1. Infections in the Elderly Part 2 Karen Greenberg, DO

2. Infections in the Elderly Part 2 This Care of the Aging Medical Patient in the Emergency Room (CAMP ER ) 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.

3. 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:

4. 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

5. 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)S. Aureus b)H. influenzae c)S. pneumoniae d)Legionella e)Mycoplasma pneumoniae

6. Question 5 Regarding infection in the elderly, which of the following statements is true? a)Most cases of fever and infection in the elderly are due to a viral cause. b)The proportion of meningitis cases involving the elderly is increasing. c)Cellulitis complicated by diabetic ulcers or pressure ulcers are usually due to group B strep. d)Post-herpetic neuralgia status post herpes zoster infection is rarely seen in the elderly. e)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.

7. 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.

8. 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.

9. 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.

10. 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.

11. Introduction Examples on nonspecific symptoms: -Generalized malaise -Falls -Changes in mental status or cognitive impairment -Anorexia

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. Influenza - Treatment Oseltamivir (Tamiflu) and Zanamivir (Relenza) are recommended; however, Relenza is inhaled and may cause bronchospasm in patients with underlying lung disease.

18. 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.

19. 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.

20. 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.

21. Influenza - Treatment Yearly influenza vaccination is recommended for all adults aged 50 years and older. Influenza vaccination of the community- dwelling 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.

22. 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.

23. 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.

24. 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)S. Aureus b)H. influenzae c)S. pneumoniae d)Legionella e)Mycoplasma pneumoniae

25. 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.

26. Cellulitis - Microbiology The microbiology is usually due to beta- hemolytic 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.

27. 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.

28. 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.

29. Cellulitis - Treatment Treatment of cellulitis is dictated by: -suspected organisms -location of the cellulitis -underlying comorbidities -severity of the infection

30. 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.

31. 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.

32. Cellulitis - Treatment MRSA: -vancomycin -linezolid -quinupristin-dalfopristin (Synercid) Adedipe A, Lowenstein R. Emerg Med Clin N Am 2006; 24(2):433-448.

33. 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.

34. 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.

35. Meningitis The most likely organisms to cause bacterial meningitis in the elderly: -S pneumoniae -Neisseria meningitides -Listeria monocytogenes -H influenzae -Gram-negative organisms

36. 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.

37. 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.

38. 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.

39. 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.

40. Meningitis - Treatment A combination of ampicillin plus a third- generation 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.

41. 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.

42. 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.

43. 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).

44. 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.

45. 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.

46. Herpes Zoster Image Source: National Institutes of Health

47. 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.

48. Herpes Zoster A long-term sequela of herpes zoster is post- herpetic 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.

49. 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.

50. Herpes Zoster - Treatment Antiviral agents used: -acyclovir -valacyclovir -famciclovir

51. Question 5 Regarding infection in the elderly, which of the following statements is true? a)Most cases of fever and infection in the elderly are due to a viral cause. b)The proportion of meningitis cases involving the elderly is increasing. c)Cellulitis complicated by diabetic ulcers or pressure ulcers are usually due to group B strep. d)Post-herpetic neuralgia status post herpes zoster infection is rarely seen in the elderly. e)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.

52. 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.

53. 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.

54. Summary Consideration of these unique aspects of the infected elderly patient will aid the emergency physician in providing optimal care to this at- risk patient population.

55. 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.