Chemical pharmacotherapy for hospital-acquired pneumonia in the elderly

ABSTRACT

Introduction: Hospital-acquired pneumonia (HAP) is a potentially serious infection that primarily affects older patients. The number of patients affected by multidrug-resistant (MDR) bacteria is increasing, including infection from strains of Staphylococcus aureus, Enterobacteriaceae, and Pseudomonas aeruginosa.

Areas covered: This article focuses specifically on HAP, excluding patients afflicted by ventilator-associated pneumonia (VAP). The pathogenesis and clinical features of HAP in the elderly are discussed as well as specific drug pharmacokinetic and pharmacodynamic considerations in elderly patients. The current recommended guidelines for the management of HAP are also discussed. Finally, the authors provide evidence on the empirical therapy used for the treatment of HAP and widely consider specific-pathogen treatment of HAP in elderly patients.

Expert opinion: In patients not at risk of MDR organism infection, antibiotics including piperacillin-tazobactam, cefepime, carbapenems or fluorquinolones are recommended. However, the emergence of MDR organisms as causal agents of HAP makes it necessary to accurately assess risk factors to these pathogens and revise our knowledge on specific antimicrobial susceptibility patterns from each institution. The authors believe that broader-spectrum empiric antibiotic therapies that target P. aeruginosa and methicillin-resistant S. aureus are best recommended in elderly patients at risk of HAP infection by MDR strains.

KEYWORDS:

• Hospital-acquired pneumonia
• elderly patients
• P. aeruginosa pneumonia
• methicillin-resistant S. aureus pneumonia

Article highlights

• HAP is a serious infection that primarily affects older patients who acquire the infection because of aspiration of oropharyngeal material. Immununosenescence and comorbidities also increase the risk of pneumonia.

• Establishing the etiological agent of HAP is difficult because sputum samples are less commonly available in HAP patients compared to those with community-acquired pneumonias, to the point that the therapeutics of choices are often empiric.

• Specific factors need to be considered with elderly patients such as polypharmacy as well as alterations in the absorption, metabolism, excretion, and target effects of antibiotics.

• For older patients with HAP not at risk from MDR-pathogens or mortality, narrow-spectrum antibiotics such as ceftriaxone, fluoroquinolones or ertapenem are the drugs of choice.

• For elderly patients with HAP at risk of mortality and/or risk of MDR-pathogens such as methicillin-resistant S. aureus and P. aeruginosa, broad-spectrum antibiotics are necessary.

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Declaration of interest

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.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The authors are funded by the Plan Nacional de I+D+I 2013-2016 and the Instituto de Salud Carlos III, Spain [REIPI RD16/0016/0003].