Transcript Fever - timg.co.il

Fever
1
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 of
(37.2 C) or greater on repeated
measures or rectal temperatures of
(37.5 C) or greater on repeated
measures.
2
The most common sign that triggers
the clinician to look for infection, fever,
is often absent in the elderly patient.
Animal models of aging demonstrate
that temperature elevations in response
to endogenous pyrogens (IL-1, IL-6,
Tumor Necrosis Factor) are diminished
with advanced age.
3
‫הקשיש עם מחלת חום‬
‫מ"ד קשיש בן ‪78‬‬
‫מובא לחדר מיון עם‬
‫חום גבוה ועירפול‬
‫הכרה‪ .‬אישתו מספרת‬
‫כי הוא סובל מבעיות‬
‫של "פרוסטטה"‬
‫ושבימים האחרונים‬
‫סבל משעול קשה‪.‬‬
‫פרט לכך מ"ד הוא‬
‫איש בריא…‬
‫‪4‬‬
5
Presentation of illness
Infectious diseases frequently present with
atypical features in older adults. Serious
infections may be heralded by nonspecific
declines in functional or mental status, or
anorexia with decreased oral intake.
Underlying illness (e.,g. congestive heart
failure or diabetes) may be exacerbated.
6
Presentation of illness
Cognitive impairment heavily
contributes to the difficulty in
diagnosing infection in the elderly.
7
Comorbidities
In the elderly individual, the increased
incidence of infection and mortality for
many infectious diseases is likely a
direct result of the comorbid
conditions:
Diabetes
Renal failure
Chronic pulmonary disease
8
Nutrition
Protein-energy malnutrition is present
in 30 to 60 percent of subjects older
than 65 years of age who are admitted
to the hospital and is linked to delayed
wound healing, decubitus ulcer
formation, CAP, increased risk of
nosocomial infection, extended lengths
of stay and increased mortality.
9
Clinical Syndromes in The
Elderly
Urinary Tract Infections
in the Elderly
10
UTI.
Urinary infection in the elderly person
is usually asymptomatic.
Recurrent urinary infection, which may
be either reinfection or relapse, is
frequent. Reinfection is recurrent
urinary infection with an organism
isolated following antimocrobial
therapy which differs from the
pretherapy isolate .
11
UTI.
Relapse is recurrent urinary
infection with the organism
isolated posttherapy similar to
that which was present prior to
therapy.
12
UTI.
The prevalence of bacteriuria is 2 to 3
percent in young women, and increases to
more than 10 percent for women older than
age 65 years. Bacteriuria is uncommon in
younger men. With aging, particularly
coincident with the development of prostatic
hypertrophy, the prevalence of bacteriuria
increases substantially, and approximately 5
percent of men older than age 70 years living
in the community have bacteriuria.
13
UTI.
The prevalence of asymptomatic
bacteriuria in institutionalized elderly
populations is remarkably high. Women
have a higher frequency than men, with
25 to 50 percent of women being
bacteriuric, as compared to 15 to 40
percent of men.
14
Prevalence of Asymptomatic bacteriuria
in elderly populations
Positive Urine Culture (%)
Population
Women
Men
Community >
70 years of age
10 – 18%
4–7%
Long-term care
25 – 55%
15 – 37 %
15
Infecting bacteria
Women:
Community vs. Institution
Escherichia coli 68% - 47%
Proteus mirab. 1% - 27%
Klebsiella
10% - 7%
Enterococcus spp. 5%- 6%
Coagulas- neg. staph. 7% -1%
Pseudomonas aeruginosa 0-5%
Providencia spp.
0-7%
16
Infecting bacteria
Men:
Community vs. Institution
Escherichia coli 20% - 11%
Proteus mirab. 5%-30%
Klebsiella
5% - 6%
Enterococcus spp. 25%- 5%
Coagulas- neg. staph.39% -2%
Pseudomonas 5%-19%
Providencia 0-16%
17
Factors contributing to the high prevalence of
bacteriuria in elderly populations
Women : Loss of estrogen effect on
genitourinary mucosa
Changes in colonizing flora
Increased residual
volume
18
Factors contributing to the high prevalence of
bacteriuria in elderly populations
Men:
Prostatic hypertrophy
Bacterial prostatitis
Prostatic calculi
Urethral strictures
External urine collecting devices
19
Factors contributing to the high prevalence of
bacteriuria in elderly populations
Both:
Genitourinary abnormalities
Bladder diverticulae
Urinary catheters (intermittent, indwelling)
Associated illnesses
Neurologic disease with neurogenic bladder
dysfunction
Diabetes Mellitus.
20
Symptomatic Urinary Infection
From 8 to 30 percent of transfers to an
acute care facility from long-term care
are necessitated by acute urinary
infection.
21
Symptomatic Urinary Infection
Morbidity and Mortality
Urinary infection occurs by the
ascending
route.
Organism
that
colonize the periurethral area ascend
the urethra into the bladder, kidney,
with
renal
infection.
For
men,
ascending infection may also lead to
prostatic infection. Renal localization is
more frequent with increasing age, and
in residents of nursing homes.
22
Clinical presentations of symptomatic urinary
tract infection in elderly populations
Probable urinary infection:
Acute lower tract irritative symptoms:
frequency, dysuria, urgency, increased
incontinence .
Acute pyelonephritis (fever, flank pain, and
tenderness).
Fever with urinary retention or obstruction of
the urinary tract .
Fever with chronic indwelling urethral
catheter.
23
Unlikely caused by urinary infection:
Gross hematuria
Not caused by urinary infection:
Chronic incontinence
Other chronic genitourinary symptoms
24
Quantitative urinary microbiology for diagnosis
of urinary tract infection
Clinical Presentation
Quantitative Microbiology
Asymptomatic urinary infection
Same organism(s) 105
CFU/mL on two Consecutive
cultures
Pyelonephritis or fever with
localizing genitourinary symptoms
104 CFU/mL
Acute lower tract symptoms
103 CFU/mL of uropathogen
Specimen collected from:
- External collecting device
(men only)
- Aspirated indwelling
catheter
105 CFU/mL
103 CFU/mL
25
Symptomatic Urinary Infection
Treatment of symptomatic urinary
infection requires optimal use of urine
culture for diagnosis, appropriate
antimicrobial selection, and an
appropriate duration of therapy. A urine
specimen for culture should be
obtained prior to antimicrobial therapy.
26
Symptomatic Urinary Infection (cont.)
Antimicrobial selection for treatment of
urinary infection is similar for elderly
and younger populations. Therapy may
be given either orally or, when oral
administration cannot be tolerated or
absorption is uncertain, by parenteral
therapy. Antimicrobial cost will also
usually be a factor, especially for
institutionalized populations.
27
Oral antimicrobial regimens for treatment of
acute urinary tract infection
Agent
Dose*
First line
Nitrofurantoin
50 – 100 mg qid
Trimethoprim/sulfamethoxazole 160/800 mg bid
Trimethoprim
100 mg bid
Amoxicillin
500 mg tid
28
Oral antimicrobial regimens for treatment of
acute urinary tract infection (cont.)
Agent
Dose*
Other
Amoxicillin/clavulanic acid
500 mg tid
Norfloxacin
400 mg bid
Ciprofloxacin
250 – 500 mg bid
Ofloxacin
200 – 400 mg bid
Cephalexin
500 mg qid
Cefaclor
500 mg qid
Cefixime
400 mg od
29
Parenteral antimicrobial regiments for the
treatment
of urinary tract infection
Agent
Dose
Preferred
Gentamicin
1-1.5mg/kg q8h or 4-5 mg/kg q24h
Tobramycin
1-1.5 mg/kg q8h or 4-9 mg/kg q24h
Ampicillin
1 g q4-6h
Cefazolin
1-2 g q8h
30
Agent
Dose
Other
Trimethoprimsulfamethoxazole
160/800 mg q12h
Amikacin
5 mg/kg q8h or 15 mg/kg q24h
Piperacillin
3 g q4h
Piperacillin/tazobactam
4 g/500mg q8h
Cefotaxime
1-2 g q8h
Ceftriaxone
1-2 g q24h
Cefepime
2 g q12h
Ceftazidime
0.5-2 g q8h
Aztreonam
1-2 g q6h
Imipenem/cilastatin
500 mg q6h
Vancomycin
500mg q6h or 1 g q12h
Ciprofloxacin
200-400 mg q12h
Ofloxacin
400 mg q12h
31
Duration of Therapy
Clinical Presentation
Women
Duration
Acute cystitis
3–7 days
Acute pyelonephritis
10-14 days
Men
Acute cystitis
Acute pyelonephritis
Relapsing infection (likely
prostatitis)
7 days
14 days
6-12 weeks
32
Long Term Indwelling Catheters
Between 5 and 10 percent of elderly
residents of institutions have urinary
voiding managed with long-term
indwelling catheters. The major
indications for catheterization are
retention and continence control.
Subjects with long-term indwelling
catheters are always bacteriuric,
usually with two to five organisms at
any time.
33
Long Term Indwelling Catheters
Morbidity from urinary infection is
increased in the presence of a longterm indwelling catheter. Symptomatic
presentations include febrile urinary
infection and complications such as
stone formation and urethral
abscesses. Catheter obstruction
occurs frequently in some patients.
Obstruction is usually secondary to
struvite formation.
34
Long Term Indwelling Catheters
Mucosal trauma may occur with
catheter change, and in the presence of
infected urine may lead to fever.
However, this occurs in less than 10
percent of episodes of catheter change.
Residents with an indwelling urinary
catheter also have an increased
mortality compared to noncatheterized
residents.
35
Pneumonia
36
The clinician defines pneumonia as a
combination of symptoms:
fever
chills
cough
pleuritic chest pain
sputum
37
Pneumonia
Sings:
hyperthermia
hypothermia
increased respiratory rate
dullness to percussion
bronchial breathing
crackles
wheezes
pleural friction rub
opacity on a chest radiograph
38
Pneumonia
In addition, laboratory findings, such
as increased white blood cell count and
decreased level of oxygen saturation,
may also be part of the definition.
39
Pneumonia
The epidemiologist or clinical trialist
defines pneumonia as two or more of
the symptoms listed above, one or
more of the physical findings listed
above, and a new opacity on chest
radiograph that is not cause by a
condition other than pneumonia (such
as congestive heart failure, vasculitis,
pulmonary infarction, atelectasis, or
drug reaction).
40
Pneumonia
Pneumonia may be also be categorized
according to the place of acquisition:
community, hospital (nosocomial) or
nursing home.
41
Pneumonia
Approximately 80 percent of adults with
CAP are treated on an ambulatory
basis. The mortality rate for those who
are 65 years of age is approximately 5
percent. The 20 percent of patients with
CAP who require admission to hospital,
the mean age of patients with CAP
requiring admission to hospital was 55
years in 1955, by year 2001, it was 71
years.
42
Risk factor for community
acquired pneumonia:
Alcoholism
Asthma
Immunosuppression
Age > 70
Aspiration
Low serum albumin
Swallowing disorder
Poor quality of life
43
Risk factors for pneumococcal
pneumonia:
Dementia
Seizures
Congestive heart failure
Cerebrovascular disease
Tobacco smoking
Chronic obstructive lung disease
44
Risk factors for legionnaires
disease include:
Male gender
Tobacco smoking
Diabetes
Hematologic malignancy
Cancer
End-stage renal disease
HIV infection.
45
Pneumonia
Significant predictors of a fatal outcome:
bedridden state prior to onset of pneumonia;
temperature, (39 C), respiratory rate 30
breaths per minute; shock; creatinine greater
than 1.4 mg/dL; and three or more lobes
involved on chest radiograph.
Pneumonia is the leading cause for transfer
of nursing home patients to hospital.
46
Most common causes of community – acquired
pneumonia in the elderly population
Streptococcus pneumoniae
Chlamydia pneumoniae
Enterobacteriaceae
Legionella pneumophila
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
Influenza A and B virus
47
Pneumonia
Presentation
Pneumonia can be one of the causes of
insidious or nonspecific deterioration
in general health and/or activities, for
example, confusion or falls in the
elderly.
48
Frequency of various signs and symptoms in adults
with community – acquired pneumonia
Symptoms and Signs
%
Respiratory symptoms
Cough
85
Dyspnea
75
Sputum production
73
Pleuritic chest pain
57
Hemoptysis
20
49
Frequency of various signs and symptoms in adults
with community – acquired pneumonia (cont.)
Nonrespiratory symptoms
Fatigue
Fever
Anorexia
Chills
90
82
73
72
Sweats
Headache
Myalgia
70
50
45
Nausea
Sore throat
Confusion
40
29
38
50
Antibiotic therapy (first and second choices)
for community acquired pneumonia when
etiology is unknown
A. Patient to be treated on an
ambulatory basis.
1. Macrolide
2. Doxycycline
51
Antibiotic therapy (first and second choices)
for community acquired pneumonia when
etiology is unknown
B. Patient to be treated in hospital
ward
Fluoroquinolone.
Cefuroxime
C. Patient to be treated in an intensive
care unit
Azithromycin
52
Antibiotic therapy (first and second choices)
for community acquired pneumonia when
etiology is unknown
D. Patient to be treated in a nursing
home.
Fluoroquinolone .
Ceftriaxone.
E. Aspiration pneumonitis/pneumonia
Poor dental hygiene and anaerobic
infection suspected: Metronidazole.
53