Post on 07-May-2019
Dept. Preventive & Social Med. Siriraj Hospital
Infection Control for the Elderly
ศ.นพ. ประเสริฐ อัสสันตชัย
สาขาวิชาเวชศาสตร์ผู้สูงอายุ
ภาควิชาเวชศาสตร์ป้องกันและสังคม
คณะแพทยศาสตร์ศริิราชพยาบาล
Dept. Preventive & Social Med. Siriraj Hospital
General Consideration
“Difference from the young”
1. Incidence, different pathogen, complications, morbidity
& mortality
2. Atypical presentation: RAMPS
Reduced body reserve : altered immune response
Atypical presentation : geriatric syndrome, absence of fever,
nonspecific presentation
Multiple pathology : coexisting diseases
Polypharmacy
Social adversity
Dept. Preventive & Social Med. Siriraj Hospital
Alteration of immune system in ageing
Cell-mediated immune system
-Thymus gland : no thymosin secretion_age 60 but still full
function even appears vestigial
- In vitro :
- changes in percentages of B and T lymphocyte ?
- no change or increase ratio of T4/T8
- no change of natural killer cell, macrophage
- lymphocyte transformation to PHA, Con A
- lymphocyte function : mosaic pattern
Dept. Preventive & Social Med. Siriraj Hospital
Cell-mediated immune system
- In vivo :
- delayed-type skin hypersensitivity still the best indicator
of CMIR in elderly
- to DNCB, tuberculin, candida, mumps, trichophyton,
varidase all with aging
- Relationship between anergy and prognosis
Dept. Preventive & Social Med. Siriraj Hospital
Humoral immune system
Relatively unchanges compared to CMIR, most obvious changes related to T-dependent antigen
total serum IgG, IgA
IgM
Peripheral B cell unchanged but mature antigen-responsive B cell
Impaired 1o and 2o immune responses to vaccination, lower peak titres and more rapid decline after HBV and influenza vaccine but not pneumococcal vaccine.
monoclonal gammopathy
autoAb both organ-specific and nonspecific ones
Dept. Preventive & Social Med. Siriraj Hospital
Polymorphonuclear leucocyte
Number, adherence to epithelial surface,
chemotactic and random migration
all no changes
Rate of migration into skin abrasion
Dept. Preventive & Social Med. Siriraj Hospital
Local defense mechanism
Abnormal gag response
Incontinence
Immobility
Respiratory excursion
Dept. Preventive & Social Med. Siriraj Hospital
General Consideration
“Difference from the young”
1. Incidence, different pathogen, complications, morbidity
& mortality
2. Atypical presentation: RAMPS
Reduced body reserve : altered immune response
Atypical presentation : geriatric syndrome,
absence of fever, nonspecific presentation
Multiple pathology : coexisting diseases
Polypharmacy
Social adversity
Dept. Preventive & Social Med. Siriraj Hospital
อาการแสดงที่ไม่แน่นอน__โรคชรา ?
ภาวะหกล้ม Instability (Fall)
สูญเสียความสามารถในการเดิน Immobility
สติปัญญาเสื่อมถอย Intellectual impairment
ปัสสาวะอุจจาระราด Incontinence
เบื่ออาหาร Inanition
เกิดภาวะแทรกซ้อนได้ง่าย Iatrogenesis
Dept. Preventive & Social Med. Siriraj Hospital
Atypical Presentation of Infection in the Elderly
Any change of temperature in any direction from baseline
Any unexplained change in functional status or behaviour
Worsening cognition
Lethargy or agitation
Anorexia or change in appetite
Falls
Incontinence
Focal neurological finding
Tachypnoea
Dept. Preventive & Social Med. Siriraj Hospital
General Consideration
“Difference from the young”
1. Incidence, different pathogen, complications, morbidity
& mortality
2. Atypical presentation: RAMPS
Reduced body reserve : altered immune response
Atypical presentation : geriatric syndrome, absence of fever,
nonspecific presentation
Multiple pathology : coexisting diseases
Polypharmacy
Social adversity
Dept. Preventive & Social Med. Siriraj Hospital
DM : adhesion, chemotaxis and phagocytosis of PMN
complement C3 opsonization
IgM to agglutinate bacteria
Chronic bronchitis : ciliary motility, local Ab response
Physical stress : adhesion, chemotaxis of PMN
Opsonization
T cell response to IL-2
Psychological stress :
T cell response to mitogen during bereavement, depression, a medical examination!
Chronic ill health
Dept. Preventive & Social Med. Siriraj Hospital
General Consideration
“Difference from the young”
1. Incidence, different pathogen, complications, morbidity
& mortality
2. Atypical presentation: RAMPS
Reduced body reserve : altered immune response
Atypical presentation : geriatric syndrome, absence of fever,
nonspecific presentation
Multiple pathology : coexisting diseases
Polypharmacy
Social adversity
Dept. Preventive & Social Med. Siriraj Hospital
T cell receptors for : Calcium channel, cholinergic, histaminic, adrenergic.
Salivary flow : anticholinergic effect of psychotropic agents, antidepressants, bladder relaxant
Corticosteroid : PMN chemotaxis, phagocytosis
Classical & alternate complement activation pathways
T cell response
B cell immunoglobulin synthesis
Alcohol :
PMN chemotaxis
macrophage activation, mobility, phagocytosis
T cell transformation, natural killer cell
B cell IgG formation
Polypharmacy
Dept. Preventive & Social Med. Siriraj Hospital
Infections worsened by delayed recognition
Intraabdominal : usually go to OR 24-48 hours later than young patients
cholecystitis → ↑gall bladder empyema, gangrene
appendicitis → rupture appendicitis, peritonitis
diverticulitis → abscess, peritonitis
Meningitis
Infective endocarditis
TB delayed infectious control
Dept. Preventive & Social Med. Siriraj Hospital
SEPTICEMIA IN THE ELDERLY
Epidemiologic point:
increased frail elderly
more invasive intervention
increased gram negative organism
increased morbidity & mortality
Dept. Preventive & Social Med. Siriraj Hospital
SEPTICEMIA IN THE ELDERLY
Clinical:
geriatric giants “5 I’s”
fever, tachycardia, tachypnea, hypotension
unreliable local signs
hypoalbuminemia, hyponatremia,
no leucocytosis
Dept. Preventive & Social Med. Siriraj Hospital
SEPTICEMIA IN THE ELDERLY
Prognosis:
primary source: IV catheter, genitourinary,
pneumonia
clinical: drowsy, hypothermia, septic shock,
more underlying diseases
leucopenia, hypoalbuminemia.
Assantachai P et al. Siriraj Hosp Gaz 1994; 46: 10-22.
Dept. Preventive & Social Med. Siriraj Hospital
Urinary tract infection in the elderly
Prevalence: common, increase with aging Bacteriuria : female20%, male10%
ratio: 2-3:1 but 30:1 in the young Institute: women 17-55%, men 15-31% Setting: frail, functional disability, perineal soiling, poor
bladder function, urinary catheter
Dept. Preventive & Social Med. Siriraj Hospital
Urinary tract infection in the elderly
Host defense:
vaginal pH,
urinary defense (pH, osmalality, urea, organic acid, bactericidal
prostatic secretion, glucose, Tamm-Horsefall protein)
micturition.
Organism: E.coli, P. mirabilis, Enterobacteriaceae,
P.aeruginosa
female: E.coli 50-70% but 75-90% in the young
male: E.coli, Klebsiella, but gram positive cocci:
Staphylococcus, Streptococcus faecalis.
Dept. Preventive & Social Med. Siriraj Hospital
Urinary tract infection in the elderly
Clinical manifestation
symptom: lower vs upper tract (may absent but
confused, nausea & vomitting, respiratory
distress)
26% misdiagnosed!
associated bacteremia: more prevalence than the
young
mortality ~ 10 - 30%
Dept. Preventive & Social Med. Siriraj Hospital
Urinary tract infection in the elderly
Investigation
pyuria (> 10 WBC/ml) : poor predictor of bacteriuria
but good predictor if no bacteriuria
indication ultrasonography:
all men
women if associated with bacteremia, poor treatment
response (within 72 hours)
relapse UTI: residual urine, voiding cystogram,
cystoscopy, IVP
Dept. Preventive & Social Med. Siriraj Hospital
Urinary Tract Infection in the Elderly
A Clinical Study
Community-acquired : nosocomial = 49 : 51 or 1 : 1
Catheter-related : noncatheter-related = 46 : 54 or 1: 1.17
Immobility prior to infection = 62.6%, 41.9% were catheter-related infection
Underlying disease: DM 41%, anemia 31% and HT 25%
Underlying with high mortality: ischemic heart dis. 70%, renal insufficiency 62.5%, stroke 50%
Mortality according to number of underlying diseases:
0% (nil), 25% (1), 38.2% (2), 51.9% (3) and 66.7% (4)
Assantachai P, et al. J Med Assoc Thai 1997; 80: 753.
Dept. Preventive & Social Med. Siriraj Hospital
Laboratory results:
anemia 80%(male), 63.5%(female)
leucocytosis 69.8%
neutrophilia 74.1%
pyuria 79.4%
correct gram stain 81.8%
hyponatremia 35.9%
hypoalbuminemia 38.2%
mortality rate among medical complications : nosocomial
infection 88.89%, congestive heart failure 69.23%,
hyperglycemic hyperosmolar coma 16.67%
Urinary Tract Infection in the Elderly A Clinical Study
Dept. Preventive & Social Med. Siriraj Hospital
E. coli was the most common isolated organism both in urine & blood
clinical manifestation found more prevalent in the dead group statistically significant :
aged > 75, immobility, catheter-related, confusion, poor intake, respiratory failure, septic shock, presence of candida in urine and extreme body temperature response.
Urinary Tract Infection in the Elderly
A Clinical Study
Dept. Preventive & Social Med. Siriraj Hospital
Independent predictors of outcome
anorexia with nasogastric tube feeding
prior bedbound status
need of mechanical ventilation
septic shock
extreme body temperature response either
less than 37 oc or more than 40 oc
Urinary Tract Infection in the Elderly
A Clinical Study
Dept. Preventive & Social Med. Siriraj Hospital
Asymptomatic bacteriuria
Women: 5-10% in aged > 60, 20-30% in aged >80
Men : 5-10% aged > 70 Abrutyn et al JAGS1991;39:388.
E.coli - most common, Proteus mirabilis, Klebsiella pneumoniae,
gram+ve coci in men
> 90% has pyuria but nonspecific (30% of control)
Rodgers et al. Can J Infect Dis 1991; 2: 142-6.
No causal relationship of asymptomatic bacteriuria and mortality.
Nordenstam et al. NEJM 1986; 314: 1152.
No benefit from treatment of asymptomatic bacteriuria !!
Abrutyn et al. Ann Intern Med 1994; 120: 827.
Dept. Preventive & Social Med. Siriraj Hospital
Pneumonia in the Elderly
Most common cause of death in aged >80
“…physical signs are ill-defined and changeable”
Sir William Osler 1892
less chill, cough, temperature, only tachypnea
55% adequate sputum with yielding 38%
more to be unknown cause 48% vs. 11%
Dept. Preventive & Social Med. Siriraj Hospital
Pneumonia in the Elderly
Reduced body reserve:
less FEV, FVC, uneven V/Q
poor gag reflex
inadequate cough
esophageal dysmotility
less conscious level
Risk factor: silent aspiration, instrumentation,
underlying diseases, prolonged admission
Dept. Preventive & Social Med. Siriraj Hospital
Pneumonia in the Elderly
Pathogenesis:
Aspiration of oropharyngeal pathogen
Community: S. pneumoniae, H. influenza,
S. aureus, gram-ve bacilli
Nosocomial: mixed flora of gr-ve bacilli,
anaerobes
Dept. Preventive & Social Med. Siriraj Hospital
Pneumonia in the Elderly
Chest x-ray: ranges from normal to alveolar infiltration, wait for 48 hours
1/3 WBC count < 10,000
1/4 PMN count < 80%
High mortality: 25 - 48% vs. 10%
Dept. Preventive & Social Med. Siriraj Hospital
Nosocomial Pneumonia in the Elderly
Risk factors for development
acute setting long-term setting
i age i frailty
i frailty, function i recent weight loss
i altered conscious level i altered conscious level
i neurological diseas i aspiration
i aspiration i nasogastric tube
i nasogastric tube i inhalation therapy
Dept. Preventive & Social Med. Siriraj Hospital
Pneumonia in the Elderly
Potential causes of failed clinical resolution
atypical infection: TB, atypical mycobacterium
recurrent aspiration
bronchial obstruction: foreign body, carcinoma
pulmonary embolic disease
drugs : amiodarone pneumonitis
malignancy: lymphoma, broncho-alveolar
carcinoma
Dept. Preventive & Social Med. Siriraj Hospital
Pneumonia Prevention in the Elderly
aseptic technique
airway care, mouth care
postural drainage
early ambulation
upright position after feeding
avoid sedatives
avoid abdominal distention : too much feeding
at least 2 hr. !!
Dept. Preventive & Social Med. Siriraj Hospital
Tuberculosis in the elderly
Under control before HIV era due to
effective anti TB drugs
public health, nutrition, standard of living
However, it is still common among the ELDERLY
Atypical presentation : breathless but less
hemoptysis, less fever high degree of suspicion
adverse drug reaction
Dept. Preventive & Social Med. Siriraj Hospital
Tuberculosis in the elderly
Pathogenesis: 90% post primary or reactivated from
Ghon complex, 85% at pulmonary MMWR Morb Mortal Wkly Rep 1999; 48: 1-13.
Host
age-related immune dysfunction
underlying illness: smoker, drinker, DM, CA,
malnutrition, corticosteroids
chronic institutionalization
75% lung, Others: miliary, meningitis, skeletal, GU.
Dept. Preventive & Social Med. Siriraj Hospital
Tuberculosis in the elderly Atypical presentation: Yoshikawa Infect Dis Clin Pract 1994; 3: 62-6.
more breathless but less hemoptysis (less cavitation:
Rassmusen’s aneurysm), less fever
poor activity of daily living
chronic fatigue
cognitive impairment (easily misdiagnosed as
dementia, delirium)
anorexia
unexplained low grade fever
Dept. Preventive & Social Med. Siriraj Hospital
Tuberculosis in the elderly-Ix
Chest x-rays: can be any finding
Differential diagnosis
: malignancy, pneumonia
: infiltration in middle or lower lobes
Perez-Guzman et al Chest 1999; 116: 961.
: less cavity due to ↓ cell-mediated immune function
: comparison with previous chest film
Dept. Preventive & Social Med. Siriraj Hospital
Infectious Control in Nursing Homes
1. Host factors
susceptibility to infections : resident’s flora
(esp.resistant pathogen : MRSA, VRE)
diagnostic uncertainty
frequent care transitions : use of antibiotics
2. Structural concerns
3. Care process factor
Dept. Preventive & Social Med. Siriraj Hospital
Infectious Control in Nursing Homes
1. Host factors
2. Structural concerns
Resource limitation
Suboptimal full-time equivalents for registered nurse,
nursing aids, high caregiver turnover
Limited availability of information system & lab.
3. Care process factor
Dept. Preventive & Social Med. Siriraj Hospital
Infectious Control in Nursing Homes
1. Host factors
2. Structural concerns
3. Care process factor Variable staff education: less skilful aids (immigrant !)
Availability & use of diagnostic specimens
Use of quality improvement tools : database, quality indicators, minimum dataset.
Dept. Preventive & Social Med. Siriraj Hospital
Roles of Infection Control Practitioner
1. Surveillance : high index of suspicious mind
2. Outbreak control
3. Isolation precautions
4. Hand hygiene
5. Antibiotic resistance
6. Staff education (such as this educational course)
7. Resident health check-up program
8. Employee health check-up program
9. Rehabilitation services infection control
Dept. Preventive & Social Med. Siriraj Hospital
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