Community-acquired pneumonia in the elderly: a practical guide to treatment

The incidence of community-acquired pneumonia (CAP), an infectious disease, sharply increases among the elderly and the main risk factor for CAP in this age group is chronic comorbidity. The use of the term CAP in the elderly population should be reserved for pneumonia acquired outside of the nursing home setting, since nursing home-acquired pneumonia differs from CAP in terms of its aetiology and clinical manifestations. The main aetiology for CAP is Streptococcus pneumoniae, but atypical pathogens also play an important role as causative agents. The clinical presentations of CAP in the elderly can be different from those in younger patients, and therefore it is important to be aware of and familiar with these differences to avoid unnecessary delays in reaching the correct diagnosis. Imaging is essential to diagnose CAP and to assess its severity. Clinical and laboratory indices can be used to identify elderly patients with CAP who are at low risk for mortality and who can be treated as outpatients. The decision not to hospitalise elderly patients with CAP is contingent on a good clinical condition and the existence of home support systems. The aetiology of CAP cannot be determined on the basis of clinical manifestations, imaging or routine laboratory test results, and the initial antibiotic therapy for elderly patients with CAP should be empirical, based on accepted guidelines. In the light of developments in recent years, elderly patients with CAP, except those who are severely ill, can be treated empirically with once-daily antibiotic monotherapy in the initial phase, using a third-generation fluoroquinolone preparation, such as sparfloxacin, levofloxacin or moxifloxacin, or a new macrolide such as clarithromycin, azithromycin or dirithromycin. In addition to antibiotic therapy, it is critically important to identify and treat the physiological disturbances that accompany CAP as well as decompensation of chronic comorbid conditions. As soon as the patient's condition permits, oral antibiotic therapy should replace intravenous therapy and early discharge from the hospital should be considered. Since influenza and pneumococcus immunisation can reduce morbidity and mortality from CAP, it is important to implement regular immunisation programmes in the primary care setting.