Thrombolysis and thrombectomy for stroke in octogenarians and nonagenarians: A regional observational study

INTRODUCTION

Elderly patients are a growing population in stroke units, characterized by higher frailty, but underrepresented in clinical trials about acute care. We investigated efficacy of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in elderlies in current practice.

METHODS

We assessed consecutive patients with acute ischemic stroke (AIS) hospitalized in the four stroke units of the French Northern Alps Emergency Network between 2015 and 2020. We compared baseline characteristics, early neurological evolution and outcome of patients aged 80-89 and≥90years old (yo).

RESULTS

Among 8367 patients, 2744 (32.8%) were 80-89 yo and 541 (6.5%) were≥90 yo. IVT and/or MT were performed in 787 patients≥80 yo (632 patients aged 80-89, 155 patients aged>90). Early neurological improvement was more frequent in patients≥80 yo treated by IVT and/or MT compared to untreated patients (45.6% versus 38.4%, P=0.002). After adjustment, reperfusion treatments improved likelihood of good outcome at discharge (OR=2.0 [1.6-2.7]) and reduced in-hospital mortality (OR=0.5 [0.4-0.7]). Age and initial NIHSS score were independent factors of poor functional outcome at discharge and in-hospital mortality. The rate of successful recanalization was comparable between octogenarians and nonagenarians (87% versus 85.2%, P=0.8). Octogenarians had better functional outcome at discharge compared to nonagenarians [modified Rankin scale (mRS) 0-2: 36% versus 25.7%, P=0.02], whatever IVT or MT strategy. In-hospital mortality was lower for octogenarians compared to nonagenarians (19.5% versus 27.1%, P=0.04).

DISCUSSION

IVT and MT improve early neurological recovery and functional outcome at discharge of both octogenarians and nonagenarians in current practice. Despite a poorer outcome for nonagenarians than octogenarians, these reperfusion treatments should not be withheld on the basis of age only.

[Survey on antibiotic prescription practices for palliative care terminally ill patients of 75 years old and more]

Infections commonly occur terminally ill oldest patients in palliative care and questioned about antimicrobial use. The aim of this study was to describe practitioners' habits.

METHOD

ancillary study on antibiotic modalities according to the setting of care from a national practices survey based on self administered questionnaire sent by e-mail in 2017.

RESULTS

220 practitioners/327 used antibiotic, 136 worked in hospital department (52 geriatricians), 20 nursing home and 64 general practitioners (GP). GP declared less palliative care patients (6/year). The antibiotic goal was symptomatic relief for 181 (82.3%) without statistically significant difference between groups. GP (25%) were the group that most collected patient opinion for antibiotic prescription. Nursing home (23%) and GP (18%) reported more urinary tract symptoms than others (11.7%) (P=0.003). Geriatricians (59.6%) declared significantly less urinary analysis than GP (90%) (P=0.0009). 212 doctor (96.4%) faced side effect (SI): more allergic reaction and less administration difficulties than the other groups. The stop decision was collegially took (156, 70,9%) significantly more in hospital (121, 89%) than in community (25, 39.1%) (P<0.001). Patient wishes were noted by 30 (46.96%) only GP.

CONCLUSION

Even if practice and number of patients follow up differ from each place of care, doctors' intention in antibiotic use respect palliative care goal to relieve discomfort. It is hard to diagnose infection and complementary exam are scarce. A repeated individualized evaluation with patient, his surrounding and his medical referent participation, is mandatory to give a constant adapted level of care in every place of care.

Impact de COVID 19 sur le statut fonctionnel des populations françaises les plus âgées : Étude multicentrique COVID-OLD

Introduction

L'infection à COVID 19 est une maladie infectieuse sévère dans les populations âgées, induisant des taux de mortalité élevés. Cependant peu d'études ont exploré l'impact de COVID 19 chez les survivants. Les maladies aigues provoquent généralement un déclin fonctionnel de 20 à 50% dans ces populations. L'objectif de notre étude était de mesurer le taux de patients présentant un déclin fonctionnel à 3 mois après la COVID et d'en déterminer les facteurs associés.

Matériels et méthodes

60 centres français ont participé à cette étude prospective observationnelle incluant des patients âgés de 70 ans et plus, hospitalisés pour une COVID 19 entre le 04/10/2020 et le 10/12/20 dans des services de maladies infectieuses ou de gériatrie. Le déclin fonctionnel était défini par une perte d'au moins 0,5 sur le score d'activité de la vie quotidienne (ADL = capacité à transférer, manger, aller au toilette,se laver, s'habiller seul et être continent coté /6) ou/et une perte d'au moins 1 sur le score d'activité instrumentale de la vie quotidienne (IADL, cotés sur /8). Les données sociodémographiques, la sévérité du COVID 19, la présentation clinique, les traitements spécifiques et non spécifiques ont été recueillis. Des analyses univariées et multivariées (sans score de propension) ont été réalisées. Les différences entre les 2 vagues ont été déterminées.

Résultats

Sur les 1083 patients inclus 662 ont eu un suivi avec données complétées. L'âge moyen était de 84 ans. 56% présentaient un déclin fonctionnel à 3 mois, 40% sur les ADLs et 38% pour les IADLs. La perte moyenne était de 1,1 point pour les ADLs et de 1,6 point pour les IADLs. Tous les items des ADL étaient également affectés. La perte fonctionnelle était équivalente durant les 2 vagues.

En analyse univariée (n= 545), la perte d'ADL aiguë avant l'hospitalisation, la confusion, la durée du séjour, la chute, l'immobilisation sont des marqueurs prédictifs du déclin fonctionnel à 3 mois. En analyse multivariée (n=415), seuls La perte d'ADL avant l'hospitalisation et la présence d'une confusion au diagnostic sont prédicteurs de la perte fonctionnelle indépendamment des autres variables (gravité immédiate de la COVID, durée d'hospitalisation, de l'âge, sexe, syndrome d'immobilisation, chute, réhospitalisation dans les 3 Mois).

Conclusion

La majorité de la population survivante à une COVID 19 présente un déclin fonctionnel à 3 mois. La gravité de la perte fonctionnelle avant l'hospitalisation et la confusion au moment du diagnostic sont les 2 prédicteurs indépendants de la gravité immédiate de la COVID et de la durée d'hospitalisation . On ne sait pas ce qui est lié à la comorbidité, à l'absence de réadaptation ou à une longue infection Covid. L'impact de la COVID 19 sur la qualité de vie et les conséquences économiques de cet impact devraient être mesurés.

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Explicit definitions of potentially inappropriate prescriptions of antibiotics in hospitalized older patients

CONTEXT

The use of explicit definitions of potentially inappropriate prescriptions of antibiotics (antibiotic PIPs) might constitute an innovative means to fight against antimicrobial resistance. Explicit definitions of PIPs can reduce the rate of inappropriate prescriptions, but explicit definitions of antibiotic PIPs in geriatric medicine are currently lacking. The objective of the study was to develop explicit definitions of antibiotic PIPs for hospitalized older patients.

METHOD

We performed a qualitative study of focus groups involving geriatricians and infectious disease specialists. The study complied with the Consolidated Criteria for Reporting Qualitative Research. Transcripts of audio recordings were analyzed in a two-step independent reviewing process. The exact wording of the definitions was validated by a steering committee, an independent expert group, and the focus group participants.

RESULTS

The four focus groups comprised 28 stakeholders. Our analysis identified 65 explicit definitions of antibiotic PIPs: 47 (73%) concerned misuse, 15 (23%) concerned overuse and three (5%) concerned underuse. Most definitions were related to critically important antibiotics: 11 (17%) for fluoroquinolones, eight (12%) for amoxicillin-clavulanic acid, eight (12%) for cephalosporins, seven (11%) for aminoglycosides, and five (8%) for carbapenems.

CONCLUSION

To address the public health challenge of antimicrobial resistance, our study generated explicit definitions for antibiotic PIPs in older patients. We intend to refine and to validate these definitions through a national Delphi survey; the resulting consensus might provide key messages for prescribers and open up perspectives for reducing the incidence of antibiotic PIPs.

Duration of antibiotic treatment using procalcitonin-guided treatment algorithms in older patients: a patient-level meta-analysis from randomized controlled trials

Background

Older patients have a less pronounced immune response to infection, which may also influence infection biomarkers. There is currently insufficient data regarding clinical effects of procalcitonin (PCT) to guide antibiotic treatment in older patients.

Objective and design

We performed an individual patient data meta-analysis to investigate the association of age on effects of PCT-guided antibiotic stewardship regarding antibiotic use and outcome.

Subjects and methods

We had access to 9,421 individual infection patients from 28 randomized controlled trials comparing PCT-guided antibiotic therapy (intervention group) or standard care. We stratified patients according to age in four groups (<75 years [n = 7,079], 75–80 years [n = 1,034], 81–85 years [n = 803] and >85 years [n = 505]). The primary endpoint was the duration of antibiotic treatment and the secondary endpoints were 30-day mortality and length of stay.

Results

Compared to control patients, mean duration of antibiotic therapy in PCT-guided patients was significantly reduced by 24, 22, 26 and 24% in the four age groups corresponding to adjusted differences in antibiotic days of −1.99 (95% confidence interval [CI] −2.36 to −1.62), −1.98 (95% CI −2.94 to −1.02), −2.20 (95% CI −3.15 to −1.25) and − 2.10 (95% CI −3.29 to −0.91) with no differences among age groups. There was no increase in the risk for mortality in any of the age groups. Effects were similar in subgroups by infection type, blood culture result and clinical setting (P interaction >0.05).

Conclusions

This large individual patient data meta-analysis confirms that, similar to younger patients, PCT-guided antibiotic treatment in older patients is associated with significantly reduced antibiotic exposures and no increase in mortality.

Dynamic SOFA score assessments to predict outcomes after acute admission of octogenarians to the intensive care unit

BACKGROUND

Identifying which octogenarians could benefit most from continuing critical care is challenging. We aimed to see if responses to therapies using the sequential organ failure assessment (SOFA) score on day 4 after unplanned admission to the intensive care unit (ICU) could be associated with short-term mortality.

METHODS

In this prospective observational cohort study, data from 4 ICUs in a University Hospital included SOFA scores on admission and day 4, along with preadmission measurements of frailty, comorbidities, nutritional status and number of medications. Outcome measures included mortality and loss of autonomy on day 90 after admission.

RESULTS

Eighty-seven critically ill patients aged 80 years or older with preadmission functional independence and no missing SOFA score data on day 4 were studied (primary analyses). The mortality rate on day 90 was 30%. In a univariate Cox model, the SOFA score on day 4 was significantly associated with mortality rate: hazard ratio = 1.18 per one-point increase, 95% confidence interval (CI), 1.08 to 1.28 (p<0.001). A SOFA score of 6 or more on day 4 could correctly classify 75% of patients who died on day 90, with a sensitivity of 54% and a specificity of 84%. After adjustment, the SOFA score on day 4, neurological failure on admission and the number of preadmission medications were significantly associated with mortality on day 90, with an area under the receiver operating characteristic curve of 0.81 (95% CI, 0.71 to 0.91). These findings were confirmed in a sensitivity analysis with 109 patients. Preadmission frailty was the only variable independently associated with loss of autonomy in the 49 surviving patients.

CONCLUSION

Measuring SOFA score on day 4 and preadmission frailty could help predict mortality and loss of autonomy on day 90 in octogenarians after their acute admission to the ICU.

Epidemiology and risk factors for ureteral stent-associated urinary tract infections in non-transplanted renal patients: a systematic review of the literature

PURPOSE

Pathophysiology and risk factors for Ureteral Stent-Associated Urinary Tract Infection (USAUTI) have been poorly investigated. This situation results in highly diverse practices regarding USAUTI prevention, diagnosis and treatment. The aim of the present study was to describe the epidemiology and risk factors for USAUTI in non-transplanted patients.

METHODS

We conducted a systematic literature review based on a comprehensive PubMed® bibliographic strategy, between October 1998 and March 2020. The methodological quality of the studies included was analyzed according to dedicated grids. The main endpoints were the correlation between different potential risk factors and infection ureteral stent-associated urinary tract infection or colonization rate. Conclusions and their level of evidence were reported on the basis of a critical analysis of the best available scientific evidence. This work has been submitted to a national review, which enabled the potentially divergent opinions of experts to be collected, thereby ensuring adequate quality of data.

RESULTS AND CONCLUSION

Twenty-six studies out of the 505 articles identified, were included in the final analysis. Staphylococcus spp, E. coli, Klebsiella spp, Pseudomona aeruginosa, Enterococcus spp. and Candida spp. were the microorganisms most often responsible for asymptomatic bacteriuria (ABU) or USAUTI. Longer indwelling time, diabetes mellitus, female gender, chronic renal failure, diabetic nephropathy and cancer were identified as risk factors for ABU and ureteral stent colonization. No specific risk factor for UTI was identified in the literature studied. A causal relationship between ureteral stent colonization and USAUTI or urosepsis remains to be demonstrated.

Infections in the older population: what do we know?

The incidence of infections increases with age and results in a higher risk of morbidity and mortality. This rise is not mainly related to chronological age per se but has been linked mostly to individual factors such as immunosenescence; the presence of comorbidities; the occurrence of geriatric syndromes such as poor nutrition, polypharmacy, and cognitive disorders; and the presence of functional impairment concomitant with environmental, healthcare-related and microbiological factors such as the increasing risk of multidrug-resistant microorganisms. The geriatric concept of frailty introduces a new approach for considering the risk of infection; this concept highlights the importance of functional status and is a more comprehensive and multicomponent approach that may help to reverse the vulnerability to stress. The aim of this article is to provide some typical hallmarks of infections among older adults in comparison to younger individuals. The main differences among the older population that are presented are an increased prevalence of infections and potential risk factors, a higher risk of carrying multidrug-resistant microorganisms, an increase in barriers to a prompt diagnosis related to atypical presentations and challenges with diagnostic tools, a higher risk of under- and over-diagnosis, a worse prognosis with a higher risk of acute and chronic complications and a particular need for better communication among all healthcare sectors as they are closely linked together.

National French Survey of Coronavirus Disease (COVID-19) Symptoms in People Aged 70 and Over

The objective of this national French survey was to determine the coronavirus disease 2019 (COVID-19) semiology in seniors (n = 353; mean, 84.7 ± 7.0 years). A total of 57.8% of patients exhibited ≤3 symptoms, including thermal dysregulation (83.6%), cough (58.9%), asthenia (52.7%), polypnea (39.9%), and gastrointestinal signs (24.4%). Patients ≥80 years exhibited falls (P = .002) and asthenia (P = .002). Patients with neurocognitive disorders exhibited delirium (P < .001) and altered consciousness (P = .001). Clinical peculiarities of COVID-19 were reported in seniors.

Clinical Trials Registration

NCT04343781.

Determinants of doctors' antibiotic prescriptions for patients over 75 years old in the terminal stage of palliative care

INTRODUCTION

Notwithstanding high prevalence of presumably bacterial infections in elderly persons (EP) in palliative care (PC), there exists no recommendation on the role of antibiotic therapy (ABP) in this type of situation.

OBJECTIVE

To describe the determinants of antibiotic prescription by general practitioners (GP) and by doctors practicing in institutions (DPI) for patients>75 years, in end-of-life situations in PC.

METHOD

Descriptive investigation by anonymous self-administered questionnaire disseminated in France by e-mail.

RESULTS

A total of 301 questionnaires analyzed: 113 GP, 188 DPIs. The latter were mainly geriatricians (69, 36.6%) and infectologists/internists (41, 21.8%). Sixty-three (55,75%) GPs and 144 (78.7%) DPIs stated that they had prescribed antibiotics. Practice in "EHPAD" retirement homes or intensive care was often associated with non-prescription of antibiotics. Age, PC training and number of patients monitored bore no influence. Family involvement in decision-making was more frequent for GPs than for DPIs. The main purpose of antibiotic therapy was to relieve different symptoms (fever, respiratory congestion, functional urinary signs). Most of the doctors (81%) had previously encountered complications (allergy, adverse effect), which represented the main causes of treatment discontinuation.

CONCLUSION

Antibiotic use in end-of-life EPs in PC seems frequent. In accordance with the principle of beneficence, its goal of often symptom-related; that said, in the absence of scientific data, antibiotic prescription in end-of-life situations should be individualized in view of observing the other ethical caregiving principles (beneficence, non-maleficence, justice, patient autonomy) and re-evaluated daily.

Communicating Benefits from Vaccines Beyond Preventing Infectious Diseases

Despite immunisation being one of the greatest medical success stories of the twentieth century, there is a growing lack of confidence in some vaccines. Improving communication about the direct benefits of vaccination as well as its benefits beyond preventing infectious diseases may help regain this lost confidence. A conference was organised at the Fondation Merieux in France to discuss what benefits could be communicated and how innovative digital initiatives can used for communication. During this meeting, a wide range of indirect benefits of vaccination were discussed. For example, influenza vaccination can reduce hospitalisations and deaths in older persons with diabetes by 45% and 38%, respectively, but the link between influenza and complications from underlying chronic non-communicable diseases such as diabetes is frequently underestimated. Vaccination can reduce antimicrobial resistance (AMR), which is growing, by reducing the incidence of infectious disease (though direct and indirect or herd protection), by reducing the number of circulating AMR strains, and by reducing the need for antimicrobial use. Disease morbidity and treatment costs in the elderly population are likely to rise substantially, with the ageing global population. Healthy ageing and life-course vaccination approaches can reduce the burden of vaccine-preventable diseases, such as seasonal influenza and pneumococcal diseases, which place a significant burden on individuals and society, while improving quality of life. Novel disease surveillance systems based on information from Internet search engines, mobile phone apps, social media, cloud-based electronic health records, and crowd-sourced systems, contribute to improved awareness of disease burden. Examples of the role of new techniques and tools to process data generated by multiple sources, such as artificial intelligence, to support vaccination programmes, such as influenza and dengue, were discussed. The conference participants agreed that continual efforts are needed from all stakeholders to ensure effective, transparent communication of the full benefits and risks of vaccination.

Procalcitonin (PCT)-guided antibiotic stewardship: an international experts consensus on optimized clinical use

Background Procalcitonin (PCT)-guided antibiotic stewardship (ABS) has been shown to reduce antibiotics (ABxs), with lower side-effects and an improvement in clinical outcomes. The aim of this experts workshop was to derive a PCT algorithm ABS for easier implementation into clinical routine across different clinical settings. Methods Clinical evidence and practical experience with PCT-guided ABS was analyzed and discussed, with a focus on optimal PCT use in the clinical context and increased adherence to PCT protocols. Using a Delphi process, the experts group reached consensus on different PCT algorithms based on clinical severity of the patient and probability of bacterial infection. Results The group agreed that there is strong evidence that PCT-guided ABS supports individual decisions on initiation and duration of ABx treatment in patients with acute respiratory infections and sepsis from any source, thereby reducing overall ABx exposure and associated side effects, and improving clinical outcomes. To simplify practical application, the expert group refined the established PCT algorithms by incorporating severity of illness and probability of bacterial infection and reducing the fixed cut-offs to only one for mild to moderate and one for severe disease (0.25 μg/L and 0.5 μg/L, respectively). Further, guidance on interpretation of PCT results to initiate, withhold or discontinue ABx treatment was included. Conclusions A combination of clinical patient assessment with PCT levels in well-defined ABS algorithms, in context with continuous education and regular feedback to all ABS stakeholders, has the potential to improve the diagnostic and therapeutic management of patients suspected of bacterial infection, thereby improving ABS effectiveness.

[Geriatric units at the beginning of the 2020 COVID-19 epidemic in France]

The COVID-19 epidemic that started in November in China became a national epidemic from March 16, 2020 with the declaration of population containment in order to reduce the spread of the virus in France. From March 17 to March 27, 2020, the monitoring unit of the French society of geriatrics and gerontology decided to conduct a survey to analyze the implementation of the mobilization of geriatric units, given that this epidemic had shown that it resulted in excess mortality mainly among the elderly. The survey was able to bring together the response of 34 services, nine of which were located in a high epidemic cluster zone. Dedicated acute geriatric units for patients infected with COVID-19 were present in eight facilities, only outside the cluster zones. Nine geriatric follow-up and rehabilitation services were dedicated, an additional telemedicine activity concerned 35% of the facilities, and family listening and tablet communication facilities concerned 36% of the facilities. This survey is a snapshot of an initial moment in the epidemic. It provides an opportunity to describe the context in which this epidemic occurred in terms of geriatric policy, and to assess the responsiveness and inventiveness of these services in meeting the needs of the elderly.

Pharmacy-based interventions to increase vaccine uptake: report of a multidisciplinary stakeholders meeting

BACKGROUND

Despite the existence of efficacious vaccines, the burden of vaccine-preventable diseases remains high and the potential health benefits of paediatric, adolescent and adult vaccination are not being achieved due to suboptimal vaccine coverage rates. Based on emerging evidence that pharmacy-based vaccine interventions are feasible and effective, the European Interdisciplinary Council for Ageing (EICA) brought together stakeholders from the medical and pharmacy professions, the pharmaceutical industry, patient/ageing organisations and health authorities to consider the potential for pharmacy-based interventions to increase vaccine uptake. We report here the proceedings of this 3-day meeting held in March 2018 in San Servolo island, Venice, Italy, focussing firstly on examples from countries that have introduced pharmacy-based vaccination programmes, and secondly, listing the barriers and solutions proposed by the discussion groups.

CONCLUSIONS

A range of barriers to vaccine uptake have been identified, affecting all target groups, and in various countries and healthcare settings. Ease of accessibility is a potentially modifiable determinant in vaccine uptake, and thus, improving the diversity of settings where vaccines can be provided to adults, for example by enabling community pharmacists to vaccinate, may increase the number of available opportunities for vaccination.

Priming effect in children with Type 1 Diabetes Mellitus

Previous studies have evidenced cognitive difficulties across various domains in Type 1 Diabetes Mellitus (T1DM) children, but the implicit memory system has not yet been systematically explored.Taking into account that the interplay between memory and perception may be modulated by the semantic category of the stimuli and their salience, we explored explicit and implicit memory using both object and food stimuli to verify whether for T1DM children there is a feebleness in performing the function of memory as a function of the stimuli used.Eighteen T1DM children and 47 healthy children performed an explicit recognition task in which they were requested to judge whether the presented image had already been shown ("old") or not ("new") and an identification priming task in which they were asked to name new and old pictures presented at nine ascending levels of spatial filtering.Results did not reveal any differences between controls and T1DM children in the explicit memory recognition task, whereas some differences between the two groups were found in the identification priming task. In T1DM children, the priming effect was observed only for food images.The dissociation between implicit and explicit memory observed in children with diabetes seems to be modulated by the category of the stimuli, and these results underscore the relevance of taking into account this variable when exploring cognitive functions.

Comprehensive geriatric assessment in older patients suffering from infective endocarditis. A prospective multicentric cohort study

OBJECTIVES

The aim was to describe the impact of infective endocarditis (IE) on functional, cognitive and nutritional statuses, and to estimate the influence of these parameters on surgical management and mortality.

METHOD

This was a prospective study over 13 months in 14 French hospitals, including patients ≥75 years of age with definite or possible IE. A comprehensive geriatric assessment (CGA) was performed during the first week of hospitalization, including a retrospective estimation of functional status 2 months before hospitalization, and 3 months after.

RESULTS

A total of 120 patients were included (mean age 83.1 ± 5.0 (75-101) years). IE was associated with a dramatic impairment of functional status between 2 months prior hospitalization and the first geriatric evaluation (90.8% able to walk vs. 35.5% (p < 0.0001), ADL (Activities in Daily Living) 5.0 ± 1.7 vs. 3.1 ± 2.1 (p < 0.0001)). The 19 operated patients (15.8%) had less comorbidities (cumulative illness rating scale geriatric 10.8 ± 8.2 vs. 15.3 ± 7.1 (p 0.0176)), better functional (ADL 5.9 ± 0.4 vs. 4.9 ± 1.8 (p 0.0171) and nutritional (mini nutritional assessment 20.4 ± 5.0 vs. 17.3 ± 6.2 (p 0.0501)) statuses than non-operated patients. Among all infectious, cardiac and geriatric parameters, body mass index (HR 0.9, range 0.8-1, p 0.05) and ADL at the time of the first evaluation (HR 0.7, range 0.6-0.9, p 0.002) were the sole independent predictors of the 3-month (32.5%) and 1-year mortality (42.5%). Three months later, the 57 assessed patients only partially recovered their ADL (3.7 ± 1.9 vs. 5.3 ± 1.4 2 months prior hospitalization and 4.6 ± 1.9 at the first CGA; p < 0.0001).

CONCLUSION

Functional and nutritional abilities are crucial components that can be accurately explored through a CGA when managing IE in oldest patients.

Antimicrobial consumption and impact of antimicrobial stewardship programmes in long-term care facilities

BACKGROUND

Antimicrobials are among the most frequently prescribed drugs in long-term care facilities (LTCFs). Implementation of antimicrobial stewardship programmes (ASPs) is often challenging because of scarce data in this setting.

OBJECTIVES

This narrative review aimed to provide data about antibiotic consumption in LTCFs and the need, implementation, and organization of ASPs in this setting.

SOURCE

PubMed was searched for studies assessing antimicrobial consumption and implementation of ASPs in LTCFs. The search was restricted to articles published in English in the last 10 years. Experts belonging to the ESCMID Study Group for Infections in the Elderly (ESGIE) reviewed the selected studies and evaluated the studies on ASPs according to the GRADE approach. Moreover, the quality of reporting has been assessed according to TREND and CONSORT checklists for quasi-experimental and cluster randomized clinical trials (cRCT), respectively.

CONTENT

Data on antibiotic consumption in LTCFs show great variability in LTCFs across and within countries. Reasons for this variability are difficult to analyse because of the differences in the types of LTCFs, their organization, and the population cared-for in the different LTCFs. However, studies show that the use of antibiotics among elderly patients in LTCFs, especially in cases of asymptomatic bacteriuria and influenza-like syndromes, is often inappropriate. High-quality cRCTs and low to moderate quality quasi-experimental studies show that educational interventions direct at nurse and physicians are effective in reducing unnecessary antibiotic prescriptions.

IMPLICATIONS

There is an urgent need for ASPs tailored for LTCFs. Multifaceted organized educational interventions, involving both clinicians and nursing staff, should be advocated and require institutional intervention by health authorities. Future studies assessing the impact of well-defined ASPs in LTCFs should produce compelling evidence in this setting.

Reactive oxygen species and NADPH oxidase 4 involvement in osteoarthritis

Osteoarthritis (OA) is a degenerative chronic disease affecting >300,000 million people around the world as of 2016. Symptomatic measures exist, but there are hardly any curative treatments available. Disruption of the cartilage homeostasis in favor of catabolism leads to cartilage destruction. ROS-macromolecular-induced damage is significantly greater in OA cartilage and OA is described as low-grade chronic systemic inflammation. This review aimed to assess the critical role of cartilage ageing and oxidative stress in the OA process, focusing in particular on NADPH oxidase and especially Nox4 involvement. With age, hypertrophic senescent cells with an altered redox cell profile accumulated. Chondrocytes are more sensitive to oxidant-mediators and the serum level of pro-inflammatory mediators increases. Age-related advanced glycation end products impact on extra cellular matrix (ECM) properties leading to the apoptosis of chondrocytes. A focus on NADPH oxidase-mediated-ROS signaling highlighted the very specific Nox4 isoform, which plays a role on the final common pathway targeting chondrocyte cells. IL-1β-mediated Nox4 stimulation induced an increase in the levels released by the chondrocyte of MMP-1 and MMP-13 proteins, which are involved in ECM degradation. In comparison with the other Nox isoforms, Nox4 remains unusual, since it is constitutively active, does not depend on cytosolic activator proteins and seems to generate H₂O₂ thanks to the specific conformation of the Nox4 E-loop. Nox4-induced ROS production appears an essential actor in the OA process and it could be relevant to focus on this target in the aim of discovering and developing new therapeutic strategies.

The public health value of vaccination for seniors in Europe

Longer life expectancy and decreasing fertility rates mean that the proportion of older people is continually increasing worldwide, and particularly in Europe. Ageing is associated with an increase in the risk and severity of infectious diseases. These diseases are also more difficult to diagnose and manage in seniors who often have at least one comorbid condition (60% of seniors have two or more conditions). Infectious diseases increase the risk of hospitalization, loss of autonomy and death in seniors. Effective vaccines are available in Europe for infectious diseases such as influenza, pneumococcal diseases, herpes zoster, diphtheria, tetanus and pertussis. Their effectiveness has been demonstrated in terms of reducing the rates of hospitalization, disability, dependency and death. The prevention of diseases in seniors also results in savings in healthcare and societal costs each year in Europe. Despite the availability of vaccines, vaccine-preventable diseases affect millions of European citizens annually, with the greatest burden of disease occurring in seniors, and the medical and economic benefits associated with are not being achieved. Vaccination coverage rates must be improved to achieve the full benefits of vaccination of seniors in Europe.

Incidence of pertussis in subjects aged 50years and older in France in 2013-2014

OBJECTIVE

To assess the incidence of pertussis (whooping cough) in subjects aged 50years and older in France.

METHODS

Participating family physicians (FPs) using the patient record management software AxiSanté^® included patients aged 50years and older, who had signed an informed consent form, presenting with persistent cough for 7 to 21days. Bordetella genetic material was detected by polymerase chain reaction (PCR) on nasopharyngeal samples collected at the FP's discretion.

RESULTS

A total of 42 FPs included 129 patients from June 2013 to August 2014 (large cities: 38; medium-sized cities: 57; rural areas: 34); 106 samples were analyzed. Overall, 30 pertussis cases were diagnosed: 10 cases confirmed by PCR, 18 purely clinical cases, and two direct epidemiological cases. The crude incidence rate per 100,000 patients aged≥50years was 103.6 (95% CI: 69.9-47.9): 77.1 in large cities, 103.1 in medium-sized cities, and 143.9 in rural areas. The extrapolated incidence rate per 100,000 persons aged≥50years was 187.1 (95% CI: 126.2-67.1): 131.1 in large cities, 256.1 in medium-sized cities, and 242.2 in rural areas.

CONCLUSION

The population aged 50years and older can serve as a reservoir. Its role in Bordetella pertussis circulation should be taken into account for pertussis booster vaccination programs.

Efficacy of indefinite chronic oral antimicrobial suppression for prosthetic joint infection in the elderly: a comparative study

BACKGROUND

During prosthetic joint infection (PJI), surgical management is sometimes impossible and indefinite chronic oral antimicrobial suppression (ICOAS) may be the only option. The outcomes of elderly patients who benefited from ICOAS with strictly palliative intent were evaluated.

METHODS

A national retrospective cohort study was performed in France, involving patients aged >75 years with a PJI who were managed with planned life-long ICOAS from 2009 to 2014. Patients who experienced an event were compared to those who did not. An event was defined as a composite outcome in patients undergoing ICOAS, including local or systemic progression of the infection, death, or discontinuation of antimicrobial therapy because of an adverse drug reaction.

RESULTS

Twenty-one patients were included, with a median age of 85 years (interquartile range 81-88 years). Eight of the 21 patients experienced an event: one had an adverse drug reaction, three had systemic progression of sepsis, and two had local progression. Two of the 21 patients died. No death was related to ICOAS or infection. There was no significant difference between the population with an event and the population free of an event with regard to demographic, clinical, and microbiological characteristics (p>0.05).

CONCLUSIONS

ICOAS appeared to be an effective and safe option in this cohort.

Recommended immunization schedules for adults: Clinical practice guidelines by the Escmid Vaccine Study Group (EVASG), European Geriatric Medicine Society (EUGMS) and the World Association for Infectious Diseases and Immunological Disorders (WAidid)

Rapid population aging has become a major challenge in the industrialized world and progressive aging is a key reason for making improvement in vaccination a cornerstone of public health strategy. An increase in age-related disorders and conditions is likely to be seen in the near future, and these are risk factors for the occurrence of a number of vaccine-preventable diseases. An improvement in infectious diseases prevention specifically aimed at adults and the elderly can therefore also decrease the burden of these chronic conditions by reducing morbidity, disability, hospital admissions, health costs, mortality rates and, perhaps most importantly, by improving the quality of life. Among adults, it is necessary to identify groups at increased risk of vaccine-preventable diseases and highlight the epidemiological impact and benefits of vaccinations using an evidence-based approach. This document provides clinical practice guidance on immunization for adults in order to provide recommendations for decision makers and healthcare workers in Europe. Although immunization is considered one of the most impactful and cost-effective public health measures that can be undertaken, vaccination coverage rates among adults are largely lower than the stated goal of ≥ 95% among adults, and stronger efforts are needed to increase coverage in this population. Active surveillance of adult vaccine-preventable diseases, determining the effectiveness of the vaccines approved for marketing in the last 5 y, the efficacy and safety of vaccines in immunocompromised patients, as well as in pregnant women, represent the priorities for future research.

Burden of herpes zoster: the direct and comorbidity costs of herpes zoster events in hospitalized patients over 50 years in France

Background

The objectives of this study were to describe hospital stays related to HZ and to evaluate the direct and indirect cost of hospitalizations due to HZ among patients aged over 50 years.

Methods

The hospitalizations of people aged over 50 years were selected from the French national hospital 2011 database (PMSI) using ICD-10 diagnosis codes for HZ.

Firstly, stays with HZ as principal or related diagnostic were described through the patient characteristics, type of hospitalization and the related costs. Secondly, a retrospective case–control analysis was performed on stays with HZ as comorbidity in 5 main hospitalizations causes (circulatory, respiratory, osteo-articular, digestive systems and diabetes) to assess the impact of HZ as co-morbidity on the length of stay, mortality rate and costs.

Results

In the first analysis, 2,571 hospital stays were collected (60 % of women, mean age: 76.3 years and mean LOS: 9.5 days). The total health assurance costs were 10,8 M€. Mean cost per hospital stay was 4,206€. In the second analysis, a significant difference in LOS and costs was shown when HZ was associated as comorbidity in other hospitalization’s causes.

Conclusions

HZ directly impacts on the hospital cost. When present as comorbidity for other medical reasons, HZ significantly increases the length of hospital stay with subsequent economic burden for the French Health System.

Symptomatic cytomegalovirus gastrointestinal infection with positive quantitative real-time PCR findings in apparently immunocompetent patients: a case series

Cytomegalovirus (CMV) gastrointestinal disease rarely occurs in immunocompetent patients, and is mainly diagnosed on the basis of histopathological findings. Real-time PCR for CMV DNA quantification is considered to be a useful diagnostic tool, but its place in the diagnostic strategy is not clearly defined. The goal of the study was to describe the clinical and paraclinical features of apparently immunocompetent patients with CMV gastrointestinal disease diagnosed according to quantitative PCR results. In this retrospective study conducted in a 1500-bed tertiary-care centre, we reviewed the case records of apparently immunocompetent patients with positive findings of CMV DNA in gastrointestinal biopsies with compatible symptoms and endoscopic findings. A total of 13 patients were included between January 2007 and December 2010. The median age was 81 years, and 54% of patients had underlying immune-modulating conditions. Diarrhoea, haematochezia and dysphagia were the main reported symptoms, and ulcers were the main endoscopic findings. The mean value of CMV DNA load in gastrointestinal biopsies was 3845 copies/μg total DNA (range, 15-15 500 copies/μg total DNA). The highest values were found in two patients who were diagnosed with adenocarcinoma in the subsequent course of CMV infection. Clinical features were similar to those in previous series in which diagnosis was based on histopathological analysis. Elderly people are more commonly affected, and a link with immune senescence is possible. Quantification of CMV DNA seems to be a useful tool for diagnosis when combined with clinical and endoscopic findings, but further studies are necessary to interpret quantitative values.

Subcutaneously administered antibiotics: a national survey of current practice from the French Infectious Diseases (SPILF) and Geriatric Medicine (SFGG) society networks

A national survey was performed to explore antibiotic prescription by the subcutaneous (sc) route among French infectious diseases and geriatric practitioners. Among the participating physicians, 367 (96.1%) declared administering sc antibiotics at some point. Ceftriaxone was prescribed sc by all but one, and ertapenem, teicoplanin, aminoglycosides and amoxicillin by 33.2%, 39.2%, 35.1% and 15.3%, respectively. The sc route was resorted to mainly in case of unavailable oral, intravenous or intramuscular routes, especially during palliative care. Pain, skin necrosis and lack of efficacy were the main adverse effects, reported by 70.8%, 12.8% and 19.9% of practitioners, respectively. Further studies are needed to precise the indications, modalities and tolerance of sc antibiotic use.

Prevalence of protein-energy malnutrition in hospital patients over 75 years of age admitted for hip fracture

INTRODUCTION

One percent of falls in over-75 years old cause hip fracture (HF). Protein-energy malnutrition (PEM) is associated with falls and fracture. PEM screening and perioperative nutritional management are recommended by the European Society of Parenteral and Enteral Nutrition, yet data on nutritional status in elderly HF patients are sparse. The Mini Nutritional Assessment (MNA) score is presently the most effective screening tool for PEM in over-75 years old.

OBJECTIVE

The principal objective of the present study was to determine the prevalence on MNA of PEM in patients aged over 75 years admitted for HF. Secondary objectives were to identify factors associated with PEM and its role as a factor of evolution.

MATERIALS AND METHODS

A prospective observational epidemiological study included 50 patients aged over 75 years admitted for HF in an 8-bed orthopedic surgery department with a geriatric follow-up unit. PEM was defined by MNA<17/30. Assessment systematically comprised associated comorbidity (Cumulative Illness Rating Scale-Geriatric [CIRS-G]), cognitive status on the Mini Mental State Examination (MMSE), functional status on activities of daily life (ADL), and mean hospital stay (MHS). Scores were compared on quantitative tests (Student t) with the significance threshold set at P<0.05.

RESULTS

Mean age for the 50 patients was 86.1 years (range, 77-94 years). Prevalence of PEM was 28%; a further 58% of patients were at risk for PEM. PEM was associated with elevated CIRS-G (P<0.006), greater numbers of severe comorbidities (P=0.006), more severe cognitive disorder (P=0.005) and functional dependence (P=0.002), and 8 days' longer MHS (P=0.012).

DISCUSSION

The present study confirmed the high prevalence of PEM in HF patients aged over 75 years, supporting longer hospital stay. MNA is a diagnostic gold standard, not to be replaced by albuminemia or body-mass index in this perioperative clinical situation. Given the present economic stakes relating to geriatric trauma patients' hospital stay, it is essential to prevent, diagnose and treat PEM in elderly subjects.

LEVEL OF EVIDENCE

Level IV; prospective cohort study.