Pneumonia in the elderly - Dr. Kiefer

Why this matters!

• 30 day mortality for 75-84 yrs old  = 11%, for those >84 yrs = 24%
• 50-70% of nursing home residents are exposed to antibiotics over any one year; increasing MDR in this population
• Risk fx: Alcoholism RR 9, COPD RR 4.2, immunosupp R 3.1, Heart disease RR 1.9, institutionalized RR 1.8
• Elderly may present atypically for pneumonia.  Latent, without chills, ill defined physical signs. 
  
• 50% of fever absent in elderly, and mortality is higher in this population
  

How about a Score?

• PORT score.  30 day mortality in >age 18. Exclude HIV, hospitalization in prior 7 days

    Step 1.  Identify low risk.  Age <50. No Hx Cancer, CHF, CVD, Renal disease, Liver disease. 
                 On exam AMS, HR>125, RR>30, SBP <90, Temp <35 or >40
    Step 2. Use MD Calc Check boxes.  

    Simple rule: With no high risk findings and women under 80, dischcarge and men under 70. 

• CURB65.  Useful for sicker patients, 37% of pts greater than 75 yo.
  

    C:Confusion
    Urea >20
    RR >30
    Blood Pressure - SBP <90, DBP <60
    Age >65

    More of these is higher mortality in 30 days


Blood Cx?

• IDSA Guidelines: ICU Admission, Cavitary infiltrates, Leukopenia, active alcoholism, severe liver dz, severe COPD, Asplenia, pleural effusion.
• If you get blood cultures, you need to a have reason
  

HCAP

• Don't necessarily need to treat everyone with healthcare exposure for HCAP
• Treat if risk of MDR.  Look up the criteria
• Common pathogens: Increased rated of gram negative bacilli, MRSA
  

• Treatment: Should reference IDSA guidelines, but in general need MRSA coverage + either 1 or 2 drug antipseudomonal therapy depending on risk

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