Managing community acquired pneumonia in the elderly – the next generation of pharmacotherapy on the horizon

ABSTRACT

Introduction: Community acquired pneumonia (CAP) is associated with high rates of morbidity and mortality, especially among the elderly. Antibiotic treatment for CAP in the elderly is particularly challenging for many reasons, including compliance issues, immunosuppression, polypharmacy and antimicrobial resistance. There are few available antibiotics that are able to address these concerns.

Areas covered: After a systematic review of the current literature, we describe seven novel antibiotics that are currently in advanced stages of development (phase 3 and beyond) and show promise for the treatment of CAP in those over the age of 65. These antibiotics are: Solithromycin, Pristinamycin, Nemonaxacin, Lefamulin, Omadacycline, Ceftobiprole and Delafloxacin. Using a novel conceptual framework designed by the present authors, known as the ‘San Antonio NIPS model’, we evaluate their strengths and weaknesses based on their ability to address the unique challenges that face the elderly.

Expert opinion: All seven antibiotics have potential value for effective utilization in the elderly, but to varying degrees based on their NIPS model score. The goal of this model is to reorganize a clinician’s focus on antibiotic choices in the elderly and bring attention to a seldom discussed topic that may potentially become a health-care crisis in the next decade.

KEYWORDS:

• CAP
• Ceftobiprole
• community-acquired pneumonia
• Lefamulin
• Nemonaxacin
• Omadacycline
• pharmacotherapy
• Pristinamycin
• San Antonio NIPS Model
• Solithromycin

Article highlights

• Antibiotic choices in the elderly are difficult and complex due to their higher rates of cognitive deficits impacting compliance, age associated immunosuppression, polypharmacy and medication interactions and finally increased rates of antimicrobial resistance to their greater cumulative exposures.

• The San Antonio NIPS model is a novel conceptual framework that can be used to evaluate the potential effectiveness of antimicrobials in the elderly based on their ability to address the unique challenges faced by this vulnerable population.

• Its overarching goal is to reorganize a clinician’s focus on antibiotic selection in the elderly, allowing more effective choices that have the potential to impact not only the morbidity and mortality of individual patients, but also health care costs.

• With aid from the San Antonio NIPS model, we present and systematically review 7 novel antibiotics that are currently in advanced stages of development (phase 3 and above) that show promise for the treatment of CAP in those over the age of 65:

  1. Solithromycin

  2. Pristinamycin

  3. Nemonaxacin

  4. Lefamulin

  5. Omadacycline

  6. Ceftobiprole

  7. Delafloxacin

• After reviewing the San Antonio NIPS model which incorporates the four key characteristics that the optimal antimicrobial agent should possess in order to adequately treat CAP in the elderly, we evaluate the relative effectiveness of these 7 antibiotics, providing each with a NIPS model score.

• Although all the antibiotics reviewed have valuable characteristics to offer for the treatment of CAP in the elderly population, Nemonaxacin and Delafloxacin were the only agents given a high NIPS score.This box summarizes key points contained in the article.

Declaration of interest

M I Restrepo’s time is partially protected by Award Number K23HL096054 from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, And Blood Institute or the National Institutes of Health or the Department of Veterans Affairs. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper was not funded.

Notes on contributors

B Amalakuhan

All authors contributed to the conception and design of this review paper, as well as revising it critically for its intellectual content. All authors provided approval of this manuscript for final publication.