IM - REVIEW Pneumonia in frail older patients: an up to date Marco Falcone • Francesco Blasi • Francesco Menichetti • Federico Pea • Francesco Violi Received: 22 March 2012 / Accepted: 26 May 2012 / Published online: 12 June 2012 Ó SIMI 2012 Abstract Despite advances in diagnosis, antimicrobial therapy and supportive care modalities, community- acquired pneumonia (CAP) remains an important cause of morbidity and mortality, especially in patients who require hospitalization. Elderly patients with poor functional status are characterized by a higher risk of developing severe CAP, due to the frequent presence of underlying respira- tory and cardiac diseases, alteration of mental status, and immunosuppression. In recent years, changes in the healthcare system have shifted a considerable part of older patient care from hospitals to the community, and the tra- ditional distinction between community- and hospital- acquired infections has become less clear. Pneumonia occurring among outpatients in contact with the healthcare system has been termed healthcare-associated pneumonia. Older frail patients have a high frequency of aspiration pneumonia and pneumonia due to gram-negative bacilli and other multidrug resistant pathogens. The contemporary presence of renal impairment usually requires specific dose adjustment of antibiotic therapy, which may be toxic in this specific patient population. This review produces a sum- mary of therapeutic recommendations on the basis of the most updated clinical and pharmacological data. Keywords Community-acquired pneumonia Á Healthcare-associated pneumonia Á Empirical antibiotic therapy Á Multi-drug resistant microorganism Á PK–PD profile Á Frail elderly Epidemiology Pneumonia is one of the most serious infectious diseases in both industrialized and developing countries, and is cur- rently the sixth leading cause of death in the US and Europe [1, 2]. The reported incidence of pneumonia ranges in different populations between 1.3 and 11.6 cases per 1,000 inhabitant year, with the highest rate in older adults [3–5]. More specifically, the incidence of pneumonia is 8.4 cases per 1,000 inhabitants among persons [ 65 years of age, and six times greater in persons over 90 years [6, 7]. Approximately one in 20 persons over 85 years of age will present a new episode of pneumonia every year, and the incidence is likely to increase in relation to the progressive aging of the general population [5]. Pneumonia has been classically divided into commu- nity-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP). However, in recent years, the progres- sive changes in the organization of health care systems make this distinction less clear with some patients having M. Falcone (&) Dipartimento di Sanita ` Pubblica e Malattie Infettive, Policlinico Umberto I, ‘‘Sapienza’’ Universita ` di Roma, Viale del Policlinico 185, 00161 Rome, Italy e-mail: marcofalc@libero.it F. Blasi Dipartimento Toraco-Polmonare e Cardiocircolatorio, IRCCS Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Universita ` degli Studi di Milano, Milan, Italy F. Menichetti Azienda Ospedaliera Universitaria Pisana, Nuovo Ospedale, Santa Chiara, Pisa, Italy F. Pea Istituto di Farmacologia Clinica e Tossicologia, Azienda Ospedaliera Universitaria di Udine, Udine, Italy F. Violi Divisione di I Clinica Medica, ‘‘Sapienza’’ Universita ` di Roma, Rome, Italy 123 Intern Emerg Med (2012) 7:415–424 DOI 10.1007/s11739-012-0796-7