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Infections in the Elderly. Jérôme Fennell, MB, MSc, PhD, FRCPath Jerome.Fennell@amnch.ie. Infections in Old Age. Risk Factors of Old Age Common Infections of Old Age RTI: Pneumonia, Influenza, TB Skin and Soft tissue infections Shingles Leg Ulcers GIT: C. Difficile UTI: ESBLs

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infections in the elderly

Infections in the Elderly

Jérôme Fennell, MB, MSc, PhD, FRCPath

Jerome.Fennell@amnch.ie

infections in old age
Infections in Old Age
  • Risk Factors of Old Age
  • Common Infections of Old Age
    • RTI: Pneumonia, Influenza, TB
    • Skin and Soft tissue infections
      • Shingles
      • Leg Ulcers
    • GIT: C. Difficile
    • UTI: ESBLs
  • Renal function and aminoglycoside and glycopeptide dosing
risk factors for infections in the elderly
Risk factors for Infections in the Elderly

Older, weaker, more at risk

  • More comorbidities
  • Gradual deterioration of immune system with age
  • May be malnourished, poor accommodation
  • More likely to harbour resistant organisms as more likely to have been
    • Hospitalised
    • in nursing home
    • Exposed to multiple antibiotics
cellular immunity in the elderly
Cellular Immunity in the Elderly
  • Altered T cell phenotype
    •  naïve T cells;  memory T cells
  • Reduced T cell responses
    •  response to TCR stimulation
    •  T cell proliferation
    •  expression of IL2-R
    •  IL2 production

Ginaldi et al 1999

case history december 1999
Case History: December 1999
  • 67 yr old woman
  • PC: cough, left sided chest pain, rigors x 24h
  • HPC: productive cough most mornings, but increasingly purulent recently
  • PMHx: MI 2 yrs ago, smoked 40/day until then
slide6
On Examination:
  • T: 40oC
  • Pulse: 130/min, BP: 145/90
  • Tachypnoea
  • PMHx: MI 2 yrs ago

smoked 40/day until then

  • Resp exam suggestive of consolidation
tests
Tests
  • FBC, WCC
  • Sputum for microscopy and culture
  • Blood culture
  • CXR
  • ABG
  • WCC – 22, 90% neutrophils
  • Sputum – pus cells, gram positive diplococci
sputum result
Sputum result

Sputum – pus cells, gram positive diplococci…What does this tell us?

More than you think –

  • No epithelial cells - suggests this is a good specimen from lower RT so should provide a good result on culture
  • Gram positive diplococci likely to be?
sputum gram stain
Sputum Gram Stain
  • No longer done routinely
  • Not sensitive or specific enough
  • Not recommended in IDSA CAP guidelines
  • Guidelines now recommend another test instead...
urinary antigen testing
Urinary Antigen Testing
  • All severe pneumonias should have urine test for
    • Legionella Urinary Antigen
    • Pneumococcal Urinary Antigen
  • Should also think of CXR, pulse oximetry, ABG,
treatment
Treatment

Pneumococcus

BenzylPen unless allergic or live in area of resistance (Irish rate of resistance-?)

When cause unknown, use augmentin or cefotaxime to cover Haemophilus

later
later…

IV BenPen

Transferred to ICU for ventilation because of hypoxia

BCs – positive for S pneumoniae x2

WCC – 35

CXR – shows increasing consolidation and pleural effusion

24 hrs later – Cardiac arrest – RIP

Next day S pneumoniae sensitivity available:

R- Penicillin

S – Erythromycin, Ceftriaxone

rti in elderly
RTI in Elderly
  • Strep. Pneumoniae
  • Influenza Virus
  • Recurrence of TB
  • Normal causes of RTI
pneumococcus
Pneumococcus
  • Common cause of community acquired pneumonia
  • Risk increased by smoking
  • Often occurs as secondary pneumonia after influenza infection
  • More common during winter months
  • Can also cause ENT, bacteremia and CNS infections
  • Latest EARSS Resistance Rates for Ireland:
    • Pen Non Susceptible 16.2%
    • Erythromycin Resistant 14.1%
    • Ceftriaxone/Cefotaxime Resistance Rare
pneumonia symptoms
Pneumonia Symptoms
  • Fever (less common in those >75)
  • Cough with coloured sputum
  • Pleuritic chest pain, dyspnea
  • Altered mental function, particularly in the elderly
  • Increased or decreased WBC
strep pneumoniae
Strep pneumoniae
  • RTI: Amoxicillin/Clarithromycin if sensitive
  • If infection severe or previous antibiotic exposure, use IV Ceftriaxone or Cefotaxime
  • Augmentin has no added benefit because resistance is not due to B-lactamase production but do to different Pen binding proteins
  • In countries where Ceftriaxone resistance occurs in significant numbers use IV Ceftriaxone and IV Vancomycin empirically
pneumococcal pneumonia
Pneumococcal Pneumonia
  • Elderly patients often have fewer or less severe symptoms than younger patients
  • Many community-acquired pneumonias are perfectly treatable as outpatients by oral antibiotics
  • >90 polysaccharide capsular types
  • HPSC Guidelines:
pneumococcal vaccines
Pneumococcal Vaccines

2 types of pneumococcal vaccine:

  • Polysaccharide Pneumococcal Vaccine (PPV23)
    • incorporates 23 of the most common capsular types which together account for up to 90% of serious pneumococcal infections
    • Only suitable for use in those ≥ 2 years of age
  • A conjugate 7 valent vaccine (PCV7) containing polysaccharide antigens from the 7 most common serotypes conjugated to a protein (CRM 197) has enhanced immunogenicity compared with the polysaccharide vaccine.
    • immunogenic even in infancy
    • active against approximately 70% of isolates causing invasive disease, and against a significant number of penicillin-resistant strains.
hpsc groups requiring vaccination
HPSC Groups Requiring Vaccination

At risk categories:

  • Asplenia or reduced splenic dysfunction (e.g. splenectomy, sickle cell disease and coeliac syndrome)
  • Chronic renal disease or nephrotic syndrome
  • Chronic heart, lung, or liver disease, including cirrhosis
  • Diabetes mellitus
  • Complement deficiency (particularly early component deficiencies C1, C2, C3, C4)
  • Immunosuppressive conditions (e.g. HIV, leukaemia, lymphoma, Hodgkin’s disease) and those receiving immunosuppressive therapies
  • CSF leaks either congenital or complicating skull fracture or neurosurgery
  • Intracranial shunt
  • Candidate for, or recipient of, a cochlear implant
  • Children under 5 years of age with a history of invasive pneumococcal disease, irrespective of vaccine history.
adults 65
Adults >65
  • All should be offered single dose of Pneumococcal Polysaccharide Vaccine (PPV23)
  • Adults 65 years or older should receive a second dose of PPV23 if they received vaccine more than 5 years before and were less than 65 years of age at the time of the first dose.
curb 65 score
CURB-65 Score
  • Confusion – new onset
  • Urea - >7 mmol/l
  • Respiratory rate >30 breaths/minute
  • Blood Pressure <90/60
  • Age>65

Score:

0-1 – Treat as outpatient

2 – consider admission or follow closely as outpatient

> 3 requires hospitalization, mortality >17%

influenza
Influenza
  • H1N1 flu pandemic declared over by WHO
  • now seen as part of seasonal flu
  • Current seasonal flu vaccine includes a H1N1 strain
  • Primary Influenza A infection can present abruptly as rapidly progressive diffuse pneumonia with pulmonary haemorrhage
  • More severe in elderly, may develop meningoencephalitis or encephalitis
influenza1
Influenza
  • Treatment: Neuraminidase inhibitors such as oseltamivir (PO) and Zanamivir (IV) given early in severe or at risk cases
  • Often followed by secondary bacterial pneumonia e.g. S pneumoniae, S aureus
  • Vaccine less effective in elderly
  • Adults over 50 should have annual vaccination
  • Those in nursing homes and other long stay facilities should also have annual vaccination
another case
Another Case
  • 82 year old woman with 2 months of cough, fatigue, night sweats
  • Poor response to Coamoxiclav, tetracycline
tb in ireland
TB in Ireland
  • Common in the 1950s
  • Many people who were exposed/treated as children then are now presenting with TB now as their immune system wanes with age
varicella zoster virus
Varicella Zoster Virus
  • Cause of Chicken Pox and later Shingles
  • Extremely infectious
  • Can be severe and even fatal in immunocompromised
  • Shingles not uncommon in elderly hospital patients, can leave severe pain of post-herpetic neuralgia
  • Pose an infection control risk to immunocompromised, and non immune staff especially to non immune pregnant staff
leg ulcers
Leg Ulcers
  • As patients age, increasing peripheral vascular disease and diabetes can predispose to venous or arterial leg ulcers
  • Wet
  • Warm
  • Oxygenated
  • Below the belt
  • So swabs will always grow something, often grow patients bowel flora
  • Treat only if infected!
case history
Case History
  • Anne, 74 yr old housewife
  • PC: Elective total hip replacement – 3/7 ago
  • PMHx: Hypertension, Gastric Ca 13 yrs ago
  • 2/7 post op catheter specimen urine showed high white cells, Mixed growth predominantly gram negative bacilli
  • Given Zinacef po x 5/7
case history1
Case History
  • 3/7 after Zinacef started, complains of diarrhoea

Causes:

  • Infectious? – Any other patients on ward affected?
  • Non-infective causes?
  • Hospital food?
  • Secondary to drugs:
    • Antibiotic assoc diarrhoea?
    • Clostridium difficile?
case history2
Case History

Investigations?

Stool Culture sent:

  • Culture – NAD, no Salmonella, Shigella, Campylobacter, or E coli 0157
  • C diff toxin studies negative
case history3
Case History

What next?

  • Repeat C diff testing: Positive
  • Treatment?
case history4
Case History
  • Treatment – po metronidazole 250 mgs qds for 10/7
  • Diarrhoea settles – D/C home
  • Seen in OPD:
what is c difficile
What is C. difficile?

Gram positive bacillus

Clostridia = anaerobe

Forms spores

Spread by touch, faecal-oral route

Main sources are:

  • asymptomatic carriers
  • Contaminated environment
resistance to antibiotics

sensitive

resistant

Resistance to Antibiotics

No antibiotic – no selection for resistant organisms

resistance to antibiotics1

sensitive

resistant

Resistance to Antibiotics

antibiotic – selects for resistant organisms

clinical picture
Clinical Picture
  • Clinical ranges from mild diarrhoea to life-threatening colitis
  • Occurs 1/7 to 6/52 after antibiotic exposure
  • Get watery diarrhoea, lower abdominal pain, blood pr
clinical picture1
Clinical Picture
  • Systemic symptoms: fever, anorexia, nausea and malaise
  • Severely ill may have no diarrhoea due to toxic megacolon
  • Complications: perforation, peritonitis – high mortality
risk factors
Risk Factors
  • Age
  • Prior antibiotic use
  • Length of hospital stay
  • Other severe underlying disease
  • C diff strain
antibiotic culprits
Antibiotic culprits
  • Any – including metronidazole
  • Main culprits include:
    • Clindamycin
    • Cephalosporins
    • Quinolones e.g. Moxifloxacin, Ciprofloxacin
    • Broad spectrum antibiotics – e.g. Augmentin, Meropenem
pathogenesis
Pathogenesis
  • Disrupts normal bowel flora
  • Many people especially neonates are colonised but not infected.
  • Carriers thought to have better immune response, infected tend to have lower Ab response
  • Two potent cytotoxins, toxins A and B
  • Can have colitis without pseudomembranes
spore formation
Spore Formation
  • Spores provide a method of survival when environmental conditions are unsuitable
  • Protect against ethanol, phenol, formaldehyde, heat
  • Killed by iodine, glutaraldehyde, hydrogen peroxide, autoclaving
pseudomembranous colitis
Pseudomembranous Colitis
  • Due to Clostridium difficile toxins, rarely due to S. aureus
  • Symptoms: diarrhoea +/- mucus or blood, abdominal pain, tenderness, fever, dehydration, electrolyte disturbances
  • Dx by toxin detection or by endoscopy (risk of perforation)
  • Tx: Stop causative agent, give metronidazole or Vancomycin PO for 10/7
diagnosis
Diagnosis
  • Culture too slow and those that grow may not express toxins
  • Therefore do toxin testing by ELISA
  • Pseudomembranes can be seen on endoscopy
  • Nursing nose!
  • No point in testing if clinically well or still on treatment
slide49

O27 strain

  • Increasingly common
  • Associated with quinolone use
  • Higher mortality
  • Higher infectivity
treatment1
Treatment
  • Hydration, electrolytes
  • Contra-indicated: Antiperistaltics, e.g. imodium
  • Severe illness may require surgery esp if perforation or toxic megacolon suspected.
  • Probiotics??

Half of recurrences thought to be due to reinfection rather than relapse.

Metronidazole resistance rare.

TX. MUST BE PO!

slide56
UTIs
  • Men often have some degree of prostatic obstruction
  • As patients age greater risk of urinary and faecal incontinence
  • Nursing home/Hospital/Antibiotic exposure predispose to resistant organisms
  • Temptation to catheterise many of these patients indefinitely, this sacrifices patient outcomes for convenience
earss ireland 02 10 e coli
EARSS Ireland 02-10 – E. coli

EARSS Quarterly Surveillance Reports –Quarter 1 2010, HPSC

esbl sample type amnch
ESBL Sample Type - AMNCH

Female: Male 3:2

amnch esbl age distribution
AMNCH ESBL Age Distribution

Average Age: 60.1

Median Age: 66

mortality
Mortality

30 day mortality (all causes) = 9.7%

Irish Data (paper in production)

treatment by class
Treatment by Class

Useless

Useless

Unreliable

If sensitive

If sensitive

Most reliable...for now

  • Penicillins
  • Cephalosporins
  • Penicillins +B-lactamase inhibitor
  • Quinolones
  • Aminoglycosides
  • Carbapenems
carbapenems
Carbapenems
  • E.g. Meropenem, 1st line choice for treatment of serious ESBL infections
  • stability to all the currently recognised, frequently occurring ESBLs
  • extensive clinical experience
  • Ertapenem also useful for UTIs, home IV tx (once daily)
  • Excess carbapenem use will result in resistance

Paterson DL and Bonomo RA. Clin Microbiol Rev 2005; 18 (4): 657-686

other antibiotics
Other antibiotics
  • Nitrofurantoin po– outpatient setting
  • Tigecycline IV– with caution in E coli and Klebsiella (Pseudomonas and Proteus inherently resistant)
  • Fosfomycin, Temocillin, Pivmecillinam
  • Trimethoprim, Aminoglycosides, Quinolones when susceptible

Paterson DL and Bonomo RA. Clin Microbiol Rev 2005; 18 (4): 657-686

vancomycin and gentamicin dosing
Vancomycin and Gentamicin Dosing
  • Vancomycin and Gentamicin are nephrotoxic and ototoxic
  • Important not to overdose in this age group
  • Elderly often have some degree of renal impairment
  • Assess renal function by urea and creatinine levels
  • If normal, treat normally but watch levels after 24 h of treatment
  • If levels high will have to reduce dose