Gutiérrez Félix, Masiá Mar
Infectious Diseases Unit, Internal Medicine Department, Hospital General Universitario de Elche, Universidad Miguel Hernández, Elche, Spain.
Drugs Aging. 2008;25(7):585-610. doi: 10.2165/00002512-200825070-00005.
Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in elderly patients. Therefore, efforts to optimize the healthcare process for patients with CAP are warranted. An organized approach to management is likely to improve clinical results. Assessing the severity of CAP is crucial to predicting outcome, deciding the site of care, and selecting appropriate empirical therapy. Unfortunately, current prognostic scoring systems for CAP such as CURB-65 (confusion, uraemia, respiratory rate, low blood pressure and 65 years of age) or the Pneumonia Severity Index have not been validated specifically in older adults, in whom assessment of mortality risk alone might not be adequate for predicting outcomes. Obtaining a microbial diagnosis remains problematic and may be particularly challenging in frail elderly persons, who may have greater difficulties producing sputum. Effective empirical treatment involves selection of a regimen with a spectrum of activity that includes the causative pathogen. Although most cases of CAP are probably caused by a single pathogen, dual and multiple infections are increasingly being reported. Streptococcus pneumoniae remains the overriding aetiological agent, particularly in very elderly people. However, respiratory viruses and 'atypical' organisms such as Chlamydia pneumoniae are being described with increasing frequency in old patients, and aspiration pneumonia should also be taken into consideration, particularly in very elderly subjects and those with dementia. Age >65 years is a well established risk factor for infection with drug-resistant S. pneumoniae. Clinicians should be aware of additional risk factors for acquiring less common pathogens or antibacterial-resistant organisms that may suggest that additions or modifications to the basic empirical regimen are warranted. In addition to administration of antibacterials, appropriate supportive therapy, covering management of severe sepsis and septic shock, respiratory failure, as well as management of any decompensated underlying disease, may be critical to improving outcomes in elderly patients with CAP. Immunization with pneumococcal and influenza vaccines has also been demonstrated to be beneficial in numerous large studies. There is good evidence that implementation of guidelines leads to improvement in clinical outcomes in elderly patients with CAP, including a reduction in mortality. Protocols should address a comprehensive set of elements in the process of care and should periodically be evaluated to measure their effects on clinically relevant outcomes. Assessment of functional clinical outcome variables, in addition to survival, is strongly recommended for this population.
社区获得性肺炎（CAP）是老年患者发病和死亡的主要原因。因此，有必要努力优化CAP患者的医疗流程。采用有组织的管理方法可能会改善临床结果。评估CAP的严重程度对于预测预后、确定治疗地点以及选择合适的经验性治疗至关重要。不幸的是，目前用于CAP的预后评分系统，如CURB-65（意识障碍、尿毒症、呼吸频率、低血压和65岁）或肺炎严重程度指数，尚未在老年人中进行专门验证，对于老年人而言，仅评估死亡风险可能不足以预测预后。获得微生物诊断仍然存在问题，在体弱的老年人中可能尤其具有挑战性，因为他们咳痰可能更加困难。有效的经验性治疗需要选择一种具有涵盖致病病原体活性谱的治疗方案。虽然大多数CAP病例可能由单一病原体引起，但双重和多重感染的报道越来越多。肺炎链球菌仍然是首要的病原体，特别是在高龄老人中。然而，呼吸道病毒和“非典型”病原体，如肺炎衣原体，在老年患者中被发现的频率越来越高，还应考虑吸入性肺炎，特别是在高龄老人和患有痴呆症的患者中。年龄>65岁是感染耐多药肺炎链球菌的公认危险因素。临床医生应了解感染较不常见病原体或抗菌药物耐药菌的其他危险因素，这可能提示有必要对基本经验性治疗方案进行补充或调整。除了使用抗菌药物外，适当的支持性治疗，包括严重脓毒症和感染性休克的管理、呼吸衰竭的管理以及任何失代偿性基础疾病的管理，对于改善老年CAP患者的预后可能至关重要。多项大型研究已证明，接种肺炎球菌疫苗和流感疫苗是有益的。有充分证据表明，实施指南可改善老年CAP患者的临床结果，包括降低死亡率。治疗方案应涵盖护理过程中的一系列综合要素，并应定期进行评估，以衡量其对临床相关结果的影响。强烈建议对该人群除生存情况外，还评估功能性临床结局变量。
