Antimicrobial therapy in the elderly

Procalcitonin to reduce exposure to antibiotics and individualise treatment in hospitalised old patients with pneumonia: a randomised study

BACKGROUND

Treating pneumonia in old patients remains challenging for clinicians. Moreover, bacterial antimicrobial resistance is a major public health threat.

OBJECTIVE

The PROPAGE study evaluated the interest of a strategy using serial measurements of procalcitonin (PCT) to reduce the duration of antibiotic therapy in old patients with pneumonia.

METHODS

PROPAGE took place from Dec.-2013 to Jun.-2016 in eight French geriatric units. It was a prospective, comparative, randomised, open-label study involving old patients (≥ 80 years) who had initiated antibiotic treatment for pneumonia in the previous 48 h. PCT was monitored in all patients and two decision-making PCT-based algorithms guided antibiotic therapy in patients from the PCT group.

RESULTS

107 patients were randomised (PCT, n = 50; Control, n = 57). Antibiotic therapy exposure was reduced in the PCT group as compared to the Control group (median duration of antibiotic therapy, 8 vs. 10 days [rank-test, p = 0.001]; antibiotic persistence rates on Days 6 and 8, 54% and 44% vs. 91% and 72%) and no significant difference was found in recovery rate (84% vs. 89.5%; Pearson Chi² test, p = 0.402).

CONCLUSION

Although, the superiority of the strategy was not tested using a composite criterion combining antibiotic therapy duration and recovery rate was not tested due to the small sample size, the present study showed that monitoring associated with PCT-guided algorithm could help shorten antibiotic treatment duration in the very old patients without detrimental effects. Measuring PCT levels between Day 4 and Day 6 could be helpful when making the decision regarding antibiotic discontinuation.

TRIAL REGISTRATION

NCT02173613. This study was first registered on 25/06/2014.

Admittances characteristics by sepsis in the Spanish internal medicine services between 2005 and 2015: mortality pattern

BACKGROUND

Studies in recent years suggest an increase in the incidence of sepsis but a decrease in mortality. The aim of this study is to describe the characteristics of patients discharged after a sepsis episode from Spanish internal medicine services between 2005 and 2015.

RESULTS

Since 2005, in which there were a total of 4,319 cases, sepsis hospitalizations has been consistently increasing yearly reaching a total of 25,820 cases in 2015. We observed that septic patients are older and with higher comorbidity than the general population admitted in Internal Medicine. On the other hand, we found a decreasing trend in the mortality rates of patients with sepsis in our series going from 35.7% in 2005 to 30.1% in 2015 (p < 0.005).

DISCUSSION

In our study, a higher comorbidity at admission and developing complications during admittance, conditioned a higher probability of death due to sepsis. The variables that were associated with increased mortality risk were age, acute renal failure, acute respiratory failure, lactic acidosis, septic shock and chronic heart failure.

CONCLUSION

As in other similar studies, we observed an increase in the hospitalizations by sepsis as a diagnosis at discharge during the study period in Internal Medicine services with a simultaneous decrease in mortality. Comorbidity at admission and complications during admittance condition mortality.

Intravenous Vancomycin Dosing in the Elderly: A Focus on Clinical Issues and Practical Application

The elderly population can be divided into three distinct age groups: 65-74 years (young-old), 75-84 years (middle-old), and 85+ years (old-old). Despite evidence of a shift in leading causes for mortality in the elderly from infectious diseases to chronic conditions, infections are still a serious cause of death in this population. These patients are at increased risk due to weakened immune systems, an increased prevalence of underlying comorbidities, and decreased physiologic reserves to fight infection. Additionally, elderly patients, especially adults in institutional settings, are at an increased risk of colonization and subsequent infection with methicillin-resistant Staphylococcus aureus at a rate that is five times higher than in younger individuals, causing an increase in empiric and definitive vancomycin use. Elderly patients have unique characteristics that make dosing vancomycin a challenge for clinicians, such as increased volume of distribution and decreased renal function. Using the best available evidence, it is recommended to initiate lower empiric maintenance doses and monitor vancomycin serum concentrations earlier than steady state to accurately calculate drug elimination and make appropriate dose adjustments.

Bloodstream infections in older patients

Bloodstream infections (BSIs) are both common and fatal in older patients. We describe data from studies evaluating older patients hospitalized with BSIs. Most older patients with BSIs present "typically" with either fever or leukocytosis. The most common source of BSI in older patients is the urinary tract, and accordingly, Gram-negative organisms predominate. A significant part of these BSIs may thus be preventable by removal of unnecessary urinary catheters. Increased long term mortality is reported following BSIs in older patients, however, data on other long-term outcomes, including functional capacity, cognitive decline and others are lacking. Management of BSIs may include less invasive procedures due to the fragility of older patients. This approach may delay the diagnosis and treatment in some cases. Older patients are probably under-represented in clinical trials assessing treatment of bacteremia. Physicians treating older patients should consider the relevance of these studies' outcomes.

Sepsis: multiple abnormalities, heterogeneous responses, and evolving understanding

Sepsis represents the host's systemic inflammatory response to a severe infection. It causes substantial human morbidity resulting in hundreds of thousands of deaths each year. Despite decades of intense research, the basic mechanisms still remain elusive. In either experimental animal models of sepsis or human patients, there are substantial physiological changes, many of which may result in subsequent organ injury. Variations in age, gender, and medical comorbidities including diabetes and renal failure create additional complexity that influence the outcomes in septic patients. Specific system-based alterations, such as the coagulopathy observed in sepsis, offer both potential insight and possible therapeutic targets. Intracellular stress induces changes in the endoplasmic reticulum yielding misfolded proteins that contribute to the underlying pathophysiological changes. With these multiple changes it is difficult to precisely classify an individual's response in sepsis as proinflammatory or immunosuppressed. This heterogeneity also may explain why most therapeutic interventions have not improved survival. Given the complexity of sepsis, biomarkers and mathematical models offer potential guidance once they have been carefully validated. This review discusses each of these important factors to provide a framework for understanding the complex and current challenges of managing the septic patient. Clinical trial failures and the therapeutic interventions that have proven successful are also discussed.

Sepsis in nonagenarians admitted to internal medicine departments: a comparative study of outcomes

BACKGROUND

Elderly patients are at a higher risk of acquiring sepsis, and are largely being treated in Internal Medicine (IM) departments.

AIM

To characterize the differences between nonagenarians and other age groups in patients admitted to IM departments with sepsis, and to assess predictors for survival in patients older than 90 years of age.

DESIGN AND METHODS

A prospective registry of all-comers with sepsis admitted to IM departments in a community-based Medical Center was build. Patients' demographics, medical history, clinical presentation and outcomes were recorded and analyzed according to age groups.

RESULTS

One thousand and eighty patients were followed for a mean of 83.63 ± 65.90 days. Nonagenarians constituted 10.93% (118/1080) of our cohort. Of these, 70.48% had a cognitive impairment and 82.60% had reduced functional state. Of these, 5.61 and 10.50% fulfilled the criteria of septic shock and severe sepsis, respectively. Sepsis category was significantly influenced by age groups (P < 0.001). Complications secondary to sepsis at admission and throughout hospitalization, and mortality rates, were higher in the nonagenarian population (61.86 vs. 51.14%, P = 0.032 and 37.29 vs. 20.06%, P < 0.001, respectively), and overall survival was significantly lower in the nonagenarian population (40.68 vs. 66.84%, P < 0.001).

CONCLUSION

Patients treated in IM departments for sepsis are old, and a significant percentage is older than 90 years of age with reduced function and mental status at baseline. These frail patients are afflicted by a worse outcome, which is most likely associated with poor functional status at baseline and severe deconditioning during the acute illness. Prognostic tools are needed to address today's trends in patient-mix and disease severity, specifically for very-old patients admitted with sepsis cared for in IM departments.

Antimicrobial prescribing in hospitalized adults stratified by age: data from the ESAC point-prevalence surveys

BACKGROUND

Geriatric infectious diseases are a major health care issue. Infections in the elderly occur more frequently than in younger adults, are often associated with higher morbidity and mortality, and may present atypically. Elderly patients are also often taking multiple medications, which increases the likelihood of drug-drug interactions. Dosing decisions should take into consideration the reduced lean body mass and declining renal function in this age group.

OBJECTIVE

Antimicrobial prescribing in three age groups (65-74, 75-84 and ≥85 years) was compared with a reference age group (18-64 years), with the aim of identifying quality of care indicators specific to the elderly.

METHODOLOGY

The ESAC (European Surveillance of Antimicrobial Consumption) final phase performed two hospital point-prevalence surveys in 2008 and 2009, respectively, using the defined daily dose (DDD) and Anatomical Therapeutic Chemical (ATC) classification system. The prescribed daily dose (PDD) was compared with the DDD. Differences in prescribing were assessed using multivariate logistic regression analyses.

RESULTS

The majority of patients (19,549 [64% of 30,836]) were from Northern Europe and 13,830 (48%) belonged to the reference group. The largest proportion of patients was admitted through the hospital's medical specialty (55% of patients) [range: 49% in the reference group to 72% in the ≥85 years age group]. Penicillins were the most frequently used antimicrobials in all age groups (range: 32% in the reference group to 41% in the ≥85 years age group). Multivariate analyses showed three significant variations between the 65-74 years age group and the reference group (quinolones: odds ratio [OR] 1.17 [95% CI 1.05, 1.29]; tetracyclines: OR 1.58 [95% CI 1.26, 1.98]; aminoglycosides: OR 0.81 [95% CI 0.70, 0.93]). The number of significant variations increased to seven and eight in the 75-84 and ≥85 years age groups, respectively. A lower likelihood for PDD > DDD was observed in the 65-74 years age group for three parenteral antimicrobials (amoxicillin/clavulanic acid, gentamicin and vancomycin). This was reiterated in the older age groups (75-84 and ≥85 years), where piperacillin/tazobactam, meropenem and oral ciprofloxacin also showed a lower likelihood for PDD > DDD.

CONCLUSIONS

Despite the methodology not being dedicated to elderly patients, the study identified elevated use of antimicrobial agents that are associated with serious adverse effects or a narrow therapeutic index as a target for quality of care improvement in elderly patients.

Severe sepsis and septic shock in the elderly: An overview

The incidence of severe sepsis and septic shock is increasing in the older population leading to increased admissions to the intensive care units (ICUs). The elderly are predisposed to sepsis due to co-existing co-morbidities, repeated and prolonged hospitalizations, reduced immunity, functional limitations and above all due to the effects of aging itself. A lower threshold and a higher index of suspicion is required to diagnose sepsis in this patient population because the initial clinical picture may be ambiguous, and aging increases the risk of a sudden deterioration in sepsis to severe sepsis and septic shock. Management is largely based on standard international guidelines with a few modifications. Age itself is an independent risk factor for death in patients with severe sepsis, however, many patients respond well to timely and appropriate interventions. The treatment should not be limited or deferred in elderly patients with severe sepsis only on the grounds of physician prejudice, but patient and family preferences should also be taken into account as the outcomes are not dismal. Future investigations in the management of sepsis should not only target good functional recovery but also ensure social independence and quality of life after ICU discharge.

Severe sepsis and septic shock in the elderly: An overview

The incidence of severe sepsis and septic shock is increasing in the older population leading to increased admissions to the intensive care units (ICUs). The elderly are predisposed to sepsis due to co-existing co-morbidities, repeated and prolonged hospitalizations, reduced immunity, functional limitations and above all due to the effects of aging itself. A lower threshold and a higher index of suspicion is required to diagnose sepsis in this patient population because the initial clinical picture may be ambiguous, and aging increases the risk of a sudden deterioration in sepsis to severe sepsis and septic shock. Management is largely based on standard international guidelines with a few modifications. Age itself is an independent risk factor for death in patients with severe sepsis, however, many patients respond well to timely and appropriate interventions. The treatment should not be limited or deferred in elderly patients with severe sepsis only on the grounds of physician prejudice, but patient and family preferences should also be taken into account as the outcomes are not dismal. Future investigations in the management of sepsis should not only target good functional recovery but also ensure social independence and quality of life after ICU discharge.

Infection in the elderly

Many functional, demographic, and immunologic changes associated with aging are responsible for increasing the incidence and severity of infectious diseases in the elderly. Management is complicated by age-related organ system changes. Because many of the elderly are on multiple medications for underlying illnesses, antimicrobial therapy needs to be chosen keeping drug interactions and adverse events in mind. Common infections seen in the elderly are infections of skin and soft tissue, urinary tract, respiratory tract, and gastrointestinal tract. Organized and well-funded programs to address infectious disease issues in the elderly are the only way to improve care.

Bacteremia and sepsis in older adults

Bacteremia and sepsis are common complications of infection in older patients. Comorbidities, institutionalization, instrumentation, and immunosenescence place older persons at high risk for bacteremia and sepsis, and clinicians must have a heightened suspicion for these infectious disorders in older patients because nonspecific clinical manifestations of infection are common in this vulnerable population. Although increasing age is associated with a high risk of death due to bacteremia and sepsis, recent evidence suggests that many older patients respond well to treatments of proven efficacy. This article discusses the epidemiology, pathophysiology, diagnosis, and prognosis of bacteremia and sepsis in older patients and provides evidence-based recommendations regarding the treatment of these infectious disorders in older persons.

Infectious Emergencies in the Elderly

As life expectancy continues to rise, the number of geriatric patients will increase and the percentages of geriatric patients seen in the emergency department will reflect those numbers. Emergency physicians are responsible for making immediate diagnoses and initiating expeditious treatment. Infectious diseases in the elderly are more prevalent, challenging to diagnose, and are associated with greater morbidity and mortality than with the younger patient population.

Insights into severe sepsis in older patients: from epidemiology to evidence-based management

Up to 60% of patients who develop severe sepsis in the United States are > or =65 years of age, and the incidence of sepsis in this population is steadily increasing. Elderly individuals have an increased risk of developing sepsis, compared with younger patients, because of frequent comorbidities, institutionalization, declining performance status, and altered immune function. The clinical presentation of older patients with sepsis is often atypical, leading to a difficult and delayed diagnosis. Although increasing age appears to confer a high risk of death due to severe sepsis, recent evidence shows that many older patients respond well to selected interventions when the interventions are initiated in a timely fashion. Newly published clinical practice guidelines outline key recommendations regarding the treatment of patients with severe sepsis. Clinicians must be aware of the level of evidence in support of various interventions and must keenly screen older survivors for ongoing deficits that will limit their functional recovery.

Antimicrobial therapy and resistance in dermatologic pathogens of the elderly

Dermatologic infections are treated to improve the elderly patient's quality of life and prevent disability and death. Pharmacokinetic changes, social issues, and the risk for adverse effects and drug interactions, however, increase the challenge to achieve successful treatment of those over age 65 as compared with younger patients. This challenge grows ever larger when coupled with the increasing trends of resistance among bacteria and fungi. The clinician can effectively face this challenge through careful consideration of diagnosis, patient risk factors, antimicrobial pharmacology, and resistance patterns.

Pharmacokinetic and pharmacodynamic issues in the treatment of bacterial infectious diseases

This review outlines some of the many factors a clinician must consider when selecting an antimicrobial dosing regimen for the treatment of infection. Integration of the principles of antimicrobial pharmacology and the pharmacokinetic parameters of an individual patient provides the most comprehensive assessment of the interactions between pathogen, host, and antibiotic. For each class of agent, appreciation of the different approaches to maximize microbial killing will allow for optimal clinical efficacy and reduction in risk of development of resistance while avoiding excessive exposure and minimizing risk of toxicity. Disease states with special considerations for antimicrobial use are reviewed, as are situations in which pathophysiologic changes may alter the pharmacokinetic handling of antimicrobial agents.

New Developments in Antibacterial Choice for Lower Respiratory Tract Infections in Elderly Patients

Elderly patients are at increased risk of developing lower respiratory tract infections compared with younger patients. In this population, pneumonia is a serious illness with high rates of hospitalisation and mortality, especially in patients requiring admission to intensive care units (ICUs). A wide range of pathogens may be involved depending on different settings of acquisition and patient's health status. Streptococcus pneumoniae is the most common bacterial isolate in community-acquired pneumonia, followed by Haemophilus influenzae, Moraxella catarrhalis and atypical pathogens such as Chlamydia pneumoniae, Legionella pneumophila and Mycoplasma pneumoniae. However, elderly patients with comorbid illness, who have been recently hospitalised or are residing in a nursing home, may develop severe pneumonia caused by multidrug resistant staphylococci or pneumococci, and enteric Gram-negative bacilli, including Pseudomonas aeruginosa. Moreover, anaerobes may be involved in aspiration pneumonia. Timely and appropriate empiric treatment is required in order to enhance the likelihood of a good clinical outcome, prevent the spread of antibacterial resistance and reduce the economic impact of pneumonia. International guidelines recommend that elderly outpatients and inpatients (not in ICU) should be treated for the most common bacterial pathogens and the possibility of atypical pathogens. The algorithm for therapy is to use either a selected beta-lactam combined with a macrolide (azithromycin or clarithromycin), or to use monotherapy with a new anti-pneumococcal quinolone, such as levofloxacin, gatifloxacin or moxifloxacin. Oral (amoxicillin, amoxicillin/clavulanic acid, cefuroxime axetil) and intravenous (sulbactam/ampicillin, ceftriaxone, cefotaxime) beta-lactams are agents of choice in outpatients and inpatients, respectively. For patients with severe pneumonia or aspiration pneumonia, the specific algorithm is to use either a macrolide or a quinolone in combination with other agents; the nature and the number of which depends on the presence of risk factors for specific pathogens. Despite these recommendations, clinical resolution of pneumonia in the elderly is often delayed with respect to younger patients, suggesting that optimisation of antibacterial therapy is needed. Recently, some new classes of antibacterials, such as ketolides, oxazolidinones and streptogramins, have been developed for the treatment of multidrug resistant Gram-positive infections. However, the efficacy and safety of these agents in the elderly is yet to be clarified. Treatment guidelines should be modified on the basis of local bacteriology and resistance patterns, while dosage and/or administration route of each antibacterial should be optimised on the basis of new insights on pharmacokinetic/pharmacodynamic parameters and drug interactions. These strategies should be able to reduce the occurrence of risk factors for a poor clinical outcome, hospitalisation and death.

[Problems of pharmacotherapy of infections in the aged]

Infectious diseases play an important role in the elderly. Disease progression is often more severe, displaying a higher complication rate and causing increased mortality. Elderly patients suffer more frequently than younger under pneumonia, exacerbations of chronic bronchitis, urinary tract infections as well as skin and soft tissue infections. When starting empiric antibiotic therapy one should consider that the bacterial spectrum afflicting elderly patients may differ from that afflicting younger patients. In addition an increasing number of nosocomial and multiresistant pathogens is seen in elderly patients due to more frequent hospitalisation and living in nursing homes. Patient multimorbidity and multiple co-medications make awareness of important drug-interactions essential. The purpose of this article is to review the indications and side-effects of well-tried and newer antibiotics with respect to patients age. Especially the newer antibiotics Ertapenem, Linezolid, Quinupristin/Dalfopristin and Telithromycin are discussed in detail.

Ageing and infection

Average life expectancy throughout developed countries has rapidly increased during the latter half of the 20th century and geriatric infectious diseases have become an increasingly important issue. Infections in the elderly are not only more frequent and more severe, but they also have distinct features with respect to clinical presentation, laboratory results, microbial epidemiology, treatment, and infection control. Reasons for increased susceptibility include epidemiological elements, immunosenescence, and malnutrition, as well as a large number of age-associated physiological and anatomical alterations. Moreover, ageing may be the cause of infection but infection can also be the cause of ageing. Mechanisms may include enhanced inflammation, pathogen-dependent tissue destruction, or accelerated cellular ageing through increased turnover. In most instances, treatment of infection leads to a satisfactory outcome in the elderly. However, in palliative care situations and in patients with terminal dementia, the decision whether or not to treat an infectious disease is becoming a difficult ethical issue.

Fluoroquinolones for the treatment of outpatient community-acquired pneumonia

The increasing prevalence of beta-lactam and macrolide resistance in bacteria that cause respiratory infections has underscored the need for effective antimicrobial agents. The broad spectrum, excellent oral bioavailability, and once-daily dosing of fluoroquinolones contributed to the introduction of several new agents in the past decade. This class is among the world's most used antimicrobial therapies in community and hospital settings. Fluoroquinolones are generally well tolerated, but safety profiles differ widely among agents. Knowledge of in vitro activity, local microbiologic susceptibility and resistance patterns, adverse effects, and potential drug interactions should influence the selection of the best agent for individual patients. This overview of the fluoroquinolones directs particular attention to use in community-acquired pneumonia and safety.