US Pharm, 2010;35(10):22-25  

Pneumonia is a common and often serious lower respiratory tract infection associated with considerable morbidity and mortality; it is the most common infectious cause of death in the United States.1 According to data from the National Hospital Discharge Survey, in the U.S., there were 21.4 million hospitalizations among individuals aged 65 years and older between 1990 and 2002; 48% were for infectious diseases and 46% of the infectious diseases were lower respiratory tract infections.2 Approximately 70% of hospitalized cases of pneumonia among adults occur in the elderly.2

 Pathologically, pneumonia is a pulmonary inflammation involving the alveoli and terminal bronchioles secondary to an infectious agent.2 While pneumonia occurs in individuals of all ages, the clinical manifestations are most severe in the very young, those with chronic illnesses (e.g., diabetes, cardiac or pulmonary disease, renal failure, HIV, malignancy), and the elderly.1   

Age is a known risk factor for pneumonia. Individuals aged 65 or older, particularly if they have comorbidities, are more prone to developing pneumonia.3 Investigators have identified specific pneumonia risk factors in seniors; these and other known risk factors, including asthma, COPD with use of inhaled corticosteroids for more than 6 months, smoking, and alcohol abuse, can be found in Table 1. Overall, the attack rate for pneumonia in adults is highest among nursing home residents.2


Management of pneumonia in the elderly is challenging. Age-related changes in the immune system, comorbidities with multiple and complex medication regimens, difficulty (cognitively or physically) with medication adherence, and socioeconomic restraints are some of the obstacles that clinicians face when treating seniors with pneumonia.  

In order to optimize outcomes in this population, it is necessary to treat promptly according to evidenced-based empirical therapy (see Reference 1). Antibiotic regimens should be selected based on presumed causative pathogens and pulmonary distribution characteristics; adjustment of regimen may be necessary to provide optimal activity against pathogens that are identified by a sputum or blood culture.1 Furthermore, clinicians should be attentive to the effect of pneumonia on comorbidities as well.2

 In addition to the human burden, pneumonia poses a significant burden on the health care system. Approximately 3 million cases of pneumonia are diagnosed in the U.S. per year, costing the health care system more than $20 billion.4,5 A focus on the prevention of pneumonia, therefore, is essential to decrease the human and economic burden of this condition. Prevention of pneumonia in adults over age 65 years should clearly be a focus for pharmacists.  

Immunizing Seniors

The most common pathogen causing community-acquired pneumonia (CAP) in otherwise healthy adults is Streptococcus pneumoniae (pneumococcus); it accounts for 75% of all acute cases.1 Approximately 50% of all cases of pneumonia requiring admission to a hospital for treatment and 60% of all cases of bacteremic pneumonia are caused by S pneumoniae.1 In the U.S. in 2009, an estimated 43,500 cases and 5,000 deaths among persons of all ages can be attributed to invasive disease from S pneumoniae, referred to as invasive pneumococcal disease, or IPD (i.e., bacteremia, meningitis, or infection of other normally sterile sites).6

Immunization is defined as rendering an individual protected from an infectious agent; much progress has been made in public health through the appropriate use of this process.7,8 Focusing on vaccination status can help prevent pneumonia in the elderly.2 Further improvements in quality of life and mortality can be achieved through continued increases in vaccination coverage when all health care providers, including pharmacists, pay careful attention to this aspect of health care.8  

Pneumococcal Vaccine (PPSV23): As previously discussed, the most common cause of CAP in older adults is S pneumoniae.2   The most common pathogens causing hospital- or nursing home-acquired pneumonia are gram-negative aerobic bacilli (e.g., Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Acinetobacter species and Staphylococcus aureus (more common in patients with diabetes mellitus, head trauma, and those in the ICU).9

 A 23-valent capsular pneumococcal polysaccharide vaccine (PPSV23) is available for use in adults to stimulate active immunity to infection caused by the serotypes of S pneumoniae contained in the individual vaccine.2,10,11 The vaccine is used for the prevention of serious or invasive pneumococcal disease caused by S pneumoniae, including pneumonia, meningitis, and bacteremia.11  

While seniors are not considered a population that mounts a good antibody response to the pneumococcal vaccine, evidence does support a beneficial effect.2 Updated recommendations (2010) from the CDC's Advisory Committee on Immunization Practices (ACIP), including changes that apply to smokers, patients with asthma, and Alaska Natives/American Indians, are summarized below and available in depth in Reference 6.

The general recommendation for seniors is that at age 65 years, all persons should receive PPSV23 vaccination. Anyone receiving PPSV23 before age 65 years for any indication should receive another dose of the vaccine at 65 years or older if at least 5 years have passed since the previous dose; only a single dose is required in patients receiving PPSV23 at or after age 65 years.12  

Compared with ACIP 1997 recommendations, the new guidelines include smoking and asthma as indications for which PPSV23 vaccination is recommended.13 Additionally, routine use of PPSV23 is no longer recommended for Alaska Natives or American Indians younger than 65 years unless they have medical or other indications for PPSV23.13 Until recently, Alaska Natives and American Indian adults were considered to have an innate risk for IPD; it has been determined, however, that the IPD cases occur in persons with underlying medical risk factors and social factors (which are also seen in the general population), including heavy alcohol consumption or smoking.6

The original ACIP recommendations that remain unchanged involve revaccination with PPSV23 in adult patient groups at greatest risk for IPD (i.e., those with functional or anatomic asplenia and those with immunocompromising conditions).13 Separate recommendations address prevention of pneumococcal disease among infants and youths 18 years or younger using the 13-valent pneumococcal conjugate vaccine and PPSV23.13  

Of note, since adults who smoke cigarettes are at substantially increased risk for IPD, the ACIP recommends that “persons aged 19 through 64 years who smoke cigarettes should receive a single dose of PPSV23 and smoking cessation counseling.”13 According to ACIP, guidance for smoking cessation should be part of the therapeutic plan for smokers regardless of immunization status.12 Additionally, some professional organizations have recommended smoking cessation counseling and pneumococcal vaccination for smokers who are hospitalized with CAP.12 The U.S. Public Health Service provides clinical practice guidelines for treating tobacco use and dependence (see Smoking Cessation Resources).

There are no known significant interactions involving an increased vaccine effect; however the levels/effects of PPSV23 may be decreased by immunosuppressants.10 Pharmacists should be aware of the requirement that all serious adverse reactions be reported to the U.S. Department of Health and Human Services Vaccine Adverse Event Reporting System (VAERS); reporting may be initiated by a health care professional or patient (see Pneumococcal and Influenza Vaccine Resources).10  


Influenza Vaccine: While seniors are less likely to accumulate antibody levels that are viewed as protective and may remain susceptible to infection, the influenza virus vaccine does confer protection from secondary complications (i.e., secondary bacterial infection causing fever, productive cough, and consolidation).8,14 Annual influenza vaccination of seniors decreases the hospital admission rate for both pneumonia and congestive heart failure.2 Specifically, influenza vaccination in seniors has been shown to reduce the risk of hospitalization by 50% to 60%; of pneumonia by 50% to 60%; and of death by 80%.8 Evidence confirms the cost-effectiveness of influenza vaccine in nursing home populations, the community-dwelling elderly, healthy working adults, and young children.15-17 Immunization of health care workers against the influenza virus has been shown to protect against nosocomial influenza.2 

Adverse reactions to the influenza vaccine include local tenderness and low-grade fever (i.e., in 3% to 5% of vaccines); salicylates or acetaminophen administration are recommended as treatment.8 As with the PPSV23, all serious adverse events must be reported via VAERS.  

Focus on Smoking Cessation

Smoking tobacco is associated with a twofold increase in risk for pneumococcal pneumonia; approximately 50% of adults aged 65 years or older who develop severe pneumococcal disease are smokers.2,12,18 Furthermore, smoking tobacco is the most common preventable cause of death.19 In fact, death associated with smoking-related problems occurs in approximately 50% of individuals who do not quit smoking.19

While there are no data from clinical trials indicating that smoking cessation will reduce the rate of pneumonia, it is likely this will occur.2 Smoking cessation is also likely to provide other health benefits including improved circulation, normalization of blood pressure, improvement in sense of smell and taste, and slowing of age-related decline in lung function.2,19 Overall, smoking cessation has been shown to help extend life.19 (For more about helping seniors quit, see Smoking Cessation Resources).  

Prevention of Aspiration Pneumonia

Aspiration pneumonia is a lung infection caused by inhaling mouth secretions, stomach contents, or both; it is more likely to occur in patients with difficulty swallowing (dysphagia) often secondary to a stroke.20,21 Poststroke, the patient may not be capable of awareness that food or liquid is entering the airways; this is referred to as silent aspiration.22 Often, it is difficult for these patients to safely swallow thin liquids because they move quickly through the mouth and throat without adequate time for the larynx to make adjustment to protect the airway; aspiration may result.22 Whereas aspiration would cause a violent cough, in a stroke survivor the cough reflex may be absent due to a reduction in sensation.22 Furthermore, a viral upper respiratory infection may impair ciliary clearance, and pneumonia may result from microaspiration of oropharyngeal microflora.2

To reduce the occurrence of aspiration both before and during the swallow, protection of the airway may be achieved by the “chin down” posture.2 The use of this posture produces a posterior shift of the anterior pharyngeal structures resulting in a narrowing of the laryngeal entrance while widening the angle of the epiglottis to the anterior tracheal wall.2  

A technique used to reduce the latency time of the swallowing reflex involves having caregivers clean the patient's teeth and gingiva after each meal.2 This technique has been shown to also increase the sensory neurotransmitter substance P in the saliva of patients with dysphagia caused by cerebrovascular disease; substance P is known to stimulate neural pathways that improve the swallowing reflex.2,7

Conclusion

In seniors, pneumonia and IPD are associated with significant morbidity and mortality. In addition to the human burden, pneumonia poses a significant financial burden on the health care system, as well. With age as a risk factor for pneumonia, pharmacists working with seniors are encouraged to promote prevention of this condition through appropriate immunization and other recommended measures.

 

REFERENCES

1. Glover ML, Reed MD. Lower respiratory tract infections. In DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York, NY: McGraw-Hill; 2008: 
1761-1778.

2. Marrie TJ. Pneumonia. In: Halter JB, Ouslander JG, Tinetti ME, et al, eds. Hazzard's Geriatric Medicine and Gerontology. 6th ed. New York, NY: McGraw-Hill; 2009:1531-1545.

3. Pneumonia. MayoClinic.com. www.mayoclinic.com/health/pneumonia/DS00135. Accessed September 20, 2010.

4. File TM Jr., Garau J, Blasi F, et al. Guidelines for empiric antimicrobial prescribing in community-acquired pneumonia. Chest. 2004;125:1888-1901.

5. Reimer LG. Community-acquired bacterial pneumonias. Semin Respir Infect. 2000;15:95-100.

6. Barclay L, Lie D. Guidelines updated for use of 23-Valent pneumococcal polysaccharide vaccine in adults. CME/CE. Medscape CME/CE. http://cme.medscape.com/viewarticle/728245?src=cmemp&uac=152591BX. Accessed September 21, 2010.

7. Hayney MS. Vaccines, toxoids, and other immunobiologics. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York, NY: McGraw-Hill. 2008:2041-2058.

8. Dorland's Pocket Medical Dictionary. 28th ed. Philadelphia, PA: Elsevier Saunders; 2009.

9. Freeman MK. Nosocomial pneumonia. US Pharm. 2010;35(7):HS2-HS4. 

10. Semla TP, Beizer JL, Higbee MD. Geriatric Dosage Handbook. 14th ed. Hudson, OH: Lexi-Comp, Inc; 2009:1321-1323.

11. Pneumovax 23 Inj. Monograph - Pneumococcal vaccine. www.medscape.com/druginfo/monograph?cid=med&drugid=5546&drugname=Pneumovax+23+Inj&monotype=monograph&secid=5. Accessed September 13, 2010.

12. Revised ACIP recommendations for preventing invasive pneumococcal disease using PPSV23. American Pharmacists Association. www.pharmacist.com/AM/Template.cfm?Section=Home2&CONTENTID=24205&TEMPLATE=/CM/HTMLDisplay.cfm. Accessed September 21, 2010.

13. Barclay L. Guidelines updated for use of 23-valent pneumococcal polysaccharide vaccine in adults. Medscape Medical News. Medscape.com. www.medscape.com/viewarticle/728115. Accessed September 21, 2010.

14. Hermsen ED, Rupp ME. Influenza. In DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York, NY: McGraw-Hill; 2008:1791-1799.

15. Nichol KL, Lind A, Margolis KL, et al. The effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med. 1995;333:889-893.

16. Salo H, Kilpi T, Sintonen H, et al. Cost-effectiveness of influenza vaccination of healthy children. Vaccine. 2006;24:4934-4941.

17. Nichol KL, Nordin J, Mullooly J, et al. Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly. N Engl J Med. 2003;348:1322-1332.

18. Greene RE, Schlamm HT, Oestmann JW, et al. Imaging findings in acute invasive pulmonary aspergillosis: clinical significance of the halo sign. Clin Infect Dis. 2007;44(3):373-379.

19. Quitting smoking. MedlinePlus. U.S. National Library of Medicine. National Institutes of Health. www.nlm.nih.gov/medlineplus/quittingsmoking.html. Accessed September 22, 2010.

20. Aspiration pneumonia. The Merck Manual of Medical Information Second Home Edition. Revised April 2008. www.merck.com/mmhe/print/sec04/ch042/ch042e.html. Accessed September 22, 2010.

21. Zagaria ME. Post-stroke aspiration pneumonia. U.S Pharmacist. 2010;35(7):20-24.

22. Difficulty swallowing after stroke. American Stroke Association, a division of American Heart Association. www.strokeassociation.org/presenter.jhtml?identifier=3031213. Accessed September 22, 2010.

23. Karnofsky Performance Scale. United States Department of Veterans Affairs. www.hiv.va.gov/vahiv?page=cm-1003_karnofsky. Accessed September 21, 2010.

 
To comment on this article, contact rdavidson@uspharmacist.com.