Transcript Infections in the Elderly

Infections in the Elderly
Part 1
Karen Greenberg, DO
Infections in the Elderly
Part 1
This Care of the Aging Medical Patient in
the Emergency Room (CAMPER)
presentation is offered by the Department of
Emergency Medicine in coordination with the
New Jersey Institute for Successful Aging.
This lecture series is supported by an educational grant from the
Donald W. Reynolds Foundation Aging and Quality of Life
program.
Overview
• Recognizing and treating infections in the
elderly patient can be particularly challenging
because symptoms are often quite subtle and
atypical in older adults.
• In this session, the emergency medicine resident
will learn how to:
Overview
• Recognize common atypical presentations of various
geriatric infections
• Institute treatment in the elderly with respect to
medication dosing and drug interactions
• Identify admission criteria and appropriate transitioning
of care from the Emergency Department
Question 1
An 82 year old male presents from home with his wife. The
patient is complaining of shaking chills and fever of 101 prior
to arrival in the ED. The patient just finished a 10 day course
of penicillin yesterday for a salivary gland infection. In the
ED his only complaint is left flank pain. Which of the
following does NOT place the patient at increased risk for
infection?
a)
b)
c)
d)
e)
History of sarcoid and taking prednisone
History of urostomy bag for 11 years
Daily Exercise
Decreased cough reflex
Malnutrition
Question 2
A 91 year old female presents from a nursing home with
change in mental status. Vital signs are temperature 101.8, BP
77/40, HR 85, RR 16, and pulse ox 92% room air. Per
patient’s niece, the patient has not been eating well, has a
nonproductive cough, and has a foley catheter in place for 2
months secondary to history of urinary retention. Which of
the following organisms is the least likely cause of infection in
this patient?
a)
b)
c)
d)
e)
Enterococcus UTI
Enterovirus
S. aureus pneumonia
S. pneumo meningitis
MRSA cellulitis
Question 3
A 71 year old male presents with confusion for the past 2
hours. Per the patient’s wife, he was complaining of chest
pain at home and she called 911. Vital signs in the ED are BP
220/110, HR 120, Temperature 99.6, RR 16, and pulse ox
93% room air. Of the following lab tests, which is associated
with a greater mortality rate during hospitalization?
a)
b)
c)
d)
e)
WBC 15,000 mcL
Serum creatinine 1.5 mg/dL
BUN 45 mg/dL
Lipase 150 Units/L
Lactate level 3.6 mmol/L
Introduction
• By 2020, patients aged 65 years old and older
will constitute 16.3% of the population.
• Already, they account for over 15 million ED
visits each year, and a large percentage of these
visits are related to infection.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Introduction
• Fever is present in 10% of all elderly ED
patients.
• The elderly account for 65% of ED patients
with sepsis.
• Elderly patients are at significantly greater
mortality risk for a given infection than are
younger adults.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Introduction
• Elderly patients have three times the mortality
from pneumonia and five to ten times the
mortality from urinary tract infection when
compared with younger adults.
• These statistics make appropriate evaluation and
treatment of the infected elderly an essential
skill.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Introduction
• The clinical presentation of infection in the elderly is
often atypical, subtle, and elusive.
• This makes early diagnosis and initiating treatment a
challenge.
• Elderly may not only have fewer symptoms, but might
present with nonspecific consequences of infection that
on the surface appear unrelated.
Introduction
• Examples on nonspecific symptoms:
-
Generalized malaise
Falls
Changes in mental status or cognitive impairment
Anorexia
Introduction
• The classical manifestation of infection, fever,
and leukocytosis, may be absent or blunted in
20-30% of serious elderly infections.
• In contrast to the young where fever is
commonly attributed to a viral process, in the
elderly it is associated with severe bacterial
infections.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Introduction
• It is important to note that criteria for fevers in
the elderly are unique, and include elevations in
body temperature from baseline of 1.1 °C or
greater.
• Furthermore, hypothermia, a decrease in body
temperature, is not an uncommon presentation
of an underlying serious infection.
Risk Factors
• Aging is associated with:
- numerous chronic illnesses and comorbid conditions
- polypharmacy and immunosuppressive medications
- changes in the immune system that include a
reduction of T-lymphocyte function and cellmediated immunity
Risk Factors
• There is an impairment of the normal physiologic
reserves seen in the elderly:
- decreased cough reflex leading to aspiration pneumonia
- impaired arterial and venous circulation
- compromised wound healing, making cellulitis a common
infection
Risk Factors
• Living environments, such as assisted living
facilities and nursing homes, allow for the
development of infection and foster the
transmission of infectious agents.
• These facilities contribute to the rise and
exposure of antibiotic-resistant bacteria (MRSA
and VRE)
Risk Factors
• Invasive devices, which include indwelling
urinary catheters, intravenous catheters, feeding
tubes, and tracheostomies, are more common in
the elderly.
• These devices compromise host defenses
enabling bacteria to enter the body and cause
infection.
Risk Factors
• Malnutrition, common in the nursing home
population, is associated with a limited immune
response and impaired wound healing.
• Polypharmacy is also frequently observed and
can contribute to infection.
Question 1
An 82 year old male presents from home with his wife. The
patient is complaining of shaking chills and fever of 101 prior
to arrival in the ED. The patient just finished a 10 day course
of penicillin yesterday for a salivary gland infection. In the
ED his only complaint is left flank pain. Which of the
following does NOT place the patient at increased risk for
infection?
a)
b)
c)
d)
e)
History of sarcoid and taking prednisone
History of urostomy bag for 11 years
Daily Exercise
Decreased cough reflex
Malnutrition
Fever and Infection
• Elevated temperature is one of the most
common complaints in the elderly and is present
in approximately 10% of elderly ED visits.
• When fever is present, it is infectious in etiology
approximately 90% of the time.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Fever and Infection
• Fever in elderly ED patients is most commonly
bacterial in origin.
• In several studies, it has been due to a viral cause
in less than 5% of cases.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Fever and Infection
• A temperature greater than 37.8 °C (100 °F) is
associated with markers of serious illness over 75% of
the time as determined by:
-
positive blood cultures
death within 1 month
the need for surgery or an invasive procedure
hospitalization for 4 or more days
the administration of IV antibiotics for 3 or more days
a repeat ED visit within 72 hours
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Fever and Infection
• Workup should include
-
CBC with differential
Urinalysis
chest radiograph
blood cultures
urine cultures
lactate
Lactate
• In patients with infections, increasing serum
lactate values of > 2 mmol/L were linearly
associated with relative risk of mortality during
hospitalization, at 30 days, and at 60 days when
compared to patients with serum lactate levels of
< 2 mmol/L.³
Lactate
• Greater magnitude of association with mortality than
either of two other commonly ordered laboratory tests,
leukocyte count and serum creatinine.
• Higher ED lactate values are associated with greater
mortality in a broad cohort of admitted patients over
age 65 years, regardless of the presence or absence of
infection.
del Portal DA, Shofer F, Mikkelsen ME, et al. Acad Emerg Med 2010;17(3):260-268.
Fever and Infection
• Also consider the possibility of other potentially
serious causes of fever which are present 10% of
the time:
-
rheumatologic disease
thyroid storm
environmental exposure
medication-related events
malignancy
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Fever and Infection
• Although fever often signifies the presence of
serious illness in elderly patients, severe
infection may also be present in the absence of
fever.
• The failure to mount a febrile response to
infection has been particularly noted in nursing
home patients.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Fever and Infection
• The most accurate definition of fever in the
elderly may be a change in temperature from the
patient’s baseline.
• Elderly ED patients with a temperature of
37.2°C (99°F) or higher, or with an increase of
1.3°C (2°F) from baseline should be considered
to be febrile.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Question 2
A 91 year old female presents from a nursing home with
change in mental status. Vital signs are temperature 101.8, BP
77/40, HR 85, RR 16, and pulse ox 92% room air. Per
patient’s niece, the patient has not been eating well, has a
nonproductive cough, and has a foley catheter in place for 2
months secondary to history of urinary retention. Which of
the following organisms is the least likely cause of infection in
this patient?
a)
b)
c)
d)
e)
Enterococcus UTI
Enterovirus
S. aureus pneumonia
S. pneumo meningitis
MRSA cellulitis
Question 3
A 71 year old male presents with confusion for the past 2
hours. Per the patient’s wife, he was complaining of chest
pain at home and she called 911. Vital signs in the ED are BP
220/110, HR 120, Temperature 99.6, RR 16, and pulse ox
93% room air. Of the following lab tests, which is associated
with a greater mortality rate during hospitalization?
a)
b)
c)
d)
e)
WBC 15,000 mcL
Serum creatinine 1.5 mg/dL
BUN 45 mg/dL
Lipase 150 Units/L
Lactate level 3.6 mmol/L
Bacteremia
• The presence of bacteremia in elderly patients
with infection signifies a more severe disease
state and greater risk of mortality.
• Blood stream infection is among the top ten
causes of death in elderly patients in the U.S.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Bacteremia
• Risk factors:
- increasing age
- comorbid diseases:





diabetes
cardiovascular disease
neuropsychiatric disease
malignancy
stroke
- recent invasive procedure or instrumentation
- presence of indwelling catheters
Bacteremia
• Elderly patients with diabetes have twice the rate of
bacteremia as those without.
• Although fever is generally considered one of the
cardinal signs of infection, numerous studies have
demonstrated than an elevated temperature is often not
present in elderly patients with blood stream infection.
Bacteremia
• As a result, the absence of fever cannot be taken
as proof of the absence of bacteremia in this
patient population.
Bacteremia
• The only independent predictors of bacteremia:
- altered mental status
- vomiting
- WBC band forms greater than 6%
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Bacteremia
• Elderly patients are likely to present with
nonspecific signs and symptoms.
• Among the most common presenting symptoms
of bacteremia in the elderly are altered mental
status, confusion, weakness, falls, and decreases
in functional status.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Bacteremia
• Laboratory testing fails to provide diagnostic certainty.
• Among the elderly with bacteremia, 20%-45% will have
a normal WBC count.
• Relying on an increase in the erythrocyte sedimentation
rate is also insensitive for the diagnosis of bacteremia in
the elderly.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Bacteremia
• The etiology of bacteremia is heavily influenced
by patient-specific factors:
- indwelling lines: skin source
- indwelling catheters: urinary source
- altered mental status or impaired gag reflex:
pulmonary source
Bacteremia
• Urinary tract sources are the most common
overall, even in the absence of indwelling urinary
devices.
• They account for 25%-55% of bateremia in
elderly patients presenting to the ED.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Bacteremia
•
•
•
•
Lower respiratory infection: 10-34%
Unknown source: 11-31%
Intra-abdominal source: 9-20%
Skin or catheter-related source: 9%
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Bacteremia
•
•
•
•
Gram-negative organisms: 70% cases
Gram-positive organisms: 25% cases
Anaerobes: < 10% cases
Polymicrobial infections: 5-17%
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Bacteremia
• Escherichia coli is the most commonly isolated
organism (22-54%)
• Other causative gram-negative organisms
include Klebsiella pneumoniae (8-16%) and
Pseudomonas (4-14%).
Bacteremia
• Gram-positive organisms include:
-
Streptococcus pneumoniae (4-20%)
Staphylococcus aureus (4-14%)
Enterococcus (3-9%)
Streptococcus viridans (4%)
Bacteremia
• The likelihood of Staphylococcus aureus bacteremia
is increased in residents of long-term care
facilities, particularly residents with nursing
home-associated pneumonia or skin and softtissue infections.
• It is less common in patients dwelling in the
community.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Bacteremia
• Bacteremia in the elderly is associated with high
mortality rates.
• Overall rates have been 20%-37% in most
studies.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Pneumonia
• In the United States, pneumonia and influenza
rank 6th among the leading causes of death.
• With advanced age, rates of morbidity and
mortality for pneumonia increase dramatically.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Pneumonia
• Nearly half of all cases of pneumonia involve
patients > 65 years of age.
• Among nursing home residents, pneumonia is
the second most common cause of infection.
• It is also the second most common cause of
bacteremia in a nursing home.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Pneumonia
• Several factors associated with the aging process
of the respiratory tract and lung tissue
predispose older people to respiratory
infections.
• Changes in the mucociliary transport system
associated with age and smoking have a negative
effect with clearing of bacterial pathogens.
Pneumonia
• Changes in lung capacity, elasticity, and
compliance are common with age.
• Most cases are in fact related to microaspiration
of bacterial pathogen colonizing the oropharynx.
• Ineffective clearing of mucus and secretions
from the respiratory tract makes patient more
susceptible to aspiration pneumonia.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Pneumonia - Microbiology
• Streptococcus pneumoniae
- most common isolate from sputum culture (20-30%
of CAP cases in the elderly).
- most common pathogen found in nursing home
residents.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Pneumonia - Microbiology
• Haemophilus influenza
- either encapsulated H influenza type B or the
unencapsulated strains
- patients have chronic lung disease
- patients are usually male
- present with productive cough
Pneumonia - Microbiology
• Legionella pneumophilia
- infections tend to occur sporadically.
- infections usually appear in the summer and fall.
- may be found in the water condensed from air
conditioning systems.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Pneumonia - Microbiology
• Mycoplasma pneumoniae
- common atypical pathogen causing pneumonia in
patients under 60 years of age.
- elderly patients have a somewhat lower proportion
of cases of atypical infections compared with
younger, healthier patients.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Pneumonia - Microbiology
• Staphylococcus aureus
-
more commonly associated with nosocomial infection
causes multilobar infiltration.
frequently associated with bacteremia.
well-known manifestation of S aureus infection is the florid
onset of pneumonia following recovery from influenza.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Pneumonia - Microbiology
• Gram-Negative Bacilli
- rare in younger patients
- more likely to affect nursing home residents
compared with community dwellers
- nearly 12% of pneumonias in patients from nursing
homes
Pneumonia
• Classically, cough, especially productive cough, and
fever are the hallmarks of respiratory tract infections.
• Other clinical manifestations of pneumonia include
pleurisy and rigors.
• In the elderly patient the clinical presentation is similar;
however, the rates of patients presenting with these
manifestations change.
Pneumonia
• Although nearly 60% of patient with communityacquired pneumonia (CAP) presented with cough, only
34% of nursing home patients were noted to have a
cough in the setting of pneumonia.
• Confounding this picture is the fact that only 60-75%
of nursing home patients are febrile on presentation.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Pneumonia
• The initial workup of patients with respiratory
infections includes:
-
pulse oximetry
chest radiograph
CBC with differential
blood cultures
serum electrolytes, including BUN
Pneumonia
• Chest radiography remains the “gold standard”
for diagnosis of pneumonia.
• Serum chemistries have little impact on patient
outcome; however, the calculation of creatinine
clearance may influence the provider’s choice
and dose of antibiotic therapy.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Community-acquired Pneumonia in the
Elderly
• The etiology of CAP pneumonia in the elderly is similar
to that in young patients.
• Strep pneumoniae is the most common etiologic agent,
accounting for approximately 50% of cases.
• Haemophilus influenzae and Moraxella catarrhalis are also
relatively common.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Community-acquired Pneumonia in the
Elderly
• Atypical agents such as Chlamydia pneumoniae,
Mycoplasma, and Legionella pneumophilia are seen
approximately 15% of the time in communitydwelling elderly persons, a lesser percentage than
in younger patients.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Community-acquired Pneumonia in the
Elderly
• Enteric gram-negative rods and Staphylococcus
aureus are rarer pathogens and are more likely to
be seen in the most severely ill patients.
• CAP developing after viral influenza has an
increased chance of being caused of S aureus.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Nursing Home – and other Health Care –
associated Pneumonias
• NHAP is clinically distinct from CAP in the
elderly.
• It is associated with increased comorbidity,
poorer functional status, and greater mortality.
• The mortality rate is 19-53% as compared with
8-14% in CAP.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Definition of HCAP
1) Hospital-acquired pneumonia (HCAP):
pneumonia not present at admission that
develops 48 hours or more after
hospitalization.
2) Ventilator-associated pneumonia (VAP):
pneumonia occurring 48-72 hours after
endotracheal intubation.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Definition of HCAP
3) Health care-associated pneumonia
(HCAP): pneumonia occurring in the
presence of any of the following:
-
Residence in a nursing home or long-term care
facility
Receipt of intravenous antibiotics, chemotherapy,
or wound care within the preceding 30 days
Hospitalization in an acute care setting for 2 or
more days in the preceding 90 days
Attendance at a hemodialysis clinic
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
HCAP
• Strep pneumoniae is still the most common
organism, however enteric gram-negative rods,
anaerobes, and Staph aureus are much more
common in these patients.
• Pseudomonas rates have been 4-25% but as high
as 52%.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
HCAP
• Haemophilus influenzae, Moraxella catarrhalis,
Chlamydia pneumoniae, and atypical agents are
much rarer than in the community-dwelling
population.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Pneumonia – Treatment
CAP
• Elderly patients who develop CAP should
receive:
- a second-generation cephalosporin plus a macrolide
or
- a nonpseudomonal cephalosporin plus a macrolide
or
- monotherapy with a flouroquinolone
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Pneumonia – Treatment
NHAP/HCAP
• Patients from nursing care facilities require
appropriate antibiotic regimens to adequately
cover multi-drug resistant organisms.
• Ideally antibiotic choice will include 2 drugs for
gram-negative coverage as well as a drug for
MRSA.
Pneumonia – Treatment
NHAP/HCAP
• The first gram-negative drug should be:
- an anti-pseudomonal cephalosporin (cefepime or
ceftazidime)
- an anti-pseudomonal carbapenem (imipenem or
meropenem) or
- an anti-pseudomonal beta-lactam inhibitor
(piperacillin-tazobactam)
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Pneumonia – Treatment
NHAP/HCAP
• The second gram-negative drug should be:
- an aminoglycoside (amikacin, gentamicin, or
tobramycin) or
- an anti-pseudomonal fluoroquinolone
(ciprofloxacin or levofloxacin)
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Pneumonia – Treatment
NHAP/HCAP
• If MRSA is a concern, vancomycin or
linezolid is recommended.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Urinary Tract Infection
• Urinary tract infections (UTIs) encompass a
spectrum of disease, from asymptomatic
bacteriuria and cystitis, to pyelonephritis and
urosepsis.
• UTIs are among the most common infections
affecting the elderly.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Urinary Tract Infection
• Among otherwise healthy geriatric patients
living in the community, rates of UTI range
from 5-30%, with higher rates seen with
advanced age.
• Among institutionalized patients, the prevalence
rates increase remarkably, between 17-55% of
women and 15-31% of men.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Urinary Tract Infection
• Anatomic variations during the aging process
increase the risk of UTIs:
- changes in prostatic function in men.
- changes in vaginal flora associated with menopause
in women.
- elderly patients are more likely to have obstructive
uropathy or anatomic changes related to childbirth
or reproductive surgery.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Urinary Tract Infection
• Other factors to consider include:
-
higher rates of incontinence
more frequent urologic instrumentation
higher rates of catheterization
comorbid diseases
medications that alter bladder function
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Urinary Tract Infection
• Among young, healthy patients, the vast majority of
UTIs are a result of Escherichia coli, Proteus mirabilis,
Klebsiella pneumoniae, Enterococcus, Pseudomonas, and
Staphylococcus species.
• Elderly patients have a lower incidence of E coli
infection and higher rates of polymicrobial infections.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Urinary Tract Infection
• Patients with short-term urinary catheters are
typically infected by a single organism, while
long-term catheters are associated with
polymicrobial infections.
• The prevalence of gram-positve UTIs in
geriatric patients has been increasing.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Urinary Tract Infection
• The elderly often present with atypical
symptoms of UTI:
-
malaise
anorexia
weakness
subtle mental status changes
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Urinary Tract Infection
• Delirium and functional decline may be the first
signs of bacteremia from a urologic source.
• Such “nonurinary” symptoms are more likely to
occur in patients with existing comorbities
including dehydration.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Urinary Tract Infection
• Urine microscopy and culture make the ultimate
diagnosis.
• Although urine cultures are rarely helpful for the
emergency physician, they help tailor the
antibiotic regimen after an initial antibiotic has
been started.
Urinary Tract Infection Treatment
• Broad antibiotic coverage for a longer duration should
be the cornerstone of any treatment plan.
• 7-10 days of treatment is preferred for women with
symptoms for longer than 1 week, women with
structural of functional changes, and for all men.²
• 14 days of treatment should be routine for elderly
patients with pyelonephritis.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Urinary Tract Infection Treatment
• Treatment of uncomplicated communityacquired UTI in the elderly is generally with a
fluoroquinolone.
• Due to increased rates of resistance, TMP-SMX
is not preferred as an empiric first-line agent.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Urinary Tract Infection Treatment
• Trimethoprim-Sulfamethoxazole (TMPSMX) may be given to elderly women when the
sensitivities are confirmed; however, there is a
higher incidence of side effects and
discontinuation when compared with
fluoroquinolones.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Urinary Tract Infection Treatment
• Alternative intravenous antibiotic therapies
include:
- a fluoroquinolone
- gentamicin plus or minus ampicillin
- a third-generation cephalosporin plus or minus an
aminoglycoside
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Urinary Tract Infection Treatment
• Selecting the optimum treatment for UTIs
acquired in a long-term care facility or in the
presence of other complicating factors is more
difficult due to the high prevalence of resistant
organisms.
Urinary Tract Infection Treatment
• A fluoroquinolone should generally be considered
although only cautiously used as monotherapy due to
increased rates of resistance in these patient
populations.
• In these cases, empiric fluoroquinolone monotherapy
may be less preferred than combination therapy.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Urinary Tract Infection Treatment
• Alternative or additional therapies may include:
- aminoglycosides plus or minus ampicillin
- anti-pseudomonal beta-lactams or
- an anti-pseudomonal carbapenem
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Urinary Tract Infection Treatment
• Patients who have an increased risk of drugresistant organism or who are moderately to
severely ill should be strongly considered for
initial two-drug therapy to ensure effectiveness
of the empiric regimen.
Urinary Tract Infection Treatment
• In patients with UTIs associated with chronic
indwelling catheters, replacement of the catheter
is associated with improved clinical outcomes
and should be undertaken in the emergency
department.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Summary
• Evaluation and management of the elderly patient with
infection in the ED presents several challenges to the
emergency physician.
• Elderly patients often present without classic signs and
symptoms of infection, requiring vigilance in the face of
nonspecific symptoms such as confusion or decreased
functional status.
Summary
• These patients are at higher risk of poor
outcomes than are younger adults.
• They are also at greater risk of infection with
resistant organisms, necessitating the empiric use
of broad-spectrum antimicrobial agents.
Summary
• Consideration of these unique aspects of the
infected elderly patient will aid the emergency
physician in providing optimal care to this atrisk patient population.
References
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