Infections in the Elderly
Part 2
Karen Greenberg, DO
Infections in the Elderly
Part 2
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 4
A 68 year old female from the community complains of cough,
nasal congestion and shortness of breath one week ago. The
patient saw her family doctor and was diagnosed clinically with
influenza. Because the patient presented after 5 days of symptoms,
no treatment was initiated. The patient now presents to the ED 10
days after initial onset of symptoms with temperature 102.6,
productive cough of yellow mucus, and expiratory wheeze bilateral
lung bases. Chest radiograph done in the ED shows a left lower
lobe infiltrate. Which of the following is the most likely cause of
the patient’s pneumonia?
a)
b)
c)
d)
e)
S. Aureus
H. influenzae
S. pneumoniae
Legionella
Mycoplasma pneumoniae
Question 5
Regarding infection in the elderly, which of the following
statements is true?
a)
b)
c)
d)
e)
Most cases of fever and infection in the elderly are due to a
viral cause.
The proportion of meningitis cases involving the elderly is
increasing.
Cellulitis complicated by diabetic ulcers or pressure ulcers are
usually due to group B strep.
Post-herpetic neuralgia status post herpes zoster infection is
rarely seen in the elderly.
Right middle lobe infiltrate on chest radiograph in a 75 year
old patient who lives at home alone, and with a history of end
stage renal disease on hemodialysis is considered community
acquired pneumonia and can be treated with Zithromax 500
mg po bid x 7 days.
Introduction
• By 2020, patients aged 65 years old and older
will constitute 16.3% of the population.¹
• 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.
Influenza
• Although it affects all age groups, influenza
causes the most severe disease in the elderly.
• Advanced age is associated with increased rates
of influenza-related hospitalizations.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Influenza
• 90% of deaths related to influenza occur in
patients aged 65 years and over.
• As is true for pneumonia, the elderly may fail to
demonstrate the classic signs of influenza.
• For example, many will not have fever or cough.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Influenza
• Secondary bacterial pneumonia may occur and is
most commonly caused by Strep pneumoniae, Staph
aureus, and Haemophilus influenzae.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Influenza - Treatment
• Oseltamivir (Tamiflu) and Zanamivir
(Relenza) are recommended; however, Relenza
is inhaled and may cause bronchospasm in
patients with underlying lung disease.
Influenza - Treatment
• Tamiflu is given in the usual adult dosage of 75
mg orally twice daily for 5 days.
• Tamiflu should be renally dosed for patients
with creatinine clearance less than 30 mL/min,
with a recommended once daily regimen for
those with clearance of 10-30 mL/min.
Influenza - Treatment
• Amantadine and rimantadine are not
recommended due to the emergence of viral
resistance as well as increased side effects in the
elderly, particularly central nervous system side
effects with amantadine.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Influenza - Treatment
• Due to the severe systemic effects and the
severity of the respiratory illness, many elderly
patients with influenza will require admission.
• For those patients being discharged, close
follow-up is essential.
Influenza - Treatment
• Yearly influenza vaccination is recommended
for all adults aged 50 years and older.
• Influenza vaccination of the communitydwelling elderly is associated with a 27%
reduction in the risk of hospitalization and 48%
reduction in the risk of death.
Caterino JM. Emerg Med Clin N Am 2008;26(2):319-343.
Influenza - Treatment
• Only the trivalent inactivated vaccine is
approved for elderly patients.
• The live attenuated intranasal vaccine should
only be used in healthy persons aged 5-49 years.
Influenza - Treatment
• Pneumococcal and influenza vaccination programs
have been successfully implemented in the emergency
department setting.
• Given the proven benefits, ED physicians should
consider offering vaccination to all appropriate patients.
Question 4
A 68 year old female from the community complains of cough,
nasal congestion and shortness of breath one week ago. The
patient saw her family doctor and was diagnosed clinically with
influenza. Because the patient presented after 5 days of symptoms,
no treatment was initiated. The patient now presents to the ED 10
days after initial onset of symptoms with temperature 102.6,
productive cough of yellow mucus, and expiratory wheeze bilateral
lung bases. Chest radiograph done in the ED shows a left lower
lobe infiltrate. Which of the following is the most likely cause of
the patient’s pneumonia?
a)
b)
c)
d)
e)
S. Aureus
H. influenzae
S. pneumoniae
Legionella
Mycoplasma pneumoniae
Cellulitis
• Cellulitis is more common, more severe, and is
associated with increased mortality in the elderly
compared with the younger population.
• Cellulitis in the elderly can often be attributed to
chronic venous insufficiency, peripheral vascular
disease, malnutrition and trauma.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Cellulitis - Microbiology
• The microbiology is usually due to betahemolytic streptococci or S aureus.
• However, cellulitis complicated by diabetic
ulcers or pressure ulcers may have different
etiologies, and can include polymicrobial flora,
Enterobacter, and anaerobes.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Cellulitis - Microbiology
• Orbital cellulitis is another exception, and may
be caused by Strep viridans and gram-negative
bacteria.
• External otitis is generally observed in the
elderly, and is caused by gram-negative bacteria,
specifically Pseudomonas species.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Cellulitis - Microbiology
• It has been widely established that bacterial
resistance is on the rise.
• MRSA is an example of such resistant bacteria,
and is more likely to occur in the elderly
population.
• Once colonized with MRSA the rate of MRSA
infection increases up to 25%, as does the risk
of mortality.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Cellulitis - Treatment
• Treatment of cellulitis is dictated by:
-
suspected organisms
location of the cellulitis
underlying comorbidities
severity of the infection
Cellulitis - Treatment
• MSSA and streptococci:
- first-generation cephalosporin
- antistaphylococcal penicillins
- clindamycin in penicillin allergic patients
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Cellulitis - Treatment
• Polymicrobial infections:
- broad spectrum antibiotics are indicated and
must include coverage for gram-positive and
gram-negative aerobes and anaerobes.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Cellulitis - Treatment
• MRSA:
- vancomycin
- linezolid
- quinupristin-dalfopristin (Synercid)
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Meningitis
• Although the overall incidence of bacterial meningitis in
the United States has decreased, the proportion of cases
involving the elderly is currently increasing.
• The recognition of meningitis in the older patient may
be more difficult, but as emergency physicians we must
maintain a high level of suspicion, and consider
bacterial meningitis as the etiology of acute illness.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Meningitis
• Higher mortality figures are seen in elderly
patients with meningitis, with case fatality rates
averaging 20-25% for pneumococcal meningitis.
• Older patients who have severe neurologic
impairment at presentation show morbidity and
mortality rates approaching 50%.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Meningitis
• The most likely organisms to cause
bacterial meningitis in the elderly:
-
S pneumoniae
Neisseria meningitides
Listeria monocytogenes
H influenzae
Gram-negative organisms
Meningitis
• Classic presenting symptoms of meningitis
include fever, headache, neck stiffness, and
photophobia.
• Other commonly encountered symptoms
include lethargy, malaise, altered sensorium,
seizures, vomiting, and chills.
Meningitis
• Although the older patient may exhibit any of
these signs and symptoms, they are less often
noted on presentation.
• Fever is a less frequently encountered finding
when compared with younger patients, and
nuchal rigidity is not universally present.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Meningitis
• Altered level of consciousness, respiratory symptoms,
and seizures are more often found in elderly patients
when compared with younger individuals.
• Among elderly patients admitted with meningitis, risk
factors for death were found to be age over 60 years,
obtunded mental status on admission, and seizures
within the first 24 hours.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Meningitis - Treatment
• The objectives in the older patient with bacterial
meningitis are prompt diagnosis and early institution of
antibiotic therapy, which may improve patient outcome.
• If the possibility of bacterial meningitis is entertained
after initial patient assessment, empiric antibiotic
coverage should be initiated immediately.
Meningitis - Treatment
• A combination of ampicillin plus a thirdgeneration cephalosporin should be used for
initial therapy, as these agents would be active
against most species of S pneumoniae, L
monocytogenes, aerobic gram-negative bacilli, H
influenzae, and N meningitidis.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Meningitis - Treatment
• The use of dexamethasone in the management
of bacterial meningitis remains controversial.
• Dexamethasone, when given, should be
administered 15-20 minutes before the first dose
of antibiotics.
Meningitis - Treatment
• All people who have had close contact with patients
diagnosed with bacterial meningitis should be
considered for prophylaxis.
• Rifampin 600 mg two times per day for four doses is
adequate protection for N meningitides.
• Ciprofloxacin 500 mg orally as a single dose is an
alternative.
.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Herpes Zoster
• Another skin infection seen more frequently in
the elderly population.
• It is a disease confined to the skin and nervous
system.
• Caused by the reactivation of the varicella-zoster
virus (VZV).
Herpes Zoster
• VZV is responsible for pediatric chicken pox, and
remains dormant in the dorsal root ganglia.
• What reactivates VZV remains unclear; however, it is
usually a disease of the elderly and the
immunocompromised.
• As cellular immunity decreases with aging, the
incidence of herpes zoster increases.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Herpes Zoster
• Pain and paresthesias over a particular
dermatome usually precede the characteristic
rash.
• Prodromal pain is lancinating and is easily
misdiagnosed as having cardiac, abdominal, and
renal etiologies.
• Symptoms may last for several days before the
hallmark lesions.
Herpes Zoster
Image Source: National Institutes of Health
Herpes Zoster
• Herpes zoster is a clinical diagnosis.
• Laboratory confirmation can be obtained via a
culture of the vesicular fluid or by observing
giant cells on Tzanck preparation.
Herpes Zoster
• A long-term sequela of herpes zoster is postherpetic neuralgia.
• The incidence of post-herpetic neuralgia
increases with age, with 50-75% of patients > 70
experiencing chronic pain over the involved
dermatome.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Herpes Zoster - Treatment
• Antiviral therapy initiated within 72 hours of
symptom onset decreases viral replication, nerve
damage, duration of eruption, and pain.²
• Administration of therapy after 72 hours may
reduce the incidence of post herpetic neuralgia,
but will not impact on the duration of
symptoms.
Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.
Herpes Zoster - Treatment
• Antiviral agents used:
- acyclovir
- valacyclovir
- famciclovir
Question 5
Regarding infection in the elderly, which of the following
statements is true?
a)
b)
c)
d)
e)
Most cases of fever and infection in the elderly are due to a
viral cause.
The proportion of meningitis cases involving the elderly is
increasing.
Cellulitis complicated by diabetic ulcers or pressure ulcers are
usually due to group B strep.
Post-herpetic neuralgia status post herpes zoster infection is
rarely seen in the elderly.
Right middle lobe infiltrate on chest radiograph in a 75 year
old patient who lives at home alone, and with a history of end
stage renal disease on hemodialysis is considered community
acquired pneumonia and can be treated with Zithromax 500
mg po bid x 7 days.
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
1. Caterino JM. Evaluation and management of geriatric
infections in the emergency department. Emerg Med
Clin N Am 2008;26(2):319-343.
2. Adedipe A, Lowenstein R. Infectious emergencies in
the elderly. Emerg Med Clin N Am 2006; 24(2):433-448.
3. del Portal DA, Shofer F, Mikkelsen ME, et al.
Emergency department lactate is associated with
mortality in older adults admitted with and without
infections. Acad Emerg Med 2010;17(3):260-268.