Gu Wei, director of the emergency medicine department of the hospital, as the author and co-corresponding author, wrote the "Expert Consensus on the Emergency Diagnosis and Treatment of Community-acquired Pneumonia in the Chinese Elderly Community" published in the Chinese Journal of Emergency Medicine in October 2023, Vol. 32, No. 10. Consensus shows that the incidence of community-acquired pneumonia in the elderly is high, and the pathogenic bacteria often have multidrug-resistant bacteria infection and multi-pathogen mixed infection, and it is recommended that viral and fungal infections should be paid attention to, and it is recommended that etiological examination be required for patients with CAP who do not respond to initial empiric antimicrobial therapy, emergency department observation, rescue, EICU, and elderly patients with CAP from nursing homes.
Elderly patients (> 65 years old) in mainland China often develop community-acquired pneumonia (CAP) due to advanced age, multiple underlying diseases, and compromised host immunity. Geriatric CAP is complex and variable, and acute onset is one of the major geriatric emergencies. The high incidence of CAP in older adults, complex pathogenic atypical symptoms, and high rates of comorbidities, and multi-organ failure often result in a high case fatality rate and a heavy medical and economic burden.
Based on the fact that there is no emergency related diagnosis and treatment standard for elderly CAP in the mainland, the Emergency Branch of the Chinese Medical Association organized multidisciplinary experts in domestic emergency, respiratory critical illness, microbiology and clinical pharmacy to establish a consensus expert group on the emergency diagnosis and treatment of community-acquired pneumonia in the elderly in China, combined with domestic and foreign literature and clinical practice, using Delphi survey method, and voting on each recommendation by all experts participating in the consensus formulation, publicly discussing and improving controversial issues, and jointly discussing and formulating the emergency diagnosis and treatment path of mainland elderly CAP ( See Figure 1) to standardize the emergency care and improve outcomes of elderly CAP
Figure 1 Flow chart of CAP emergency care for the elderly
The consensus describes the emergency care of CAP in the elderly from ten parts: epidemiological characteristics, risk factors, distribution of pathogenic bacteria, atypical manifestations and diagnosis, commonly used severity scores, empiric use regimens of initial antimicrobials, viral CAP treatment, comprehensive treatment, monitoring and treatment of multi-organ dysfunction, and nursing and prevention, and produces a total of 15 recommendations (Figure 2).
Fig. 2 Recommended opinions of the Expert Consensus on the Emergency Treatment of Community-acquired Pneumonia in the Elderly in China
The risk factors and pathogenic characteristics of infection in elderly patients with CAP were clarified
The aging situation of the mainland population is extremely grim, ≥ 13.50% of the population aged 65, CAP has become one of the main diseases of the elderly in China, reaching a peak in the elderly over 80 years old.
Aspiration pneumonia is one of the leading causes of CAP in older adults, with studies showing that aspiration pneumonia accounts for nearly 70% of CAP in older adults. The elderly often have consciousness disorders, dysphagia, impaired cough reflex, etc., and invisible aspiration is the main cause of aspiration pneumonia in the elderly. Studies have found that men, neurological disorders, underlying lung diseases, and taking specific drugs (antiepileptic drugs, proton pump inhibitors) are strongly associated with aspiration.
At the same time, elderly CAP patients have high comorbidities, more than 75% of elderly CAP patients have underlying diseases, and the top three most common comorbidities are cardiovascular disease, chronic respiratory disease and cerebrovascular disease. The mortality rate of elderly patients with CAP was significantly correlated with age, and the mortality rate increased correspondingly with older age, especially in patients over 65 years old.
Advanced age, underlying diseases, swallowing dysfunction, immunocompromise, sarcopenia, and nursing home residence are the main risk factors for the development of CAP in the elderly. Invisible aspiration due to dysphagia and cough reflex disorders is the leading cause of aspiration pneumonia in older adults. The distribution of pathogenic bacteria of elderly CAP has the inherent characteristics of elderly patients, gram-negative bacilli and Streptococcus pneumoniae are still one of the main pathogenic bacteria, and there are often multidrug-resistant bacteria infection and mixed infection of multiple pathogens, and attention should be paid to viral and fungal infections.
Risk factors for CAP-resistant infection in older adults include COPD, immunosuppression, diabetes mellitus, use of antacids, nasogastric tube therapy, and antimicrobial use within 90 days. Co-infection with drug-resistant bacteria often has many risk factors (Figure 3).
Fig. 3 Risk factors for infection of drug-resistant pathogenic bacteria
Develop a rational empiric antimicrobial regimen for elderly patients with CAP
Emergency physicians need to develop a reasonable empirical antimicrobial regimen based on factors such as factors such as their own factors, underlying disease, severity of disease, nutritional immune status, organ function, complications, pharmacokinetic/pharmacodynamic characteristics of antimicrobials, pathogenic microbial characteristics, and local microbial epidemiology in elderly patients with CAP (Figure 4). The consensus indicates that the incidence of viral CAP in the elderly is high, and the possibility of co-bacterial infection should be considered, and it is recommended to start early empiric therapy with antiviral combination antibacterial drugs in high-risk elderly patients.
Figure 4 Recommendations of empiric antimicrobials for different diagnosis and treatment units and possible infection with pathogenic bacteria
A number of bacterial resistance surveillance data in mainland China show that the resistance rate of Streptococcus pneumoniae and Mycoplasma pneumoniae to macrocyclic lipids is more than 80%, while quinolones induce QT interval prolongation, resulting in insomnia, headache and psychiatric symptoms and other adverse reactions in the elderly, and patients with intolerance can be replaced with the new generation of tetracycline drug omacycline. Omacycline is comparable to moxifloxacin in monotherapy for the treatment of non-severe CAP in adults with non-severe CAP and remains effective in the setting of tetracycline resistance.
Elderly CAP treatment should pay attention to monitoring organ function, according to age, creatinine clearance and blood concentration to adjust the drug type, dose and frequency of administration, in the emergency department for the elderly with poor compliance try to choose a single administration, easy to use without skin test, low toxicity, liver and kidney dual channel metabolism, oral dosage form can be sequentially treated, and the bactericidal effect is better. The broad spectrum of omacycline covers common pathogens of community-acquired infections (including drug-resistant bacteria such as ESBLs-producing bacteria, MRSA, etc.); High tissue permeability, the drug can be widely distributed to most tissues throughout the body; Elderly patients with impaired liver and kidney function do not need to adjust the dose; The hepatic metabolic rate is extremely low, and it is neither a potent substrate, inducer or inhibitor of cytochrome P450 enzymes nor glucuronosyltransferase, and drug interactions may be small; It has a fast onset of action, once a day, and can be administered intravenously-orally sequentially, making clinical use convenient (Figure 5).
Fig. 5 Omacycline broad-spectrum, potent, and has advantages in clinical application
In addition to antibacterial therapy, CAP in the elderly needs comprehensive treatment, and in addition to antibacterial therapy, it is also necessary to pay attention to airway management, nutritional support, volume management, immune regulation, traditional Chinese medicine therapy and hormone therapy. Individualized quality care plays an important role in improving the prognosis of CAP in the elderly, including nutritional assessment, airway care, bowel management, functional rehabilitation, personal cleaning protection, and vaccination.
The release of the "Expert Consensus on the Emergency Diagnosis and Treatment of Community-acquired Pneumonia in China" in 2023 will fill the gap in the diagnosis and treatment norms of elderly CAP in the emergency field in mainland China, help the diagnosis and treatment of elderly CAP patients, and improve the prognosis of patients.