INTEGRATED CASE DISCUSSION

PNEUMONIA IN ELDERLY
1. Arto Yuwono Soeroto
Divisi Respirologi dan Kritis Respirasi
Departemen Ilmu Penyakit Dalam
FK Unpad/ RSUP Dr Hasan Sadikin
Bandung

2. Sri Sunarti
Divisi Geriatri
Departemen Ilmu Penyakit Dalam
FKUB/RSUD dr Saiful Anwar
Malang
 Mr PB , 73-year-old male was admitted to the hospital
with shortness of breath (SOB)
SOB occurred since 5 days ago and getting worse 3 days prior
to admission. He also complained cough with yellowish
sputum which hard to be expectorated. Also, fever, malaise and
dizziness.
Patient had been hospitalized twice with similar complaints in
previous year and diagnosed as COPD since 10 years ago.
Patient was a smoker for over than fifty years but had stopped
after he was diagnosed COPD.
 Compos mentis, GCS 4-5-6
Vital sign:
Blood Pressure 125/76 mmHg
Heart Rate 112 x/min
Respiratory Rate 30 x/min
Temperature 38,2 C
Saturation 92% (room level FiO2)
No anemia, no icterus and no cyanosis
JVP 5+ 3 cm
Cardiac findings:
Slight enlargement
Pulmonary examination:
Dullness in left lower hemithorax, crackles in both lower hemithorax,
bronchovascular sound in left lower hemithorax
wheezing (+)
Liver : just palpable
Extremities : Normal
 White blood cell (WBC) count 20.220/L; Granulocyte 83.8%
and CRP 134.1 mg/dL
Liver function were mildly elevated ( SGOT 64 U/L and SGPT
51 U/L)
Renal function; Ureum 68 mg/dL, Creatinine 2.84 mg/dL
Electrolyte Serum was normal
Blood Gas Analysis (O2 room level): pH 7.336; pCO2 53; pO2 53;
HCO3 28.4; BE 2.7 and SO2 85.2%
EKG: P Pulmonal (RAE), RAD and RVH
 Severe dyspnea (30 breath/min)
Ronchi (crackles) at lower
Leukocytosis (WBC: 20.220/L)
Granulocytosis (Neut : 83.8%)
CRP 134.1 mg/dL
Increase of RFT (Ureum: 68 mg/dL, SC:2.84
mg/dL)
BGA: Respiratory Acidosis Partially Compensated
with Mild Hypoxemia
Chest X-Ray: Infiltrate (+)
Co-morbid : COPD
 Community Acquired Pneumonia
COPD acute exacerbation
Acute on chronic Hypercapnic
Respiratory failure
Chronic Congestive Heart Failure
Acute Kidney Injury
Diagnosis of Pneumonia (CAP) and its
severity
 PNEUMONIA
Diagnostic criteria
1. New or progressive radiographic infiltrate
2. Clinical feature
- fever (> 38 0 C)
- leukocytosis or leukopenia
- purulent tracheal secretion
One clinical feature : high sensitivity, low specificity
Two clinical features : 69% sensitivity, 75% specificity
Three clinical features : low sensitivity, high specificity
Issues of microorganism and empiric
antibiotics
 Community Acquired Pneumonia
Inpatient

Inpatient
Non ICU

S. pneumoniae
M. pneumoniae
C. pneumoniae
H. Influenzae
Legionella species
Aspiration
Respiratory
viruses

a respiratory
Fluoroquinolonoe
(strong recommendation)
a B lactam + A macrolide
(strong recommendation)
Prefered : cefotaxime
Ceftrioxone, ertapenem
Doxycyclin alternative
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
for macrolide
 Community Acquired Pneumonia
Inpatient

In patient
ICU

S. Pneumoniae
Staph aureus
Legionella spesies
Gram negative bacilli
H. Influenzae

a B lactam
(cefotaxime, cefriaxone
or ampicillin sulbactam)
+
Azythromycin
or
Fluoroquinolone
(strong recommendation)
Penicillin allergic
Fluoroquinolone
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
+
Azetreonam
 Community Acquired Pneumonia
Inpatient

In patient
ICU
Pseudomonas
infection

Structural lung disease

Severe COPD with frequent
Steroid and/or antibiotic use
prior Antibiotic therapy

Antipneumococcal, antipseudomonal
B lactam (piperacillin-tazobactam
cefepime, imipenem, meropenem)
+
Ciprofloxacin or levofloxacin750mg
OR
The above B lactam +
an aminoglycoside
And an antipneumococcal
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2) Fluoroquinolone/azithromycin
(moderate recommendation)
 Community Acquired Pneumonia
Inpatient

In patient
ICU
CA MRSA

ESRD
Injection drug abuser
Prior influenzae
Prior antibiotic th/
(especially fluoroquinolone)

Add vancomycin or
Linezolid
(moderate recommendation)

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

 MODIFYING FACTORS

Pseudomonas aeruginosa

Sructural lung disease (bronchiectasis)

Corticosteroid therapy (>10 mg of prednison/day)
Broad-spectr. antibiotic tx for >7 d in the past month
Malnutriton
What are the treatment of this patient ?
Hospitalized in ICU room :

O2 8 lpm simple mask

IVFD
Combivent nebulation/6 hours
Levofloxacine 750 mg/24 hours i.v
Cefepime inj. 1 gr/8 hours i.v
Methylprednisolone inj. 62.5 mg/8 hours i.v
Furosemide 1 x 1 amp IV
Bisoprolol oral 2.5 mg -0-0
Euphyllin R tablet 1-0-1
 No dyspnea, RR 20 x/min, HR 96 x/min and temperature 37.6 0C
WBC was normal (6.430/L); granulocyte 92,2%; CRP 86 mg/dL
SGOT and SGPT were more elevated (110 U/L and 3.83 U/L)
Renal Function; Ureum 45 mg/dL and Creatinine S 0.97 mg/dL
Serum electrolyte was normal
Blood Gas Analysis (with O2 4 lpm nasal): pH 7.418; pCO2 44.8;
pO2 75.2; HCO3 act 28.3; BE ecf 3.8 and SO2 93.1%)
 Sputum gram stain :
No bacterial found
Leucocyte cell 12-25/field

Sputum culture :
No bacterial growth
 O2 3 lpm nasal canule
IVFD
Combivent nebulation/8 hours
Levofloxacine 750 mg iv
Cefepime inj. iv was stopped
Methylprednisolon 3 x 62,5 mg iv
Euphylline R tablet 1-0-1
Furosemide tab 1-0-0
Bisoprolol 2.5 mg tab -0-0
 O2 3 lpm nasal canule
IVFD
Combivent nebulation/8 hours
Levofloxacin was switched from iv to oral 1 x 750 mg
Methylprednisolon iv is stopped
Euphylline R tablet 1-0-1
Furosemide tablet 1-0-0
Bisoprolol 2.5 mg tab 1/2 -0-0
Clinical: Laboratory:
GCS 4-5-6, compos WBC 6.340 /L ;
mentis Granulocyte 72,2 %; CRP
16.3mg/dL
Vital sign:
BP :130 /70 mmHg SGOT 39 U/L ; SGPT 86U/L
HR : 86 x/m
RR : 20 x/m Ureum 40 mg/dL,
Creatinine S 0.80 mg/dL
T : 36.80 C
Saturation : 96% (with
O2 room level)
Treatment
Levofloxacine 1x 750 mg po
Euphylline R tablet 1-0-1
Tiopropium bromide DPI 1x 18 ug
Furosemide tablet -0-0
 Levofloxacine 750 mg tablet
was stopped after 10 days
treatment

Euphylline R tablet 1-0-1

Tiopropium bromide DPI

Furosemide tab -0-0

 Penurunan cadangan Gangguan refleks
paru muntah
Penurunan transport Melemahnya imunitas
mukosilier Gangguan respon
Penurunan refleks pengaturan suhu
batuk Koinsiden dengan
Penurunan elastisitas penurunan faal jantung
alveoli
CDC, 2008
1. The elderly patient without clinical criteria of
frailty: this patient performs basic and
instrumental daily life activities independently
and does not usually have significant
comorbidity or other associated mental or
social problems. From a management and
prognostic point of view there are no
differences compared to an adult patient
2. The elderly patient with clinical criteria of frailty: pneumonia
in this patient may produce a functional and/ or cognitive
impact and condition short term results. The risk of having an
adverse outcome depends on the grade of deficiencies
accumulated, on the medical (comorbidity, polypharmacy,
sensory, nutrition, use of hospital services...) functional
(equilibrium and mobility, history of falls, daily life activities,
continence...) neuropsychiatric (cognition, mood, delirium...)
and social areas (social support, institutionalization...), that is,
the greater the number of deficiencies the greater the grade of
frailty and thus, of the risk of having an adverse outcome.