1 Fever. 2 Fever in the elderly adult be defined as persistent elevation of body temperature of at least (1.1 C) over baseline values or oral temperatures.

11

FeverFever

22

Fever in the elderly adult be defined as Fever in the elderly adult be defined as persistent elevation of body persistent elevation of body temperature of at least (1.1 C) over temperature of at least (1.1 C) over baseline values or oral temperatures of baseline values or oral temperatures of (37.2 C) or greater on repeated (37.2 C) or greater on repeated measures or rectal temperatures of measures or rectal temperatures of (37.5 C) or greater on repeated (37.5 C) or greater on repeated measures. measures.

33

The most common sign that triggers The most common sign that triggers the clinician to look for infection, fever, the clinician to look for infection, fever, is often absent in the elderly patient. is often absent in the elderly patient. Animal models of aging demonstrate Animal models of aging demonstrate that temperature elevations in response that temperature elevations in response to endogenous pyrogens (IL-1, IL-6, to endogenous pyrogens (IL-1, IL-6, Tumor Necrosis Factor) are diminished Tumor Necrosis Factor) are diminished with advanced age. with advanced age.

44

הקשיש עם מחלת חום 78מ"ד קשיש בן

מובא לחדר מיון עם חום גבוה ועירפול

הכרה. אישתו מספרתכי הוא סובל מבעיות

של "פרוסטטה" ושבימים האחרונים

. סבל משעול קשהפרט לכך מ"ד הוא

…איש בריא

55

66

Presentation of illnessPresentation of illnessInfectious diseases frequently present with Infectious diseases frequently present with atypical features in older adults. Serious atypical features in older adults. Serious infections may be heralded by nonspecific infections may be heralded by nonspecific declines in functional or mental status, or declines in functional or mental status, or anorexia with decreased oral intake. anorexia with decreased oral intake. Underlying illness (e.,g. congestive heart Underlying illness (e.,g. congestive heart failure or diabetes) may be exacerbated. failure or diabetes) may be exacerbated.

77

Presentation of illnessPresentation of illness

Cognitive impairment heavily Cognitive impairment heavily contributes to the difficulty in contributes to the difficulty in diagnosing infection in the elderly. diagnosing infection in the elderly.

88

ComorbiditiesComorbiditiesIn the elderly individual, the increased In the elderly individual, the increased incidence of infection and mortality for incidence of infection and mortality for many infectious diseases is likely a many infectious diseases is likely a direct result of the comorbid direct result of the comorbid conditions:conditions:DiabetesDiabetesRenal failureRenal failureChronic pulmonary diseaseChronic pulmonary disease

99

NutritionNutrition

Protein-energy malnutrition is present Protein-energy malnutrition is present in 30 to 60 percent of subjects older in 30 to 60 percent of subjects older than 65 years of age who are admitted than 65 years of age who are admitted to the hospital and is linked to delayed to the hospital and is linked to delayed wound healing, decubitus ulcer wound healing, decubitus ulcer formation, CAP, increased risk of formation, CAP, increased risk of nosocomial infection, extended lengths nosocomial infection, extended lengths of stay and increased mortality.of stay and increased mortality.

1010

Clinical Syndromes in The Clinical Syndromes in The ElderlyElderly

Urinary Tract Infections Urinary Tract Infections in the Elderlyin the Elderly

1111

UTI.UTI.

Urinary infection in the elderly person Urinary infection in the elderly person is usually asymptomatic. is usually asymptomatic. Recurrent urinary infection, which may Recurrent urinary infection, which may be either be either reinfectionreinfection or or relapserelapse, is , is frequent. frequent. ReinfectionReinfection is recurrent is recurrent urinary infection with an organism urinary infection with an organism isolated following antimocrobial isolated following antimocrobial therapy which differs from the therapy which differs from the pretherapy isolatepretherapy isolate . .

1212

UTI.UTI.

RelapseRelapse is recurrent urinary is recurrent urinary infection with the organism infection with the organism isolated posttherapy similar to isolated posttherapy similar to that which was present prior to that which was present prior to therapy. therapy.

1313

UTI.UTI.

The prevalence of bacteriuria is 2 to 3 The prevalence of bacteriuria is 2 to 3 percent in young women, and increases to percent in young women, and increases to more than 10 percent for women older than more than 10 percent for women older than age 65 years. Bacteriuria is uncommon in age 65 years. Bacteriuria is uncommon in younger men. With aging, particularly younger men. With aging, particularly coincident with the development of prostatic coincident with the development of prostatic hypertrophy, the prevalence of bacteriuria hypertrophy, the prevalence of bacteriuria increases substantially, and approximately 5 increases substantially, and approximately 5 percent of men older than age 70 years living percent of men older than age 70 years living in the community have bacteriuria.in the community have bacteriuria.

1414

UTI.UTI.

The prevalence of asymptomatic The prevalence of asymptomatic bacteriuria in institutionalized elderly bacteriuria in institutionalized elderly populations is remarkably high. Women populations is remarkably high. Women have a higher frequency than men, with have a higher frequency than men, with 25 to 50 percent of women being 25 to 50 percent of women being bacteriuric, as compared to 15 to 40 bacteriuric, as compared to 15 to 40 percent of men.percent of men.

1515

Prevalence of Asymptomatic bacteriuriaPrevalence of Asymptomatic bacteriuriain elderly populationsin elderly populations

Positive Urine Culture)%(

PopulationWomenMen

Community > 70 years of age

10 – 18%4 – 7%

Long-term care25 – 55%15 – 37%

1616

Infecting bacteria Infecting bacteria

CommunityCommunity vs.vs. InstitutionInstitution

WomenWomen:: Escherichia coli 68% - 47%Escherichia coli 68% - 47%

Proteus mirab.Proteus mirab. 1% 1% - 27%- 27%

Klebsiella Klebsiella 7% - 10%7% - 10%

Enterococcus spp. 5%- 6%Enterococcus spp. 5%- 6%

Coagulas- neg.Coagulas- neg. staph. 7% -1%staph. 7% -1%

Pseudomonas aeruginosa 0-5%Pseudomonas aeruginosa 0-5%

Providencia spp. 0-7% Providencia spp. 0-7%

1717

Infecting bacteria Infecting bacteria

CommunityCommunity vs.vs. InstitutionInstitution

MenMen:: Escherichia coli 20% - 11%Escherichia coli 20% - 11%

Proteus mirab.Proteus mirab. 5%-5%- 30% 30%

Klebsiella Klebsiella 6% - 5%6% - 5%

Enterococcus spp. 25%- 5%Enterococcus spp. 25%- 5%

Coagulas- neg.Coagulas- neg. staph.39% -2%staph.39% -2%

Pseudomonas Pseudomonas 5% 5% -19%-19%

Providencia 0-16%Providencia 0-16%

1818

Factors contributing to the high prevalence of Factors contributing to the high prevalence of bacteriuria in elderly populationsbacteriuria in elderly populations

Women : Loss of estrogen effect on Women : Loss of estrogen effect on

genitourinary mucosagenitourinary mucosa

Changes in colonizing floraChanges in colonizing flora

Increased residual Increased residual

volumevolume

1919


Men:Men:

Prostatic hypertrophyProstatic hypertrophy

Bacterial prostatitisBacterial prostatitis

Prostatic calculiProstatic calculi

Urethral stricturesUrethral strictures

External urine collecting devicesExternal urine collecting devices

2020


Both:Both:

Genitourinary abnormalitiesGenitourinary abnormalities

Bladder diverticulae Bladder diverticulae

Urinary catheters (intermittent, indwelling)Urinary catheters (intermittent, indwelling)

Associated illnessesAssociated illnesses

Neurologic disease with neurogenic bladder Neurologic disease with neurogenic bladder dysfunction dysfunction

Diabetes Mellitus.Diabetes Mellitus.

2121

Symptomatic Urinary InfectionSymptomatic Urinary Infection

From 8 to 30 percent of transfers to an From 8 to 30 percent of transfers to an acute care facility from long-term care acute care facility from long-term care are necessitated by acute urinary are necessitated by acute urinary infection. infection.

2222

Symptomatic Urinary InfectionSymptomatic Urinary InfectionMorbidity and MortalityMorbidity and Mortality

Urinary infection occurs by the Urinary infection occurs by the ascending route. Organism that ascending route. Organism that colonize the periurethral area ascend colonize the periurethral area ascend the urethra into the bladder, kidney, the urethra into the bladder, kidney, with renal infection. For men, with renal infection. For men, ascending infection may also lead to ascending infection may also lead to prostatic infection. Renal localization is prostatic infection. Renal localization is more frequent with increasing age, and more frequent with increasing age, and in residents of nursing homes.in residents of nursing homes.

2323

Clinical presentations of symptomatic urinary Clinical presentations of symptomatic urinary

tract infection in elderly populationstract infection in elderly populations Probable urinary infection:Probable urinary infection:Acute lower tract irritative symptoms: Acute lower tract irritative symptoms: frequency, dysuria, urgency, increased frequency, dysuria, urgency, increased incontinence .incontinence .Acute pyelonephritis (fever, flank pain, and Acute pyelonephritis (fever, flank pain, and tenderness).tenderness).Fever with urinary retention or obstruction of Fever with urinary retention or obstruction of the urinary tract .the urinary tract .Fever with chronic indwelling urethral Fever with chronic indwelling urethral catheter.catheter.

2424

Unlikely caused by urinary infection:Unlikely caused by urinary infection:

Gross hematuriaGross hematuria

Not caused by urinary infection:Not caused by urinary infection:

Chronic incontinenceChronic incontinenceOther chronic genitourinary symptomsOther chronic genitourinary symptoms

2525

Quantitative urinary microbiology for diagnosis Quantitative urinary microbiology for diagnosis of urinary tract infectionof urinary tract infection

Clinical PresentationQuantitative Microbiology

Asymptomatic urinary infection

Pyelonephritis or fever with localizing genitourinary symptoms

Acute lower tract symptoms

Specimen collected from: - External collecting device (men only)

- Aspirated indwelling catheter

Same organism(s) 105

CFU/mL on two Consecutive cultures

104 CFU/mL

103 CFU/mL of uropathogen

105 CFU/mL

103 CFU/mL

2626

Symptomatic Urinary InfectionSymptomatic Urinary Infection

Treatment of symptomatic urinary Treatment of symptomatic urinary infection requires optimal use of urine infection requires optimal use of urine culture for diagnosis, appropriate culture for diagnosis, appropriate antimicrobial selection, and an antimicrobial selection, and an appropriate duration of therapy. A urine appropriate duration of therapy. A urine specimen for culture should be specimen for culture should be obtained prior to antimicrobial therapy. obtained prior to antimicrobial therapy.

2727

Symptomatic Urinary Infection (cont.)Symptomatic Urinary Infection (cont.)

Antimicrobial selection for treatment of Antimicrobial selection for treatment of urinary infection is similar for elderly urinary infection is similar for elderly and younger populations. Therapy may and younger populations. Therapy may be given either orally or, when oral be given either orally or, when oral administration cannot be tolerated or administration cannot be tolerated or absorption is uncertain, by parenteral absorption is uncertain, by parenteral therapy. Antimicrobial cost will also therapy. Antimicrobial cost will also usually be a factor, especially for usually be a factor, especially for institutionalized populations.institutionalized populations.

2828

Oral antimicrobial regimens for treatment of Oral antimicrobial regimens for treatment of acute urinary tract infectionacute urinary tract infection

AgentDose*

First line

Nitrofurantoin50 – 100 mg qid

Trimethoprim/sulfamethoxazole

160/800 mg bid

Trimethoprim100 mg bid

Amoxicillin500 mg tid

2929

Oral antimicrobial regimens for treatment of Oral antimicrobial regimens for treatment of acute urinary tract infection (cont.)acute urinary tract infection (cont.)

AgentDose*Other

Amoxicillin/clavulanic acid500 mg tid

Norfloxacin400 mg bid

Ciprofloxacin250 – 500 mg bid

Ofloxacin200 – 400 mg bid

Cephalexin500 mg qid

Cefaclor500 mg qid

Cefixime400 mg od

3030

Parenteral antimicrobial regiments for the Parenteral antimicrobial regiments for the treatmenttreatment

of urinary tract infection of urinary tract infection

AgentDose

Preferred

Gentamicin1-1.5mg/kg q8h or 4-5 mg/kg q24h

Tobramycin1-1.5 mg/kg q8h or 4-9 mg/kg q24h

Ampicillin1 g q4-6h

Cefazolin1-2 g q8h

3131

AgentDose

Other

Trimethoprim- sulfamethoxazole

160/800 mg q12h

Amikacin5 mg/kg q8h or 15 mg/kg q24h

Piperacillin3 g q4h

Piperacillin/tazobactam4 g/500mg q8h

Cefotaxime1-2 g q8h

Ceftriaxone1-2 g q24h

Cefepime2 g q12h

Ceftazidime0.5-2 g q8h

Aztreonam1-2 g q6h

Imipenem/cilastatin500 mg q6h

Vancomycin500mg q6h or 1 g q12h

Ciprofloxacin200-400 mg q12h

Ofloxacin400 mg q12h

3232

Duration of TherapyDuration of Therapy

Clinical PresentationDuration

Women

Acute cystitis3–7 days

Acute pyelonephritis10-14 days

Men

Acute cystitis7 days

Acute pyelonephritis14 days

Relapsing infection (likely prostatitis)

6-12 weeks

3333

Long Term Indwelling CathetersLong Term Indwelling Catheters

Between 5 and 10 percent of elderly Between 5 and 10 percent of elderly residents of institutions have urinary residents of institutions have urinary voiding managed with long-term voiding managed with long-term indwelling catheters. The major indwelling catheters. The major indications for catheterization are indications for catheterization are retention and continence control. retention and continence control. Subjects with long-term indwelling Subjects with long-term indwelling catheters are always bacteriuric, catheters are always bacteriuric, usually with two to five organisms at usually with two to five organisms at any time.any time.

3434


Morbidity from urinary infection is Morbidity from urinary infection is increased in the presence of a long-increased in the presence of a long-term indwelling catheter. Symptomatic term indwelling catheter. Symptomatic presentations include febrile urinary presentations include febrile urinary infection and complications such as infection and complications such as stone formation and urethral stone formation and urethral abscesses. Catheter obstruction abscesses. Catheter obstruction occurs frequently in some patients. occurs frequently in some patients. Obstruction is usually secondary to Obstruction is usually secondary to struvite formation.struvite formation.

3535


Mucosal trauma may occur with Mucosal trauma may occur with catheter change, and in the presence of catheter change, and in the presence of infected urine may lead to fever. infected urine may lead to fever. However, this occurs in less than 10 However, this occurs in less than 10 percent of episodes of catheter change. percent of episodes of catheter change. Residents with an indwelling urinary Residents with an indwelling urinary catheter also have an increased catheter also have an increased mortality compared to noncatheterized mortality compared to noncatheterized residents.residents.

3636

PneumoniaPneumonia

3737

The clinician defines pneumonia as a The clinician defines pneumonia as a combination of combination of symptoms:symptoms:

feverfever

chillschills

cough cough

pleuritic chest painpleuritic chest pain

sputumsputum

3838

PneumoniaPneumonia

SingsSings: : hyperthermiahyperthermia hypothermiahypothermia increased respiratory rateincreased respiratory rate dullness to percussiondullness to percussion bronchial breathingbronchial breathing cracklescrackles wheezeswheezes pleural friction rubpleural friction rub opacity on a chest radiographopacity on a chest radiograph

3939

PneumoniaPneumonia

In addition, laboratory findings, such In addition, laboratory findings, such as increased white blood cell count and as increased white blood cell count and decreased level of oxygen saturation, decreased level of oxygen saturation, may also be part of the definition.may also be part of the definition.

4040

PneumoniaPneumonia

The epidemiologist or clinical trialist The epidemiologist or clinical trialist defines pneumonia as two or more of defines pneumonia as two or more of the symptoms listed above, one or the symptoms listed above, one or more of the physical findings listed more of the physical findings listed above, and a new opacity on chest above, and a new opacity on chest radiograph that is not cause by a radiograph that is not cause by a condition other than pneumonia (such condition other than pneumonia (such as congestive heart failure, vasculitis, as congestive heart failure, vasculitis, pulmonary infarction, atelectasis, or pulmonary infarction, atelectasis, or drug reaction).drug reaction).

4141

PneumoniaPneumonia

Pneumonia may be also be categorized Pneumonia may be also be categorized according to the place of acquisition: according to the place of acquisition: communitycommunity, , hospitalhospital (nosocomial) or (nosocomial) or nursing home.nursing home.

4242

PneumoniaPneumonia

Approximately 80 percent of adults with Approximately 80 percent of adults with CAP are treated on an ambulatory CAP are treated on an ambulatory basis. The mortality rate for those who basis. The mortality rate for those who are 65 years of age is approximately 5 are 65 years of age is approximately 5 percent. The 20 percent of patients with percent. The 20 percent of patients with CAP who require admission to hospital, CAP who require admission to hospital, the mean age of patients with CAP the mean age of patients with CAP requiring admission to hospital was 55 requiring admission to hospital was 55 years in 1955, by year 2001, it was 71 years in 1955, by year 2001, it was 71 years.years.

4343

Risk factor for community Risk factor for community acquired pneumonia:acquired pneumonia:

AlcoholismAlcoholism AsthmaAsthma Immunosuppression Immunosuppression Age > 70Age > 70 AspirationAspiration Low serum albuminLow serum albumin Swallowing disorderSwallowing disorder Poor quality of lifePoor quality of life

4444

Risk factors for pneumococcal Risk factors for pneumococcal pneumonia:pneumonia:

DementiaDementia

SeizuresSeizures

Congestive heart failureCongestive heart failure

Cerebrovascular diseaseCerebrovascular disease

Tobacco smoking Tobacco smoking

Chronic obstructive lung diseaseChronic obstructive lung disease

4545

Risk factors for legionnaires Risk factors for legionnaires disease include:disease include:

Male genderMale gender

Tobacco smokingTobacco smoking

DiabetesDiabetes

Hematologic malignancyHematologic malignancy

Cancer Cancer

End-stage renal diseaseEnd-stage renal disease

HIV infection.HIV infection.

4646

PneumoniaPneumonia

Significant predictors of a fatal outcome: Significant predictors of a fatal outcome: bedridden state prior to onset of pneumonia; bedridden state prior to onset of pneumonia; temperature, (39 C), respiratory rate 30 temperature, (39 C), respiratory rate 30 breaths per minute; shock; creatinine greater breaths per minute; shock; creatinine greater than 1.4 mg/dL; and three or more lobes than 1.4 mg/dL; and three or more lobes involved on chest radiograph.involved on chest radiograph.

Pneumonia is the leading cause for transfer Pneumonia is the leading cause for transfer of nursing home patients to hospital.of nursing home patients to hospital.

4747

Most common causes of community – acquired Most common causes of community – acquired pneumonia in the pneumonia in the elderly populationelderly population

Streptococcus pneumoniaeStreptococcus pneumoniaeChlamydia pneumoniaeChlamydia pneumoniaeEnterobacteriaceaeEnterobacteriaceaeLegionella pneumophilaLegionella pneumophilaHaemophilus influenzaeHaemophilus influenzaeMoraxella catarrhalisMoraxella catarrhalisStaphylococcus aureusStaphylococcus aureusInfluenza A and B virusInfluenza A and B virus

4848

PneumoniaPneumonia

PresentationPresentation

Pneumonia can be one of the causes of Pneumonia can be one of the causes of insidious or nonspecific deterioration insidious or nonspecific deterioration in general health and/or activities, for in general health and/or activities, for example, confusion or falls in the example, confusion or falls in the elderly.elderly.

4949

Frequency of various signs and symptoms in adults Frequency of various signs and symptoms in adults with community – acquired pneumoniawith community – acquired pneumonia

Symptoms and Signs%

Respiratory symptoms

Cough85

Dyspnea75

Sputum production73

Pleuritic chest pain57

Hemoptysis20

5050

Frequency of various signs and symptoms in adults Frequency of various signs and symptoms in adults with community – acquired pneumonia (cont.)with community – acquired pneumonia (cont.)

Nonrespiratory symptoms

Fatigue90 Fever82

Anorexia73 Chills72 Sweats70

Headache50 Myalgia45

Nausea40 Sore throat29

Confusion38 Vomiting32 Diarrhea30

Abdominal pain29

5151

Antibiotic therapy (first and second choices) Antibiotic therapy (first and second choices) for community acquired pneumonia when for community acquired pneumonia when

etiology is unknownetiology is unknown A. A. Patient to be treated on an Patient to be treated on an ambulatory basis.ambulatory basis.

1. Macrolide1. Macrolide

2. Doxycycline2. Doxycycline

5252


etiology is unknownetiology is unknown B. B. Patient to be treated in hospital Patient to be treated in hospital wardward

Fluoroquinolone.Fluoroquinolone.

CefuroximeCefuroxime

C. C. Patient to be treated in an intensive Patient to be treated in an intensive care unitcare unit

AzithromycinAzithromycin

5353


etiology is unknownetiology is unknown D. D. Patient to be treated in a nursing Patient to be treated in a nursing home.home.

Fluoroquinolone .Fluoroquinolone .

Ceftriaxone.Ceftriaxone.

E. E. Aspiration pneumonitis/pneumoniaAspiration pneumonitis/pneumonia

Poor dental hygiene and anaerobic Poor dental hygiene and anaerobic infection suspected: Metronidazole.infection suspected: Metronidazole.

1 Fever. 2 Fever in the elderly adult be defined as persistent elevation of body temperature of at least (1.1 C) over baseline values or oral temperatures.

Documents

elderly slide

fever slide

percent of women

recurrent urinary infection

elderly individual

elderly adult

elderly person

elderly patient