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The use of anti-infective chemotherapy drugs in the elderly

The high incidence of infectious pathology in the elderly, along with its unfavorable prognosis, justifies the widespread use of AMP in them. The latter are one of the most frequently prescribed (about 40%) drugs in specialized departments of extended stay of elderly patients. However, the appointment of AMP in older age groups is not always clinically justified.

Decision-making on the appointment of AMS to the elderly requires mandatory consideration of the characteristics of this age group:

age-related morphological and functional changes in various organs and tissues;

polymorbidity (the presence of two or more diseases);

chronic course of many diseases;

drug therapy, requiring the use of (often prolonged) several drugs (forced polypharmacy);

features of the clinical manifestations of infection;

more frequent and severe drug complications;

features of psychosocial status.

The choice of AMP in older people is determined by various factors, the most important of which are discussed below.

A rough definition of the etiology of infection is the most important criterion in the choice of AMP. This is due to the need to start therapy as early as possible, which is associated with a high risk of rapid progression of infectious inflammation, the development of complications, frequent decompensation of concomitant pathology, and an unfavorable prognosis of the disease. For example, mortality in the first 30 days in patients older than 65 years with severe pneumonia, in whom antibiotic therapy was started in the first 8 hours from the time of admission, was significantly lower compared with patients who were used for AMP at a later date.

Clinical manifestations of infection in elderly patients may be atypical, nonspecific or even absent. One of the features of the clinical manifestations of geriatric infection is the frequent absence of fever, the presence of cognitive impairment, sudden onset of confusion, and the mild local symptoms of the infection. Often, the clinical symptoms of infection in the elderly, in particular with infections of the MEP, are generally absent.

In the elderly, there are some features of the etiology of infections. So, if the causative agents of community-acquired pneumonia in the general population is a fairly limited spectrum of microorganisms (S. pneumoniae, H. influenzae, M. pneumoniae and C. pneumoniae), then in elderly people, along with the above bacteria, the causative agents of the disease can be enterobacteria and P. aeruginosa.

Older people represent the highest risk group for tuberculosis, not counting patients with HIV infection. Tuberculosis mortality also increases with age. Its level in the elderly is 10 times higher than in the young.

The most typical geriatric infections are infections of MVP, mortality from which in the elderly is 5-10 times higher than in the young. In contrast to people of a younger age, in whom MVP infections occur mainly in sexually active women, among older people this infection is observed in patients of both sexes. The main causative agents of MVP infections are E. coli, Proteus spp., Other enterobacteria, less commonly Enterococcus spp., S.aureus. Most cases of MVP infections in the elderly are secretive, asymptomatic bacteriuria is often detected, which causes difficulties in interpreting and deciding on the appropriateness of antibiotic therapy.

Special situations in geriatric practice are infections in people living in nursing homes. Approximately 75% of all infections in them are pneumonia, infections of MVP, infections of the skin and soft tissues.

The spectrum of pneumonia pathogens in people living in boarding schools includes S. pneumoniae (12.9%), H. influenzae (6.4%), S. aureus (6.4%), M. catarrhalis (4.4%) , family Enterobacteriaceae (13.1%). The etiology of pneumonia in this contingent is not always possible to determine, due to the frequent impossibility of obtaining an adequate sputum sample for research. Another problem is the difficulty in distinguishing between microbial colonization by aerobic gram-negative microorganisms and true infection. It is known that the frequency and degree of colonization of the oropharynx by gram-negative microorganisms increases with age.

The pharmacokinetic properties of AMP in the elderly may vary due to concomitant diseases with the presence of functional disorders of the kidneys and liver. Along with manifest pathologies (CRF, impaired liver function, etc.), age-related changes in the kidneys and liver that affect the metabolism and elimination of AMP should also be taken into account.
It is known that with age, a decrease in glomerular filtration occurs, which should be considered when prescribing AMP excreted by the kidneys. When choosing AMP in elderly patients with concomitant chronic renal failure, it is preferable to prescribe drugs metabolized in the liver (macrolides, metronidazole) or having a double elimination pathway (cefoperazone). For AMP with renal excretion, it is necessary to reduce the dose in proportion to the decrease in glomerular filtration.

The pharmacokinetic interaction of AMP with other drugs is of particular importance in the elderly, receiving several drugs due to their often associated pathology (calcium, iron, NSAIDs, theophylline, etc.). For example, the absorption of fluoroquinolones may be impaired in elderly patients receiving iron, aluminum, magnesium, calcium preparations in connection with concomitant pathology.

Pharmacotherapy compliance. In people of advanced and senile age, it is preferable to use AMP prescribed 1-2 times a day. This is especially true for injectable drugs, since it provides not only a convenient dosage regimen, but also reduces the risk of post-injection complications (phlebitis, hematomas). A single or double oral administration of AMP contributes to greater compliance of elderly patients, who, due to impaired memory, vision and often lack of extraneous control, have problems observing the prescribed intake regimen.

AMP resistance in older people is more common than in young people. This is facilitated by the polymorbidity of the elderly, the more frequent preceding antibiotic therapy, especially in patients with repeated infectious exacerbations of COPD or recurrent infections of MVP and, finally, living in boarding houses. The widespread and often unreasonable use of AMP contributes to the formation of resistance not only to "old", but also to relatively recent drugs, for example, fluoroquinolones. Therefore, when choosing AMP for empirical therapy, one should take into account the local epidemiology of antibiotic resistance that has developed in the region, hospital, department.

The safety of AMP is of particular importance in elderly patients in connection with concomitant, often multiple, diseases. Thus, in senile people, the nephrotoxic and ototoxic effects of aminoglycosides, the nephrotoxic effect of high doses of cephalosporins are more often recorded, and the appointment of cotrimoxazole is associated with a higher risk of neutropenia. It is advisable to reduce the dose of AMP in patients with a pronounced decrease in body weight, especially in women. When prescribing AMP excreted by the kidneys, a dose adjustment is necessary taking into account creatinine clearance, which decreases after 30 years of life by 1 ml / min annually. Caution should be prescribed to the elderly or, if possible, avoid the use of aminoglycosides, amphotericin B, vancomycin.

In order to ensure greater safety, it is more preferable to administer AMP inward or timely switch from the parenteral route of administration to the oral route (stepwise therapy).

The criteria for the transition from the parenteral route of administration to oral AMP should be considered normal indicators of body temperature with a 2-fold measurement over the past 16 hours, a tendency to normalize the number of leukocytes, subjective improvement in well-being, and the absence of signs of malabsorption. The optimal time for switching from parenteral to oral therapy is 48-72 hours. Usually they switch to the oral form of the same AMP, however, it is possible to use a drug that is similar in activity spectrum to parenteral AMP. For example, if ampicillin was administered parenterally, amoxicillin is given orally. To ensure high compliance, preference should be given to AMP with good bioavailability and a convenient dosage regimen (1-2 times a day). Such fluoroquinolones, in particular levofloxacin, can meet these requirements. Currently, there are numerous data on the high clinical and microbiological effectiveness of levofloxacin in the framework of step therapy, comparable to ceftriaxone and superior to the combination of ceftriaxone or cefuroxime axetil in combination with erythromycin or doxycycline in the treatment of severe community-acquired pneumonia.

The cost of ILA, all other things being equal, is of no small importance for the elderly. At the same time, evaluating their financial capabilities, the doctor should be aware that the use of cheaper drugs can often lead to an insufficient effect, a protracted course, the development of complications and, ultimately, the treatment is more expensive. Ultimately, the most expensive AMP is one that has no effect.
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