Elderly pneumonia

　　1, Gram-negative bacilli are more common
　　In the 1950s, Streptococcus pneumoniae was the main pathogen of pneumonia (90%). However, with the advent of penicillin and some synthetic penicillins, the incidence and harm of this type of pneumonia were reduced. In the past ten years, infections caused by Gram-negative bacilli have increased significantly (82%), mostly Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae, etc. Although new antibiotics are constantly emerging, this trend has not changed yet.

　　2, Gradual increase in respiratory conditionally pathogenic bacteria infection
　　Due to the reduced body's resistance in the elderly, the commonly resident bacteria (fungi, anaerobic bacteria, etc.) in the oropharynx can cause pneumonia. The number of anaerobic bacteria in the normal oral and pharyngeal flora is 10 to 20 times more than that of aerobic bacteria, and about 1/3 to 1/2 of pneumonia is caused by anaerobic bacterial infection. Since routine culture cannot grow, it is easily overlooked. Therefore, routine anaerobic bacterial culture should be performed when sending samples for examination. Whether Gram-negative bacilli reside in the oropharynx or not is related to the health status of the body. In normal people, Gram-negative bacilli in the oropharynx account for only 2%, in outpatients 20%, in inpatients up to 30% to 40%, and in critically ill patients up to 75%. This may be the main reason for elderly Gram-negative bacillary pneumonia.

　　3, Mixed infections are common
　　Due to the weakened immune function in the elderly, they often have mixed infections caused by various pathogens. Such as bacteria plus virus, bacteria plus fungus, aerobic bacteria plus anaerobic bacteria, etc.

　　4, Increase in drug-resistant bacteria
　　Due to the extensive and widespread use of antibiotics, pathogenic microorganisms have changed their genes, resulting in drug resistance. Gram-negative bacilli are the most prominent among them.

　　Elderly patients with pneumonia often have a variety of chronic diseases. Studies have shown that 60% to 91% of elderly patients with pneumonia requiring hospitalization have one or more underlying diseases, commonly involving heart, lung, brain, and metabolic diseases. Once a severe pulmonary infection occurs, the condition changes rapidly, complications are severe, and it is easy to cause infectious shock, arrhythmia, stress ulcer, DIC, and MODS.

　　(1)Mostly without fever, chest pain, and sputum with rust-colored sputum, etc., typical symptoms. Only about 35% of patients have symptoms.

　　(2)The initial symptoms are prominent with non-respiratory symptoms: Elderly patients with pneumonia may first present with gastrointestinal symptoms such as abdominal pain, diarrhea, nausea, vomiting, and decreased appetite, or cardiovascular symptoms such as palpitations and dyspnea, or neuro-psychiatric symptoms such as apathy, drowsiness, delirium, agitation, and consciousness disorders. Elderly individuals often manifest one or more of the typical elderly disease pentad (urinary incontinence, mental confusion, lack of activity, falls, loss of life ability, etc.).

　　(3)Lack of typical signs: It is rare to have typical signs of pneumonia such as increased vocal resonance, bronchial breathing sounds, and other lung consolidation signs. Symptoms such as tachycardia, rapid breathing, weakened breath sounds, and wet rales at the lung base may occur, but they are easily confused with coexisting chronic bronchitis, heart failure, and other conditions.

　　1. To the best of their ability, actively participate in physical exercise to enhance physical fitness and improve cold resistance and disease resistance.
　　2. Eat more nourishing Yin and moistening Lung foods, such as pears, lilies, mushrooms, radishes, sesame, etc.
　　3. Pay attention to indoor hygiene, keep the living environment clean, fresh air, and sufficient sunshine; pay attention to keeping warm to prevent the invasion of cold evil, which may trigger a cold.
　　4. Before going to bed every day, you can sit on a chair, the body is upright, the knees are naturally apart, the hands are gently placed on the thighs, the head is straight and the eyes are closed, the whole body is relaxed, focus on Dan Tian, breathe in the chest, and pat from top to bottom while exhaling, about 10 minutes, then tap the lung Shu points on the back with the back of the hand. This method has the effect of clearing the lungs and benefiting the Qi.
　　5. To enhance respiratory function, gradually shift from chest breathing to abdominal breathing, that is, breathe in while puffing up the abdomen to lower the diaphragm, breathe into Dan Tian, the action should be as slow and relaxed as possible to enhance the depth of breathing.

　　I. Chest X-ray examination
　　Chest X-ray examination can provide the basis for diagnosis and differential diagnosis, and chest CT can often provide important additional information about the cause of X-ray infiltration.

　　II. Sputum examination
　　Sputum examination is the first step in the traditional determination of the cause of pneumonia. Due to the inability of the elderly to cough appropriately or cooperate, the qualified rate of sputum specimens is only 1/3. Qualified sputum specimens are poly nuclear leukocytes > 25/low power field, squamous epithelial cells
　　III. Blood culture
　　About 10% of elderly pneumonia patients' blood cultures can isolate specific pathogens, and it is rarely misleading for treatment. Currently, it is considered that for non-critical elderly CAP patients, blood culture should not be routine examination, but for patients with early treatment failure, blood culture is valuable.

　　IV. Pleural fluid culture
　　After the pleural effusion of pneumonia patients is aspirated, perform pleural fluid bacteriological examination, which can often detect the pathogenic bacteria in Streptococcus pneumoniae patients.

　　V. Invasive diagnostic tests
　　For elderly pneumonia patients, these examinations are occasionally used to provide etiological diagnosis.

　　1. Drink plenty of water and eat easily digestible or semi-liquid food to facilitate the secretion of sputum and timely expectoration.
　　2. Pneumonia often accompanied by high fever, with significant body consumption, so high-energy food should be provided, eating high-protein and easily digestible food.
　　3. Eat more fruit appropriately to increase moisture and vitamins. Vitamin C can enhance the body's resistance, and vitamin A is beneficial for protecting the respiratory tract mucosa.
　　4. Abstain from smoking and alcohol, and be cautious with spicy and irritating foods to avoid excessive coughing.

　　1. Selection of Antibiotics
　　(1) Prior to identifying the pathogenic bacteria: primarily consider Gram-positive cocci infections, and the first choice is penicillin or first-generation cephalosporins. Mild cases can use oral antibacterial drugs such as amoxicillin, or injectable penicillin G, 800,000 units, twice a day. For those allergic to penicillin, use erythromycin or oral roxithromycin; for those with moderate symptoms or above, apply strong antibiotics such as second and third-generation cephalosporins (Xilixin), ceftriaxone (Yanbizhi), cefoperazone (Xianfubei), and so on.
　　(2) After determining the pathogen: medication should be selected based on the type of pathogen and the results of drug sensitivity.
　　Gram-positive cocci: generally use broad-spectrum antibiotics or combined medication. For example, Haemophilus influenzae and Klebsiella pneumoniae can be selected for ampicillin, or second or third-generation cephalosporins; Pseudomonas aeruginosa, Escherichia coli, and Klebsiella pneumoniae should be首选 second or third-generation cephalosporins or third-generation quinolones, and can also be used in combination; for Legionnaires' disease in the lungs, erythromycin is the first choice.
　　Mycoplasma or Chlamydia: erythromycin or ciprofloxacin is preferred, with a medication duration of 2-4 weeks.
　　Anaerobic bacteria: mostly double infection, use penicillin G or broad-spectrum antibiotics plus metronidazole.

　　2. Rational use of antibacterial drugs
　　Rational use of antibiotics, prevent abuse, minimize adverse reactions, and reduce the occurrence of drug resistance should follow the following principles:
　　(1) Be familiar with the indications, antibacterial activity, pharmacokinetics, pharmacodynamics, and side effects of the selected drugs.
　　(2) Use medication rationally based on the patient's physiological, pathological, and immune status. Due to the decrease in plasma albumin, decreased renal function, and decreased enzyme activity of the liver in the elderly, the blood concentration of drugs after administration is higher than that in young people, the half-life is prolonged, and toxic and side effects are more likely to occur. Therefore, the dosage should be small, about 50%-70% (1/2-2/3) of the adult dosage, and medication should be selected based on renal function status, and aminoglycosides should be used with caution.
　　(3) Due to the decrease in gastric acid secretion, the prolongation of gastric emptying time, and the weakening of intestinal peristalsis in the elderly, it is easy to affect the absorption of drugs. For moderate to severe patients, intravenous administration should be used mainly, and oral administration should be changed after the condition improves.
　　(4) Determine the etiological diagnosis in a timely manner and select medication based on the pathogenic bacteria and drug sensitivity test.
　　(5) Master the administration schedule and course of treatment. Due to the presence of other underlying diseases in the elderly, appropriate methods and routes of administration should be chosen. The duration of medication should be long to prevent recurrence. Generally, medication should be discontinued 7-14 days after the body temperature drops and symptoms subside. In special cases, such as Legionnaires' disease pneumonia, the duration of medication can reach 3-4 weeks. If medication is ineffective for 48-72 hours during the acute phase, consider changing medication.
　　(6) Closely observe adverse reactions during treatment. The elderly are prone to dysbacteriosis, pseudomembranous colitis, and secondary infections, which should be prevented and treated in a timely manner.
　　(7) Be familiar with the interactions between drugs to avoid increasing toxic and side effects and to exert synergistic effects.