for:
Methicillin-resistant Staphylococcus aureus (MRSA)
Pseudomonas aeruginosa
Influenza A
• Empiric antimicrobial regimens should cover S.
pneumoniae with β-lactam medications or new
respiratory fluoroquinolones, and atypical pathogens
should be treated with macrolides or respiratory
fluoroquinolones
• Severe pneumonia patients admitted to the ICU should
be stratified as to whether or not the patients are at risk
for Pseudomonas species infection and be treated
accordingly
• The duration of therapy in pneumonia patients requiring
hospitalization is 7–10 days, but those with atypical
pathogens such as Legionella species, should receive
treatment for 10–14 days
• For influenza infection – antivirals agents (oseltamivir or
zanamivir)
• Antiviral drugs that are approved for the treatment of
COVID-19 - Remdesivir
Comorbidities include heart, lung, liver, or renal disease, diabetes mellitus,
alcoholism, malignancy, and asplenia
Anita R. Modi, Christopher S. Kovacs. Cleveland Clinic Journal of Medicine March 2020, 87 (3) 145-151
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice
guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019
18. Prevention of pneumonia in older persons (1)
Risk factor Recommendation
Patient status
Old age Vaccination against H. influenza and S. pneumonia
Swallowing disorder Thicken liquids, small bolus, adjust head position
Hyposalivation Chewing of gum, oral moisturizers
Malnutrition Food supplements, adjustment of diet, assuring chewing efficiency
Frailty Physiotherapy
CPAP prior to surgery and preoperative training
Environment
Environmental exposure Limit exposure to nitrogen dioxide and fine particulate matter
Living in a nursing home or frequently exposed
to healthcare environment
Favor home care when possible
Habits
Smoking Smoking cessation
Alcohol Adjust alcohol consumption
Chebib, N., Cuvelier, C., Malézieux-Picard, A. et al. Pneumonia prevention in the elderly patients: the other sides. Aging Clin Exp Res (2019)
Aging Clinical and Experimental Research https://doi.org/10.1007/s40520-019-01437-7
CPAP continuous positive airway pressure
19. Prevention of pneumonia in older persons (2)
Risk factor Recommendation
Medications
Immunosuppressive drugs and oral steroids Monitor carefully when used and adjust if possible
PPI and H2 receptor antagonists Monitor carefully when used and adjust if possible
Inhaled corticosteroids Monitor carefully when used and adjust if possible
Antipsychotics Monitor salivary flow and in case of hyposalivation treat xerostomia
Benzodiazepine Check level of sedation and adjust where necessary
Statin Prescribe when indicated, as it may reduce the risk of pneumonia
ACE inhibitors and ARB’s Prescribe when indicated, as it may reduce the risk of pneumonia in Parkinson patients
Amantadine Prescribe when indicated, as it may reduce the risk of pneumonia in stroke patients
Oral health
Oral hypofunction Regular dental check-up visits and treatment where indicated
Poor oral hygiene Daily oral hygiene in addition to regular oral hygiene provided by dental hygienist
Poor tongue hygiene Use of tongue scrapping
Dental prosthesis Assure denture hygiene and remove denture during sleep
PPI proton-pump inhibitors, H2 histamine 2 receptor antagonist, ACE inhibitors angiotensin-converting enzyme inhibitors, ARB angiotensin II receptor blockers
Chebib, N., Cuvelier, C., Malézieux-Picard, A. et al. Pneumonia prevention in the elderly patients: the other sides. Aging Clin Exp Res (2019)
Aging Clinical and Experimental Research https://doi.org/10.1007/s40520-019-01437-7
20. Examples of diagnoses and treatment plans (1)
• Pneumonia lobularis lobi inferioris dextri (sinistri, bilateralis).
Hypovolaemia (dehydratio)
• Treatment:
• Pulv. Cefuroximi 1,5 g+sol. NaCl 0,9 % -15,0 6:00-14:00-22:00 i/v (adjust dose
of cefuroxime if GFR<20 ml/min./1,72 m²)
• Sol. Ringeri 500,0 (or sol. Glucosae 5 % – 500,0) 12:00-17:00 i/v
• PVC (peripheral vein catheter) and care
23. Summary
• Pneumonia is the fifth leading cause of death and the most common cause of
death from infectious diseases in persons aged 65 years
• Immunosuppression, smoking, chronic obstructive pulmonary disease, congestive
heart failure, diabetes mellitus, lung cancer, serious nonpulmonary malignancy
and previous hospitalizations for pneumonia were all independently associated
with risk of patients aged 65 years and over
• The most common pathogen isolated in patients over 65 years is Streptococcus
pneumoniae, although atypicals and Gram-negative bacilli play an important role
• Empiric antimicrobial regimens should cover S. pneumoniae with β-lactam
medications or new respiratory fluoroquinolones, and atypical pathogens should
be treated with macrolides or respiratory fluoroquinolones
• Measures directed at prevention, such as vaccination for pneumococcal and
influenza infections, and smoking cessation programs for at-risk patients may
help to decrease the incidence and severity of pneumonia
