[Chinese expert consensus on the diagnosis and treatment of pneumonia in the elderly (2024 Edition)].

China is experiencing a demographic shift as its population ages. The elderly population becomes increasingly susceptible to pneumonia. Pneumonia in the elderly is characterized by its insidious onset, rapid progression, multiple comorbidities, poor prognosis, and high morbidity and mortality. Physicians need to pay attention to developing more comprehensive diagnostic evaluations and treatment strategies, and ensuring personalized care to the greatest extent. In order to improve the prevention and management of pneumonia in elderly, this consensus incorporates the latest guidelines and consensus from both domestic and international sources. The latest progress in this research field is also included. The document addresses 17 clinical issues in a question-and-answer format and provides 13 recommendations on the etiology, pathogenesis, clinical diagnosis, treatment, and prevention of pneumonia in older adults. It provides reference for the prevention and treatment of pneumonia in elderly, improving their quality of life, reducing hospitalization and mortality, and promoting healthy aging. The specific recommendations are as follows.Recommendation 1:The main risk factors for pneumonia in the elderly include age (Recommended Level ⅠA), age-related systemic factors (such as poor physical condition, underlying diseases, and concomitant medications), and specific factors (specifically dysphagia and aspiration). The risk increases progressively with age (Recommended Level Ⅱ-1A).Recommendation 2:Pneumonia in elderly individuals often presents with an insidious onset and atypical respiratory symptoms, especially in super-elderly patients. Initially, symptoms may include fatigue, loss of appetite, and disturbance of consciousness. Moreover, elderly patients often have underlying conditions such as pulmonary, cardiovascular, and neurological disorders, which can lead to rapid deterioration, multiple complications and sequelae. Pneumonia-related laboratory parameters in the elderly lack typical characteristic changes (Recommended Level ⅢA). The high proportion of comorbidities significantly increases the risk of pneumonia, especially pneumonia caused by drug-resistant bacteria, and the likelihood of a worse prognosis in elderly patients (Recommended Level Ⅱ-2A). Neurological or psychiatric disorders and therapeutic drugs such as antipsychotic drugs increase the risk of pneumonia including aspiration pneumonia, necrotizing pneumonia, lung abscess, hypostatic pneumonia and atelectasis in elderly patients (Recommended Level Ⅱ-2B).Recommendation 3:For elderly patients with suspected pneumonia, chest CT should be performed as early as possible in cases of long-term bed-ridden patients, aspiration pneumonia, or viral pneumonia (Recommended Level ⅢA). If conventional tests fails to identify the pathogen and empirical treatment proves to be ineffective, or if special pathogen infection such as viruses, severe or complex infection, or immunosuppression is suspected, it is advised to use invasive procedures to obtain bronchoalveolar lavage fluid (BALF), pleural effusion, or lung biopsy, and to conduct molecular biology testing (PCR, mNGS, tNGS, etc.) concurrently with conventional pathogen tests (Recommended Level ⅢA).Recommendation 4:The pharmacokinetics (PK) changes of antimicrobial drugs in elderly patients and necessity of dosage reduction should be evaluated according to the unique physiological characteristics of the elderly, such as declining body function, the presence of multiple diseases, and potential medication interactions. It is recommended to combine the PK/PD characteristics of antimicrobial drugs and therapeutic drug monitoring (TDM) methods to guide the individualized and precise prescription for elderly patients with pneumonia. This approach aims to ensure efficacy, minimizing the risk of bacterial resistance, and reduce the incidence of adverse reactions (Recommended Level Ⅱ-2B).Recommendation 5:Timing of treatment: Empiric antimicrobial therapy should be initiated as soon as the diagnosis is made. Except for outpatient clinic visitors with mild symptoms, properly collected respiratory secretions and blood samples should be sent without delay for pathogenic microorganisms testing. During the influenza season, timely empiric antiviral therapy should be initiated without positive result (Recommended Level Ⅱ-1A).Recommendation 6:Coverage of possible pathogens: Due to the increased detection rate of various pathogens such as gram-negative bacteria, anaerobic bacteria, fungi, etc., the initial treatment should cover the possible pathogens. Individualized treatment should be started according to the estimation of drug resistance risk, the of PK/PD principle, and potential drug side effects (Recommended Level Ⅱ-1A).Recommendation 7:Appropriate treatments for promoting sputum drainage and airway clearance in elderly pneumonia patients should be chosen after a comprehensive evaluation of the patient's condition. It is crucial to assess the patient's coughing efficacy to avoid asphyxia (Recommended Level ⅢA).Recommendation 8:We recommend cautious use of glucocorticoids in elderly pneumonia patients. When it is indeed necessary to use glucocorticoids in severe pneumonia cases accompanied by septic shock and hemodynamic instability, it's crucial to tailor drug regimens carefully, monitor closely for adverse reactions, and avoid excessive or prolonged glucocorticoid use (Recommended Level ⅢB).Recommendation 9:Assessing the swallowing abilities of elderly patients is important, and individuals with dysphagia should undergo swallowing rehabilitation. These measures can help reduce the risk of aspiration pneumonia, such as adopting a semi-recumbent posture, thickened fluids and soft foods, proper dental care, tube feeding, and discontinuing medications that increase the risk of aspiration pneumonia in older patients (Recommended Level ⅡA).Recommendation 10:We recommend that elderly individuals get an annual influenza virus vaccine (Recommended Level ⅠA), 23-valent pneumococcal polysaccharide vaccine (PPV 23) or the 13-valent pneumococcal conjugate vaccine (PCV 13) to prevent CAP (Recommended Level ⅠB), and COVID-19 vaccine should also be recommended in accordance with national guidelines (Recommended Level ⅠA).Recommendation 11:Older individuals should quit smoking, limit alcohol intake, participate in moderate-intensity physical activity (Recommended Level Ⅱ-1A), have regular dental examinations, maintain good nutritional status and personal hygiene, and avoid close contact with children with acute viral respiratory infections (Recommended Level Ⅱ-2A).Recommendation 12:The super-elderly are more likely to experience geriatric syndromes, particularly sarcopenia and frailty, which are closely associated with the occurrence of aspiration pneumonia. Preventing and improving sarcopenia and weakness through nutrition supplement, exercise, cognitive training, etc., can effectively reduce the incidence of pneumonia (Recommended Level ⅢA).Recommendation 13:We recommend that older adults with chronic underlying medical conditions, who are at increased risk of developing pneumonia, should receive personalized management and comprehensive preventive measures to strengthen the management of underlying diseases. Perioperative care for older patients should be optimized to reduce the risk of postoperative pneumonia (Recommended Level ⅢA).