Sunday, December 4, 2022

Antibiotics For Pneumonia In Elderly

What About Hospital Treatment

Treating Community-Acquired Pneumonia

Hospital admission may be advised if you have severe pneumonia, or if symptoms do not quickly improve after you have started antibiotic treatment. Also, you are more likely to be treated in hospital if you are already in poor health, or if an infection with a more serious infecting germ is suspected. For example, if infection with Legionella pneumophila is suspected. Even if you are in hospital, you are likely to be offered antibiotics in capsule, tablet or liquid form unless you have difficulties taking them, in which case they may be given through a vein. Your antibiotic treatment will be stopped after five days, unless you are very unwell.

Sometimes oxygen and other supportive treatments are needed if you have severe pneumonia. Those who become severely unwell may need treatment in an intensive care unit.

When you return home, even though the infection is treated, you may feel tired and unwell for some time.

What Is The Mortality Of Cap

The reported mortality of adults with CAP managed in the community is low and less than 1%. Deaths in the community due to CAP are rare in the UK. In one study only seven cases were identified by coronersâ post mortems over 1 year in Nottingham, a large urban city of three quarters of a million, giving an incidence of 1 per 100â000.

The reported mortality of adults hospitalised with CAP has varied widely. The BTS multicentre study reported a mortality of 5.7%, but did not study patients over the age of 74 years. Other UK studies have reported mortalities of 8%, 12% and 14%. Countries with similar healthcare systems have reported hospital mortality rates of 4%, 7%, 8% and 10%.

The longer term mortality of CAP is high, reflecting the frailty of many patients who develop CAP in the first instance. In a US study the 90-day all-cause mortality was 8.7% and mortality at 5.9 years was 39.1%. Age, level of education, male sex and nursing home residence were independently associated with long-term mortality. Other studies found long-term mortality to be 20.8% at 1 year, 34.1% at a mean of 901 days and 35.8% at 5 years.

Summary

What Predictive Models For Assessing Severity On Or Shortly After Hospital Admission Have Been Tested

Clinical assessment of disease severity is dependent on the experience of the attending clinician, but such clinical judgement has been shown to result in apparent underestimation of severity. No single prognostic factor of mortality is adequately specific and sensitive, so various severity scoring systems and predictive models have been developed in an attempt to help the clinician identify patients with pneumonia and a poor prognosis at an early stage.

  • No predictive model allows the unequivocal categorisation of patients into definite risk groups.

  • Predictive models based on severity are best viewed as useful adjuncts to clinical judgement.

  • Regular reassessment of severity during the course of hospital stay is mandatory if treatment is to be adjusted appropriately, avoiding the morbidity of overtreatment as well as the complications of undertreatment.

6.3.1 Pneumonia-specific predictive models

Pneumonia Severity Index

In clinical practice, the major limitation of the PSI with regard to its widespread and routine adoption in primary care, emergency departments or medical admission units is the complexity involved in the calculation of the score.

CURB65 score

6.3.2 Generic predictive models

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How Is Pneumonia Treated

Pneumonia can be serious so its important to get treatment quickly. The main treatment for pneumonia is antibiotics, along with rest and drinking plenty of water. If you have chest pain, you can take pain killers such as paracetamol.

Treatment depends on how severe your pneumonia is. Treatment with antibiotics should be started as soon as possible after diagnosis. If youre admitted to hospital, this should be within 4 hours of admission.

What Is The Recovery Time For Pneumonia In The Elderly

Antibiotic Therapy for Adults Hospitalized With Community

A simple Google search for that question makes us think that an elderly person can recover from pneumonia in in as little as two weeks but it may take two months or longer to recover completely.

A study that appeared in the Patient Related Outcome Measures Journal shed some light on the vast difference between a short recovery and a long one.

They begin by understanding the health status of the elderly person who is afflicted with pneumonia. For those that are in good health, expect a recovery time of about three weeks. In that period, shortness of breath, weakness, and fatigue are common. If the elderly person has existing health conditions, especially those that involve the respiratory system, such as COPD the recovery period can take as long as 60 or more days and be far more challenging.

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When Should The Chest Radiograph Be Repeated During Recovery And What Action Should Be Taken If The Radiograph Has Not Returned To Normal

Repeat chest radiographs are probably often ordered unnecessarily following CAP. Although it has become usual practice to repeat the chest radiograph on hospital discharge and again at âroutineâ hospital clinic follow-up at around 6 weeks later, there is no evidence on which to base a recommendation regarding the value of this practice in patients who have otherwise recovered satisfactorily.

The practice of performing bronchoscopy in patients admitted to hospital with CAP prior to hospital discharge has been investigated. In patients aged > 50 years or who were current or ex-smokers, 14% were found to have an abnormality at bronchoscopy .

Recommendations

  • The chest radiograph need not be repeated prior to hospital discharge in those who have made a satisfactory clinical recovery from CAP.

  • A chest radiograph should be arranged after about 6 weeks for all those patients who have persistence of symptoms or physical signs or who are at higher risk of underlying malignancy whether or not they have been admitted to hospital.

  • Further investigations which may include bronchoscopy should be considered in patients with persisting signs, symptoms and radiological abnormalities at around 6 weeks after completing treatment.

  • It is the responsibility of the hospital team to arrange the follow-up plan with the patient and the general practitioner for those patients admitted to hospital .

Therapeutic Strategies To Manage Cap In Elderly Patients

Antimicrobials are the cornerstone of therapy for CAP in any population, including the elderly. In addition, some nonantibiotic strategies may be important when treating CAP 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 CAP patients present with primarily nonpulmonary symptoms, such as mental status changes or renal dysfunction. Owing to this fact, the following discussion will focus on both the antibiotic and nonantibiotic therapies for elderly patients with CAP. The therapeutic strategies reviewed next are an update from our prior work published in Aging Health, and the discussion is designed to serve as a review of the most relevant literature since the initial publication in 2006 .

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Study Design And Antimicrobial Therapy

This was a multicentre, prospective, randomized, double-blind trial. Patients were randomlyassigned to two groups of equal size, to receive either cefepime 2 g every 12 h for a minimum of3 days and up to 14 days or ceftriaxone 1 g every 12 h for a minimum of 3 days and up to 14days. Pharmacists adjusted the dosage of cefepime in the presence of a reduced creatinineclearance. The study investigators were kept unaware of dosage alterations. Antibiotic therapywas maintained until at least 48 h after the resolution of fever. No other antibiotics werepermitted.

What General Investigations Should Be Done In A Patient With Suspected Cap In The Community

Vaccination against pneumococcal pneumonia in elderly Video abstract [130405]

General investigations are performed to assess severity , to assess the impact on or to detect the presence of any comorbid disease, to provide some pointer to the particular aetiological agent or group of pathogens, identify complications and to monitor progress .

It may be appropriate to perform investigations in selected patients, especially if there is delayed improvement on review. However, no firm recommendations can be offered. It is a matter of clinical judgement.

Recommendations

  • General investigations are not necessary for the majority of patients with CAP who are managed in the community. Pulse oximeters allow for simple assessment of oxygenation. General practitioners, particularly those working in out-of-hours and emergency assessment centres, should consider their use .

  • Pulse oximetry should be available in all locations where emergency oxygen is used.

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What Factors And Action Should Be Considered In Patients Who Fail To Improve In Hospital

For patients in hospital with CAP, the median time to improvement in heart rate and blood pressure is 2 days and in temperature, respiratory rate and oxygen saturation is 3 days. Failure to improve with initial management may occur in 6â24% of patients.

Independent risk factors for failure to improve that have been identified include multilobar involvement, cavitating pneumonia, presence of a pleural effusion, co-existing liver disease, cancer or neurological disease, aspiration pneumonia, legionella pneumonia, Gram-negative pneumonia, leucopenia, high disease severity on admission and inappropriate antimicrobial therapy.

Patients who fail to improve have a poorer prognosis. Studies have reported a mean increase in length of hospital stay of 4 days and an increase in mortality.

Failure to improve should lead to consideration of various possibilities summarised in box 5.

Box 5 Reasons for failure to improve as expected

Incorrect diagnosis or complicating condition
  • Common

  • For example, in elderly patients

Recommendations

What Is Walking Pneumonia

Walking pneumonia is a mild form of pneumonia . This non-medical term has become a popular description because you may feel well enough to be walking around, carrying out your daily tasks and not even realize you have pneumonia.

Most of the time, walking pneumonia is caused by an atypical bacteria called Mycoplasma pneumoniae, which can live and grow in the nose, throat, windpipe and lungs . It can be treated with antibiotics.

Scientists call walking pneumonia caused by mycoplasma atypical because of the unique features of the bacteria itself. Several factors that make it atypical include:

  • Milder symptoms
  • Natural resistance to medicines that would normally treat bacterial infections
  • Often mistaken for a virus because they lack the typical cell structure of other bacteria

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What Review Policy Should Be Adopted In Patients Managed In The Community

When to review a patient with CAP in the community will be determined by the initial severity assessment and other factors such as reliable help in the home. Patients assessed as being at low severity should improve on appropriate therapy within 48 h, at which time severity reassessment is recommended. Those who fail to improve within 48 h should be considered for hospital admission. Patients who do not fulfil the criteria for low severity and are being managed at home will require more frequent review.

Recommendations

  • Review of patients in the community with CAP is recommended after 48 h or earlier if clinically indicated. Disease severity assessment should form part of the clinical review.

  • Those who fail to improve after 48 h of treatment should be considered for hospital admission or chest radiography.

Quality Improvement And Prevention

Treatment Of Community

The Centers for Medicare and Medicaid Services has developed a set of core measures for CAP that is collected for every hospital and reported on the Hospital Compare Web site . Adhering to national guidelines has been shown to improve length of hospital stay and other outcomes33,34 however, they do not take into account individual patient differences and should not supplant physician judgment. Pneumococcal vaccination is recommended for all persons 65 years and older, adults younger than 65 years who have chronic illness or asplenia, and all adults who smoke or have asthma.35 However, effectiveness may decrease with age, and studies evaluating its effectiveness against pneumonia without bacteremia have been mixed.3638 The influenza vaccine is also important for the prevention of CAP. However, its effectiveness is influenced by host factors and how closely the antigens in the vaccine are matched with the circulating influenza strain.12 The influenza vaccine has also been shown to effectively prevent pneumonia, hospitalization, and death in older persons.39

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Complications And Failure To Improve

Failure to improve in hospital

  • For patients who fail to improve as expected, there should be a careful review by an experienced clinician of the clinical history, examination, prescription chart and results of all available investigation results.

  • Further investigations including a repeat chest radiograph, C-reactive protein and white cell count and further specimens for microbiological testing should be considered in the light of any new information after the clinical review.

  • Referral to a respiratory physician should be considered.

  • Common complications of CAP

  • Early thoracocentesis is indicated for all patients with a parapneumonic effusion.

  • Those found to have an empyema or clear pleural fluid with pH < 7.2 should have early and effective pleural fluid drainage.

  • The British Thoracic Society guidelines for the management of pleural infection should be followed.

  • Less usual respiratory pathogens including anaerobes, S aureus, Gram-negative enteric bacilli and S milleri should be considered in the presence of lung abscess.

  • Prolonged antibiotic therapy of up to 6 weeks depending on clinical response and occasionally surgical drainage should be considered.

  • What Are The Economic Consequences Of Cap

    A prevalence-based burden of illness study estimated that CAP in the UK incurred a direct healthcare cost of £441 million annually at 1992â3 prices. The average cost for managing pneumonia in the community was estimated at £100 per episode compared with £1700â5100 when the patient required admission to hospital. Hospitalisation accounted for 87% of the total annual cost.

    A similar exercise conducted in 1997 in the USA calculated that annual costs of CAP amounted to $8.4 billion, 52% of the costs being for the inpatient care for 1.1 million patients and the remaining costs for the 4.4 million outpatient consultations. The average hospital length of stay varied between 5.8 days for those under 65 years of age and 7.8 days for older patients. A prospective study of costs and outcome of CAP from five hospitals in North America concluded that costs of antibiotic therapy varied widely but had no effect on outcome or mortality. Patients treated in the hospitals with the lowest costs did not have worse medical outcomes.

    Summary

    • The direct costs associated with CAP are high and mostly associated with inpatient care costs.

    • Substantial costs savings could likely be made by strategies to prevent CAP, to reduce the requirement for hospital admission and to shorten the length of hospital stay.

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    How To Prevent Pneumonia In Elderly Loved Ones

    The key to preventing complications like sepsis is preventing infections like pneumonia from occurring in the first place. Since influenza predisposes elderly people to pneumonia, the number of cases tends to spike during flu season. Dr. Schaffner recommends that all people over age 65 get an annual flu shot as well as a pneumococcal vaccine. This one-time shot protects against the Streptococcus pneumoniae bacteria.

    Caregivers and other family members should also be vaccinated to avoid getting sick themselves and passing the illness to their loved ones. The CDC recommends that anyone who has prolonged contact with an elderly person should get vaccinated, urges Dr. Schaffner.

    In addition to staying current with vaccines, a healthy lifestyle plays a critical role in preventing pneumonia. Quitting smoking, practicing good oral hygiene, exercising regularly and maintaining a healthy weight through a nutritious diet can all help boost a seniors immune system and stave off diseases. Of course, good hand-washing habits are another strong defense.

    It is important for family caregivers to educate themselves on pneumonia and other medical conditions that commonly affect seniors. This information will give you added peace of mind that you are doing as much as you can to keep your loved one healthy.

    Antibiotics For Community Acquired Pneumonia In Adult Outpatients

    Pneumonia Treatment, Nursing Interventions, Antibiotics Medication | NCLEX Respiratory Part 2

    Cochrane Database of Systematic Reviews 2009 October 7, : CD002109

    BACKGROUND: Community-acquired pneumonia , the sixth most common cause of death worldwide, is a common condition representing a significant disease burden for the community, particularly in the elderly. Antibiotics are helpful in treating CAP and are the standard treatment. CAP contributes significantly to antibiotic use, which is associated with the development of bacterial resistance and side-effects. Several studies have been published concerning treatment for CAP. Available data arises mainly hospitalized patients studies. This is an update of our 2004 Cochrane Review.

    OBJECTIVES: To summarize current evidence from randomized controlled trials concerning the efficacy of different antibiotic treatments for CAP in participants older than 12.

    SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials which contains the Cochrane Acute Respiratory Infections Groups Specialized Register MEDLINE , and EMBASE .

    SELECTION CRITERIA: RCTs in which one or more antibiotics were tested for the treatment of CAP in ambulatory adolescents or adults. Studies testing one or more antibiotics and reporting the diagnostic criteria as well as the clinical outcomes achieved, were considered for inclusion.

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    How Can Walking Pneumonia Be Prevented

    Unfortunately, no vaccines are available to prevent walking pneumonia caused by Mycoplasma pneumoniae. Even if you have recovered from walking pneumonia, you will not become immune, so it is possible to become infected again in the future.

    Tips for preventing walking pneumonia include:

    • Cover your nose and mouth with a tissue when you sneeze or cough. If a tissue isnt available, sneeze or cough into the inside of your elbow or sleeve. Never sneeze or cough into your hands. Place used tissues into a waste basket.
    • Wash your hands often with warm water and soap for at least 20 seconds. Use an alcohol-based hand sanitizer if soap and water are not available.
    • Wear a mask around sick people if you have respiratory conditions or other chronic health conditions that would make getting pneumonia even riskier for you.
    • Get your annual Influenza shot. Bacterial pneumonia can develop after a case of the flu.
    • Ask your doctor about the pneumococcal vaccine. Two types of vaccines are available, Prevnar 13® and Pneumovax 23®. Each vaccine is recommended for people at different age points or who are at increased risk for pneumococcal disease, including pneumonia.

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