16.Pneumoni Pd Lansia, Bhn Kuliah

7/29/2019 16.Pneumoni Pd Lansia, Bhn Kuliah

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Muhammad Ilyas

Pulmonology Division Dept.Of Internal Medicine

Faculty Of Medicine Hasanuddin University



Definition:◦ … an acute infection of the pulmonary

parenchyma that is associated with at leastsome symptoms of acute infection,

accompanied by the presence of an acuteinfiltrate on a chest radiograph, orauscultatory findings consistent withpneumonia, in a patient not hospitalized or

residing in a long term care facility for > 14days before onset of symptoms



CAP is a common illness, with increasedmortality in certain population, particularlythe elderly and those with severe illness

The association between advance age andmortality is well known

Sir William Oslers infamous view was that

pneumonia was the “friend of the aged” thatoften allowed patients with advanced illnessto die peacefully



It is more difficult to diagnose pneumonia inthe elderly than in young patient because theusual clinical clues for its diagnosis might beabsent at the time of onset of the illness

Cardinal signs and symptoms, such ascough, fever and dyspnea, may be not

present in same older patient withpneumonia



Metlay et al : studied 1812 pneumonia

patient and observed that both repiratory andnonrespiratory symptoms were lesscommonly reported by older patient than byyounger patient

Other ways in which advanced age couldinderectly increas CAP mortality include ahigh frequency of comorbid illness as well as

a predisposition to more virulent pathogensand pathogenic mechanisms



Pneumonia can also lead to worsening f

chronic medical illness, such as COPD andCHF

The Coexistence of neurological and GIdesease in the elderly may account for their

increased risk of aspiration as a commonmechanisms of infection

Immune dysfunction is common in the

elderly, either as a consequence ofcomorbid illness or directly due to ageingself



◦ Age◦ Alcoholism◦ Smoking◦

Asthma◦ Immunosuppression◦ Institutionalization◦ COPD◦ PVD◦ Dementia



◦ Men: age and smoking, weight gain RR 1.5 for age 50-54, 4.17 for > 70

Smoking, current: RR 1.5; heavy: 2.54; Quit<10 yrs: 1.5

Weight gain >40 kg since age 21

◦ Women: smoking, BMI, weight gain

BMI 25-26.9, RR 1.53: BMI >30, RR 2.22

Exercise protective: RR 0.66 for most active◦ Alcohol consumption NOT associated with

increased risk in men or women



◦ older, unemployed, unmarried

◦ common cold in the previous year

◦ asthma, COPD; steroid orbronchodilator use

◦ Chronic disease

◦ Amount of smoking◦ Alcohol NOT related to increased risk



◦Age◦Bacteremia (for S. pneumoniae)

◦Extent of radiographic changes

◦Degree of immunosuppression

◦Amount of alcohol



Streptococcus pneumoniae

Haemophilus influenzae

Bordetella pertussis Chlamydia pneumoniae

Legionella pneumophila

Mycoplasma pneumoniae



◦

S. pneumoniae: 20-60%◦ H. influenzae: 3-10%

◦ Ch. pneumoniae: 4-6%

◦ Myc.pneumonaie: 1-6%

◦ Legionella spp. 2-8%◦ S. aureus: 3-5%

◦ Gram negative bacilli: 3-5%

◦ Viruses: 2-13%

40-60% - NO CAUSE IDENTIFIED

2-5% - TWO OR MORE CAUSES



Present in nasopharynx ofasymtomatic individuals

High incidence of colonization ininfants under 2 years of age

Low incidence in young people

High incidence in people in their 70s



Pneumonia develops over several days

Cough, sputum , dyspnoea, chest pain andmyalgia

In healthy young adults: Hyperacutepresentation with a dramatic rigor

Older people, an insidious presentation,

with only confusion and hypothermia Examination: Consolidation, x-ray reveals

infiltration



Evaluation for CAPHistory, PE, CXR

No infiltrate

manage/evaluate for alternate diagnosisInfiltrate + clinical evidence of pneumonia

evaluate for admission

outpatient:

empiric treatment with macrolide, doxycycline, FQ

hospitalize

labs

medical ward:abx < 8 hrs ICU: abx < 8 hrs

no pathogen identified

B-lactam + macrolide

FQ

no pathogen identified

B-lactam + macrolide

B-lactam + FQ



Laboratory Tests: CXR

CBC with differential

BUN/Cr

glucose liver enzymes

electrolytes

Gram stain/culture of sputum

pre-treatment blood cultures oxygen saturation



CXR◦ usually needed to establish diagnosis

◦ prognostic indicator

◦ rule out other disorders

◦ may help in etiological diagnosis

Only 3% of outpatients and 28% of ER patients withsuggestive signs and symptoms actually have

pneumonia



RR > 30 PaO2/FiO2 < 250, or PO2 < 60 on room air

Need for mechanical ventilation

Mulitlobar involvement

Hypotension

Need for vasopressors

Oliguria

Altered mental status



Rational use of microbiologylaboratory

Pathogen directed antimicrobial

therapy whenever possible Prompt initiation of therapy

Decision to hospitalize based on

prognostic criteria



Outpatient:◦ macrolide

◦ doxycycline

◦

Fluoroquinolone

NOT IN ANY SPECIFIC ORDER



Patients in ICU:3GC + macrolide3GC + FQ

B/B-I + macrolideB/B-I + FQ



◦ Second generation generationcephalosporin plus a macrolide, non-pseudomonal third generation

cephalosporin plus a macrolide, or afluoroquinolone alone were all associatedwith a lower 30 day mortality in patientswith CAP.

16.Pneumoni Pd Lansia, Bhn Kuliah

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