Pneumonia in Older Adults: An Update - 2010 Suzanne F. Bradley, M.D. Professor of Internal Medicine Geriatrics & Infectious Diseases University of Michigan Medical School GRECC - VA Ann Arbor HCS
ID Hospitalizations 2000-2002 Diagnoses - > 65 yrs 15.3 20.4 7.7 12.2 15.5 46.1 LRTI Urinary Sepsis Cellulitis Prosthetic Other Curns et al. Arch Intern Med 2005;165:2514.
ID Deaths 2000-2002 Diagnoses - > 65 yrs 33.7 2.1 9.2 1 47.8 LRTI Urinary Sepsis Cellulitis Prosthetic Other 6.2 Curns et al. Arch Intern Med 2005;165:2514.
Pneumonia in Older Adults Update Risk factors What is modifiable? Treatment in LTCF CAP vs HCAP Oral care - is it the key? Impact of vaccinating other populations More antigen = a better vaccine? New causes - all pneumonia isn t bacterial Improving surveillance in LTCF
Pneumonia-Older Adults Risk Factors Exposure Pathogens Altered Flora RTI Altered Clearance Cough Gastric Acid Swallowing Altered Immunity
Pneumonia - Older Adults Infection Control Effect Drugs Rapid Dx Oral Care Disinfectants Probiotics RTI Positioning Feeding approach Substance P Suctioning Vaccination Appropriate Rx
Empiric Rx IDSA (2003) CAP NH Hospital Nursing Home Pneumonia Rx 3 Guidelines = No Consensus oral quinolone or amox/clav + macrolide IV 3 rd ceph or amox/sulbactam + macrolide or quinolone Mylotte JM. Clin Geriatr Med 2007;23:553. CIDS (2000) CAP oral quinolone or 2 nd ceph + macrolide IV quinolone or IV 2 nd -4 th cephs + macrolide ATS/IDSA (2005) HCAP NA 3 rd -4 th cephs carbepenem or pip/tazo + cipro & vanco or linezolid
NHAP in Hospital CAP vs HCAP Rx 334 pts at 3 Buffalo hospitals Retrospective analysis Difference HCAP (n=76) vs CAP (n=258), p<.001 longer LOS, longer time to oral rx No difference co-morbidities, function, PSI, BSI, multilobar time to Ab, vaccines, O2 assessment time to clinical stability, 30 day mortality El Solh A et al. JAGS 2009;57:1030.
Pneumonia-Older Adults Modifiable Risk Factors 1 yr surveillance 5 NH (n=613) CXR proven pneumonia Inadequate HR (95% CI) P value* Oral care 1.55 (1.0-2.3) 0.03 Swallowing 1.61 (1.0-2.6) 0.43 * COPD, age, NH, immobility, co-morbidities Not significant flu vaccine, sedatives, smoking, acid reduction rx, feeding position, ace inhibitor Quagliarello V et al. Clin Infect Dis 2005;4:1-6.
Oral Hygiene for Older Adults Pneumonia/LRTI Rates/Deaths RCT Intervention ARR (95% CI CHX post op 6.6 (1.6-11.5) Brushing/1% povidone 7.3 (0-14.6) Brushing/1% povidone 11.3 (6.5-44.2) Professional cleaning q wk 11.7 (-0.9-24.2) Sjogren P et al. JAGS 2008;56:2124.
Pneumonia in NH Pts Oral Hygiene/Swallowing Manual oral brushing reduce bacterial pathogens, increase substance P, improve swallowing NH Rx by CNAs feasibility (%) oral brushing fluoride paste x 2 minutes (100%) chlorhexidine 0.12% rinse x 2 minutes (100%) upright feeding position 90 x 15-20 min (95%) chin tuck feeding position when assisted (48%) significant improvement plaque score by 3 mo Quagliarello V et al. JAGS 2009;57:1226.
Changes in Overall Invasive Pneumococcal Disease, 1998 2007 Cases/100,000 population 120 100 80 60 40 PCV7 introduced Age Group (years) < 5 5 17 18 49 50 64 65 2007 vs baseline (% reduction) 76 43 40 18 37 20 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 i Pilishvili T et al. J Infect Dis 2010;201:32. Year et al. J Infect Dis. 2010;2P01:32-41.
Invasive Pneumococcal Disease Penicillin Non-susceptible Kyaw M et al. NEJM 2006;354:1455. Kyaw M, et al. N Engl J Med. 2006;354:1455-1463.
Invasive Pneumococcal Disease Serotype 19A Moore M et al. J Infect Dis 2008;197:1016. Moore M, et al. J Infect Dis. 2008;197:1016-1027.
IPD and S. pneumoniae Serotypes Children < 5 years Adults > 50 years Moore M et al. J Infect Dis 2008;197:1016. Moore M, et al. J Infect Dis. 2008;197:1016-1027. White bars: penicillin susceptible; gray bars: penicillin intermediate; black bars: penicillin resistant
Pneumococcal Polysaccharide Vaccine (PPV23) Single dose recommended for: All 65 years 2 64 years (immunocompromised hosts): diabetes, chronic cardiovascular, pulmonary, liver disease alcoholism, CSF leaks, asplenia, cochlear implants Asthmatics and smokers age 19-64 years One-time revaccination (proposed): 5 years after the first dose immunocompromised hosts 2-64 yrs ACIP www.cdc.gov/vaccines/recs/schedules/default.htm CDC www.dcd.gov/vaccines/recs/provisional/downloads/pneumo-oct2008-508.pdf ACIP Schedules. http://www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed September 2009. CDC. http://www.cdc.gov/vaccines/recs/provisional/downloads/pneumo-oct-2008-508.pdf. Accessed Oct 2009.
H1N1 Pandemic Influenza Deaths Bacterial Pneumonia (29%) A B Bacteria Number of Cases S. pneumoniae 10 S. aureus 7 S. pyogenes 6 S. mitis 2 H. influenzae 1 Multiple pathogens 4 Histochemical and Immunohistochemical diagnosis of S. pneumoniae infection A: Lillie-Twort Gram stain of lung tissue B: Immunohistochemical staining of multiple S. pneumoniae CDC. MMWR Morb Mortal Wkly Rep. 2009;58(38):1071-1074.
Pneumonia in Older Adults Influenza Vaccine High-dose Inactivated Vaccine Trivalent injectable FDA approved > 65 yrs 60 µg vs 15 µg HA per strain Higher antibody titers local injection reactions 36% vs 24% fever 1.1% vs 0.3%? protective flu or pneumonia not known no recommendation re use Falsey AR et al. J Infect Dis 2009;2009;200:172; MMWR 59:485, 2010.
Outbreaks in LTCF Non-Influenzal Illness Virus Attack LRTI Transfer Death Culture RT-PCR Rate % % % Rate % (+) (+) RSV 42-0.1 14.3 2/22 7/22 hmpv 22-72 18 21-50 31-5 16.1-2/13 0/20 6/13 5/14 Rhinovirus 24 62 100 33 52 27 38 16 1.8 5 6 21 - - 7/13 4/10 6/19 7/13 Caram LB et al., JAGS 2009;57:482.; Boivin G et al. CID 2007;44:1152.; Louie JK et al. CID 2007;196:705.; Hicks LA et al., JAGS 2006;54:284.
Pneumonia in LTCF Can We Improve Surveillance? Revising McGeer definitions - 1st draft SHEA LTCF SIG/CDC systematic review literature National surveillance system for LTCF establish benchmarks assess impact of interventions performance improvement
Revising McGeer Draft Definitions CXR + pneumonia or new infiltrate and At least one respiratory criterion and new or worse sputum or cough 02 sat < 94% on RA or <3% from baseline new or changed lung exam pleuritic chest pain RR > 25 breaths per min
Revising McGeer Draft Definitions At least one constitutional sign/sx and fever > 37.8 C (100 F) orally leukocytosis > 14K or left shift > 6% or 1.5K acute change in MS/function Absence of another cause (CHF) McGeer A et al. Am J Infect Control 1991;19:1.
Pneumonia in Older Adults Summary Common infection & severe outcome Optimal Rx NHAP debated Focus on oral care for prevention Vaccination other populations effective Newer vaccines coming NH pneumonia surveillance will help define the extent of the problem target areas for intervention baseline for reassessment and improvement