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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.

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Presentation on theme: "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."— Presentation transcript:

1 1 Fever

2 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 of (37.2 C) or greater on repeated measures or rectal temperatures of (37.5 C) or greater on repeated measures.

3 3 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.

4 4 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…

5 5

6 6 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.

7 7 Presentation of illness Cognitive impairment heavily contributes to the difficulty in diagnosing infection in the elderly.

8 8 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

9 9 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.

10 10 Clinical Syndromes in The Elderly Urinary Tract Infections in the Elderly

11 11 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.

12 12 UTI. Relapse is recurrent urinary infection with the organism isolated posttherapy similar to that which was present prior to therapy.

13 13 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.

14 14 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.

15 15 Prevalence of Asymptomatic bacteriuria in elderly populations Positive Urine Culture (%) PopulationWomenMen Community > 70 years of age 10 – 18%4 – 7 % Long-term care 25 – 55%15 – 37 %

16 16 Infecting bacteria Community vs. Institution Community vs. Institution Women: Escherichia coli 68% - 47% Proteus mirab. 1% - 27% Proteus mirab. 1% - 27% Klebsiella 7% - 10% Klebsiella 7% - 10% Enterococcus spp. 5%- 6% Enterococcus spp. 5%- 6% Coagulas- neg. staph. 7% -1% Coagulas- neg. staph. 7% -1% Pseudomonas aeruginosa 0-5% Pseudomonas aeruginosa 0-5% Providencia spp. 0-7% Providencia spp. 0-7%

17 17 Infecting bacteria Community vs. Institution Community vs. Institution Men: Escherichia coli 20% - 11% Proteus mirab. 5%- 30% Proteus mirab. 5%- 30% Klebsiella 6% - 5% Klebsiella 6% - 5% Enterococcus spp. 25%- 5% Enterococcus spp. 25%- 5% Coagulas- neg. staph.39% -2% Coagulas- neg. staph.39% -2% Pseudomonas 5% -19% Pseudomonas 5% -19% Providencia 0-16% Providencia 0-16%

18 18 Factors contributing to the high prevalence of bacteriuria in elderly populations Women : Loss of estrogen effect on genitourinary mucosa genitourinary mucosa Changes in colonizing flora Changes in colonizing flora Increased residual Increased residual volume volume

19 19 Factors contributing to the high prevalence of bacteriuria in elderly populations Men: Prostatic hypertrophy Prostatic hypertrophy Bacterial prostatitis Prostatic calculi Urethral strictures External urine collecting devices

20 20 Factors contributing to the high prevalence of bacteriuria in elderly populations Both: Genitourinary abnormalities Bladder diverticulae Bladder diverticulae Urinary catheters (intermittent, indwelling) Urinary catheters (intermittent, indwelling) Associated illnesses Associated illnesses Neurologic disease with neurogenic bladder dysfunction Diabetes Mellitus. Diabetes Mellitus.

21 21 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.

22 22 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.

23 23 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.

24 24 Unlikely caused by urinary infection: Gross hematuria Not caused by urinary infection: Chronic incontinence Other chronic genitourinary symptoms

25 25 Quantitative urinary microbiology for diagnosis of 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) 10 5 CFU/mL on two Consecutive cultures 10 4 CFU/mL 10 3 CFU/mL of uropathogen 10 5 CFU/mL 10 3 CFU/mL

26 26 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.

27 27 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.

28 28 Oral antimicrobial regimens for treatment of acute urinary tract infection AgentDose* First line Nitrofurantoin 50 – 100 mg qid Trimethoprim/sulfamethoxazole160/800 mg bid Trimethoprim100 mg bid Amoxicillin500 mg tid

29 29 Oral antimicrobial regimens for treatment of acute urinary tract infection (cont.) AgentDose* Other Amoxicillin/clavulanic acid500 mg tid Norfloxacin400 mg bid Ciprofloxacin 250 – 500 mg bid Ofloxacin 200 – 400 mg bid Cephalexin500 mg qid Cefaclor500 mg qid Cefixime400 mg od

30 30 Parenteral antimicrobial regiments for the treatment 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

31 31 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 Ciprofloxacin mg q12h Ofloxacin400 mg q12h

32 32 Duration of Therapy Clinical PresentationDuration Women Acute cystitis 3 – 7 days Acute pyelonephritis10-14 days Men Acute cystitis7 days Acute pyelonephritis14 days Relapsing infection (likely prostatitis) 6-12 weeks

33 33 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.

34 34 Long Term Indwelling Catheters Morbidity from urinary infection is increased in the presence of a long- term 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.

35 35 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.

36 36 Pneumonia

37 37 The clinician defines pneumonia as a combination of symptoms: fever chills chills cough cough pleuritic chest pain pleuritic chest pain sputum sputum

38 38 Pneumonia Sings: Sings: hyperthermia hyperthermia hypothermia hypothermia increased respiratory rate increased respiratory rate dullness to percussion dullness to percussion bronchial breathing bronchial breathing crackles crackles wheezes wheezes pleural friction rub pleural friction rub opacity on a chest radiograph opacity on a chest radiograph

39 39 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. In addition, laboratory findings, such as increased white blood cell count and decreased level of oxygen saturation, may also be part of the definition.

40 40 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).

41 41 Pneumonia Pneumonia may be also be categorized according to the place of acquisition: community, hospital (nosocomial) or nursing home.

42 42 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.

43 43 Risk factor for community acquired pneumonia: Alcoholism Asthma Asthma Immunosuppression Immunosuppression Age > 70 Age > 70 Aspiration Aspiration Low serum albumin Low serum albumin Swallowing disorder Swallowing disorder Poor quality of life Poor quality of life

44 44 Risk factors for pneumococcal pneumonia: Dementia Seizures Seizures Congestive heart failure Congestive heart failure Cerebrovascular disease Cerebrovascular disease Tobacco smoking Tobacco smoking Chronic obstructive lung disease Chronic obstructive lung disease

45 45 Risk factors for legionnaires disease include: Male gender Male gender Tobacco smoking Tobacco smoking Diabetes Diabetes Hematologic malignancy Hematologic malignancy Cancer Cancer End-stage renal disease End-stage renal disease HIV infection. HIV infection.

46 46 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. 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.

47 47 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

48 48 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.

49 49 Frequency of various signs and symptoms in adults with community – acquired pneumonia Symptoms and Signs% Respiratory symptoms Cough85 Dyspnea75 Sputum production73 Pleuritic chest pain57 Hemoptysis20

50 50 Frequency of various signs and symptoms in adults with community – acquired pneumonia (cont.) Nonrespiratory symptoms Fatigue90 Fever82 Anorexia73 Chills72 Sweats70 Headache50 Myalgia45 Nausea40 Sore throat29 Confusion38 Vomiting32 Diarrhea30 Abdominal pain29

51 51 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 1. Macrolide 2. Doxycycline 2. Doxycycline

52 52 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

53 53 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.


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