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