Infectious Diseases in the Elderly Flashcards
important infections in the elderly
- Pneumonia
- UTI
- Intra-abdominal infections
- Soft tissue infections
- Endocarditis
- meningitis
- septic arthritis
- Tuberculosis
Pneumonia
leading cause of death in hospitalized elderly, fifth leading cause of death in people > 65
UTI
most frequent bacterial infection in the elderly, most common cause of sepsis in the elderly
Intra-abdominal infections
diverticulitis and cholecystitis are more common in the elderly
Soft tissue infections
pressure ulcers and surgical wound infections are more common in the elderly
Tuberculosis
probably more common in the elderly due to relapse associated with immunodeficiency of old age and causes greater mortality in the elderly
What is one way that pressure ulcers can be avoided?
constantly turning the pt
Factors Which Increase the Risk of Infections in the Elderly
- Diminished humoral and cellular immunity
- Decreased blood perfusion of organs
- Decreased cough reflex
- Thinning of skin
- More and longer hospitalizations
- Dementia and stroke increases risk of pneumonia, UTI and soft tissue infections
- lack of clearance of sputum
Unique Features of Infectious Diseases in the Elderly
- Fever, leukocytosis, left shift may be absent
- Cough or sputum production may be absent in the older people with pneumonia (may not have the physical strength to cough)
- Frequency or burning may be absent in older people with urinary tract infections
- Anorexia, cognitive impairment, fatigue, weight loss, decline in functional status, falls, hypotension are non-specific symptoms commonly seen in older people with infections
- Empiric therapy is recommended as soon as infection is suspected accompanied by obtaining objective information
- Resolution after initiation of appropriate therapy is prolonged in the elderly
What are common etiologies of bronchitis?
- Influenza virus
- Adenovirus
- Coronavirus
- Parainfluenza virus
- Mycoplasma pneumoniae
- Bordetella pertussis (rare)
- Chlamydia pneumoniae
- Streptococcus pneumoniae (often 2º)
- Haemophilus influenzae (often 2º)
- Moraxella catarrhalis (often 2º)
What are the ways in which pneumonia can be acquired in the elderly?
- Community acquired
- Hospital acquired
- Nursing home acquired
What are common pathogens of pneumonia in CAP?
- S. pneumoniae
- H. influenzae
- Klebsiella sp
- M. catarrhalis
- S. aureus
- Often preceded by viral infections
What is the difference between in-pt and out-pt treatment of CAP?
same but in-pt uses IV formulations
treatment of CAP
- Macrolides (azithromycin or clarithromycin)
- Fluoroquinolone with S. pneumoniae activity – moxifloxacin, gatifloxacin, levofloxacin or gemifloxacin
- Beta-lactam (high dose amoxicillin, high dose amoxacillin/clavulanate, cefpodoxime, cefprozil or cefuroxime)
What are common pathogens of pneumonia in HAP?
- Klebsiella sp
- E. coli
- Enterobacter sp
- Pseudomonas aeruginosa
Prevention of Pneumonia in the Elderly
- Pneumococcal vaccination: PCV 13 first, followed by 12 months later of PPSV23
- Influenza vaccination (high dose) or prevention (oseltamivir (Tamiflu), zanamivir (Relenza) or oseltamivir + rimantadine combination when resistance is prevalent)
symptomatic bacteriuria
manifesting as typical symptoms (frequency, burning) or functional decline, cognitive impairment, or anorexia
What is the lab value that defines bacteriuria?
> 10^5 cfu/ml
When do you treat bacteriuria?
- symptomatic pts
- if pt has symptoms and a catheter, treat only if symptoms of UTI cannot be explained by other causes
When should diagnostic evaluation be warranted?
- elderly men with recurrent UTI, upper tract infection, or sepsis
- recurrence of UTI in women
- note: Chronic bacterial prostatitis should be excluded in elderly men with recurrent UTI
Duration of treatment of UTI
- generally 3 days but 7 to 10 days may be more appropriate for elderly women and 2 weeks for elderly men
- recurrent UTI may require up to 6 weeks of therapy
What are the most common organism causing UTI in the elderly?
- E. Coli
- Proteus spp
- Klebsiella spp
- Enterococcus spp
Treatment of UTI (uncomplicated)
- Trimethoprim / sulfamethoxazole
- First generation cephalosporin
- Amoxicillin/clavulanate
- Quinolone
Treatment of UTI (complicated)
- Second or third generation cephalosporin
- Aztreonam
- Quinolone
- Aminoglycoside + Ampicillin
Prevention of UTI’s in the elderly
- Adequate fluid intake (cranberry juice?)
- Topical vaginal estrogen in women
- Condom catheters for men versus indwelling catheters
- Prophylactic antibiotics
When is prophylactic antibiotics appropriate?
- Indicated if ≥ 2 UTIs in 6 months or ≥ 3 UTIs in 12 months
- Shown to decrease recurrence
- Duration 6 months (TMP, TMP/SMX, nitrofurantoin, norfloxacin)
What is the duration or therapy for it to be considered chronic?
> 90 days
Concerns about chronic nitrofurantoin in the elderly
- Beers list medication
- Concerns about increased risk of pulmonary, hepatotoxicity and peripheral neuropathy; risk increased with renal insufficiency.
- Of limited value if CrCl< 30 ml/min (new guideline)
- Development of resistance. Avoid prolonged use for prophylaxis
Discuss infections in the long term care setting
- Over 1.5 million infections annually
- Approximately 1-2 infections per resident per year
- Most frequent reason for transfer to hospital
- Responsible for 25% of hospitalization from LTC
Prevention and Minimization of Infections in Nursing Homes
- Management strategies
- Patient care strategies
Management strategies
- Infection control program: Surveillance, Outbreak investigation
- Antimicrobial utilization program
- Employee health program
Patient care strategies
- Optimal management of associated diseases
- Optimal nutrition
- Avoidance of invasive devices
- Vaccinations: Influenza, Pneumococcus, Tetanus
- Screening : Tuberculosis
