Infections in Elderly Care

Dr Lucia Pareja-CebrianMicrobiology Consultant

12th March 2014

• Who

• Why

• What

WHO

• Difficult cutoff point: ?65, ?70 ?85

• Aging population– 1900s: 1% of world’s population (15 m) >65yo– 1992: 6% of population (342 m) >65 yo– 2020: 20% of population (6b) >65 yo

• >85 are high risk group

WHY

• Decline in host defences– Inmune senescence– Changes in non adaptive inmunity– Chronic illness– Medication– Malnutrition– Functional impairments

Immunity

• T-cell production decreases with age

• Antibody production decrease

• Malnutrition affects cell mediated immunity

Non adaptive immunity

• Thining skin, chronic ulcers• Enlarged prostate• Impaired cough reflex• Functional impairments: – Dysphagia– Inmobility– Incontinence

Chronic illness and intervention

• Diabetes• Hypertension• Dementia• Decreased gastric acid• Indwelling devices, medication,

Lifestyle

• Leisure: travelling, gardening, sports?

• Contact with healthcare: Outpatients, inpatients?

• Living arrangements: nursing homes, residential care?

Sitting ducks or sentinel chickens?

WHAT?

• Skin and soft tissue• UTIs and the “new kids on the block”– ESBLs– Carbapenemases

• GI• Respiratory• HCAI• Vaccine preventable

The trouble with infections…

…is it a bird, is it a plane…?

…is it a UTI, is it a chest infection…?!

Challenges in diagnosis

• Temperature response• Communication• Immune response• Pain• Confusion

Skin and soft Tissue

• Thining skin• Chronic ulcers • Colonisation vs infection?• Organisms involved: – Streptococcus (A,B,G, C)– Staph aureus (MRSA)

UTI

• No benefit in treating asymptomatic UTI• …symptoms are hard to spot!• How long to treat:– 3 days for uncomplicated UTI– 5-7 days in males– 10-14 days pyelonephritis

Ecoli

• Urinary tract infections

• Catheterised (not exclusively)• • Preventable?– Peak in summer– The role of primary care– Symptoms

ESBLs

• Extended spectrum betalactamases• Resistant to coamox, amox, cephalosporins,

piptazo• Usually associated resistance to quinolones

and gentamycin• Usually urines, many in the community• What’s left: Temocilin, fosfomycin,

meropenem, ertapenem

Carbapenemase producing enterobacteria

• CPE

• Urines, pneumonia, wounds and ulcers

• Travel to South Europe, India… and Manchester

• What’s left: fosfomycin, colystin…or nothing!

Respiratory: challenges

• Existing pathology: COPD, bronchiectasis

• Decreased cough reflex

• Dysphagia, stroke

• The trouble with CXR!

Respiratory• Seasonal illness– Influenza– Parainfluenza– RSV

• Non seasonal illness– Pneumococcal– Haemophilus

• Aspiration pneumonia• Legionella-not just for travellers!

GI

• Norovirus– Not just winter vomiting!– Pre-admission management

• PEG • Cryptosporidium, Salmonella, Campylobacter• Listeria• Hepatitis (A, B and E, also C)

Cdiff• Colonisation increases with age

• PPIs and antibiotics predispose• • NG feeding, GI pathology, malnutrition

• Recurrence is common

• Length of stay

HCAI

• MRSA, MSSA, Cdiff and Ecoli

• Other: ESBLs,Carbapenemases

• Contact with healthcare and interventions

• >50% HCAI in >65yo

MRSA, MSSA

• 30% population colonised with Staph aureus• Skin and soft tissue• Pneumonia• Endocarditis• 20-30% mortality risk • Decolonisation difficult in elderly population

Vaccine preventable

• Influenza• Pneumococcus• Varicella• Meningococcus • Haemophilus• Pertussis

Summary

• Predisposing factors

• Care beyond hospitals

• HCAIs and resistance

• Education

• Prevention