Clinical Relevance 1
Urinary infection is an important problem in elderly populations. As with any clinical problem in this group, the significance and manifestations vary depending on the characteristics of the population. Thus, urinary infection needs to be considered within a continuum from the ambulant, well elderly in the community to the highly functionally disabled long-term care facility resident. There are also special considerations for elderly subjects with long-term indwelling catheters. The kidney,...
Essential Elements Of An Infection Control Program
Each nursing facility should have an infection control program in accordance with state or national regulations and guidelines. Infection control programs in the long-term care setting are required by the Omnibus Budget Reconciliation Act of 1987 OBRA for skilled-care facilities, the Health Care Financing Administration HCFA for Medicare or Medicaid patients, the Occupational Safety and Health Administration OSHA for blood-borne pathogens and tuberculosis exposures, and the Joint Commission on...
VIRAL HEPATITIS 21 Hepatitis A
Hepatitis A HAV is an RNA virus in the picornavirus family see Table 2 . The virus is easily transmitted by the fecal-oral route. In countries where the virus is endemic and sanitation is poor, most people become infected in early childhood when the disease is mild and life-long immunity results 59 . Recently, a shift in the prevalence of cases from childhood to adulthood has occurred, presumably due to improved living conditions. In the United States and other industrialized nations, the...
Bronchitis
Several advances have occurred in our knowledge of the natural history and management of bronchitis. The first step has been a classification of patients with chronic bronchitis into four groups see Table 1 1 . Chronic bronchitis is a syndrome defined by cough and production of sputum on most days for at least 3 months a year for 2 consecutive years 2 . It is often complicated by airway obstruction leading to the commonly used term chronic obstructive pulmonary disease COPD . Acute bronchitis...
Prevention Aev
For both caries prevention and treatment of periodontitis in the elderly, the long-term goal must continue to be active promotion of oral hygiene and more ready accessibility to dental care and restorative prosthodontic treatment programs. Underlying diseases such as diabetes mellitus and conditions that predispose to salivary gland hypofunction should be rigorously treated. Medications that cause xerostomia or gingival hyperplasia should be avoided. Saliva substitutes, noncariogenic lozenges...
Therapy
Asymptomatic urinary infection in elderly populations should not be treated. Prospective, randomized, comparative trials of therapy compared with no therapy for the treatment of asymptomatic infection in institutionalized men or women have not docu mented improvements in morbidity or mortality with treatment 4,5,12 . For long-term care residents with chronic incontinence and bacteriuria, antimicrobial treatment of urinary infection does not improve continence 16 . Attempts to treat asymptomatic...
Clinical Manifestations Phj
The usual symptoms and signs of meningitis include fever, headache, alteration of sensorium, photophobia, and neck stiffness. In major reviews of these findings in the older adult, however, fever was noted in less than 60 in one study and nuchal rigidity was found in less than 60 in another see Table 2 4,6,12 . Similarly, the classical, discriminating signs of meningitis may not be entirely specific since a significant percentage of older adults may have nuchal rigidity or other signs usually...
Resistance In Grampositive Bacteria
2.1. fi-Lactam-Resistant Staphylococci Penicillin resistance in staphylococci dates back to the 1950s 24 . Hence, it is now rare to find staphylococci susceptible to penicillin. Despite its prevalence, the ubiquitous nature of penicillin resistance in staphylococci should not be accepted with complacency. The staphylococcal penicillinase PC1 is an inducible -lactamase exo-enzyme. Four variants A-D exist. The staphylococcal penicillinase genes are carried on plasmids and transposons and can be...
References
1. Bone, R.C., Fisher, C.J., Clemmer, T.P., et al. 1989 Sepsis syndrome a valid clinical entity. Crit. Care Med. 17, 389-393. 2. Bone, R.C., Balk, R.A., Cerra, F.B., et al. 1992 American College of Chest Physicians Society of Critical Care Medicine Consensus Conference definitions for sepsis and multiple-organ failure and guidelines for the use of innovative therapies in sepsis. Chest 101, 1644-1655. 3. Rangel-Frausto, M.S., Pittet, D., Costigan, M., et al. 1996 The natural history of the...
Clinical Relevance And Epidemiology
Sexually transmitted diseases STDs are not perceived by most health care practitioners as a significant problem for older adults over age 50 in the United States. In fact, many practitioners do not view older adults as even being sexually active, much less at risk for STDs. Aging, intercurrent illnesses, and psychosocial factors often have significant impact on sexual function or the enjoyment of sex in the elderly. Psychosocial factors, such as attitudes toward sexual behavior, reaction to...
Treatment And Prevention
The CDC in conjunction with the American Thoracic Society in 1994 modified its TB treatment recommendations because of the rise of MDR-TB cases see Table 1 30 . However, the CDC also recommends that if the frequency of isoniazid resistance is 4 or less in a given community or if the population in question has a low risk for drug resistance, the empiric four-drug regimen is not necessary. Although there has been much concern over the emergence of drug-resistant isolates of Mtb and the complex...
Erysipelascellulitis
Erysipelas and cellulitis are acute spreading infections of the skin, usually involving large confluent areas and accompanied by systemic toxicity. Erysipelas is a superficial skin infection involving the cutaneous lymphatic vessels, caused most commonly by group A streptococci and occasionally by group C or G streptococci. Erysipelas most often involves the face, has a characteristic, well-demarcated appearance with raised margins, and is accompanied by systemic symptoms of fever and chills....
References Jgk
1. Magaziner, J., Tenney, J. H., DeForge, B., et al. 1991 Prevalence and characteristics of nursing home acquired infections in the aged. J. Am. Geriatr. Soc. 39, 1071-1078. 2. Kauffman, C. A., Terpenning, M. S., He, X., et al. 1993 Attempts to eradicate methicil-lin-resistant Staphylococcus aureus from a long-term care facility with the use of mupirocin ointment. Am. J. Med. 94, 371-378. 3. Baddour, L. M. and Bisno, A. L. 1984 Recurrent cellulitis after coronary artery bypass surgery. JAMA....
DIAGNOSTIC TESTS 31 Urine Culture
A positive urine culture is necessary for a microbiologic diagnosis of urinary infection. A urine specimen for culture should be obtained whenever a diagnosis of symptomatic urinary infection is considered. This specimen will not only confirm the presence of bacteriuria, but also identify the infecting organism and antimicrobial susceptibilities so antimicrobial therapy may be optimized. In every case, the urine specimen should be collected prior to the institution of antimicrobial therapy to...
Pacemaker Infections
6.1. Epidemiology and Clinical Relevance A pacemaker consists of essentially two components. The pulse generator is the power source that is used to deliver the electrical stimulus. This is linked to a pacing electrode, either an endocardial or epicardial lead. Elderly patients seem to be especially prone to pacemaker infections. The average age of patients with pacemaker endocarditis is 72 yr. Pacemaker infections may appear as either a localized infection and or abscess in the pulse-generator...
Pulmonary TB
Pulmonary TB is by far the commonest form of TB in the elderly population 9 . Although aging patients with pulmonary TB can present with typical respiratory as well as systemic symptoms, i.e., sputum production, hemoptysis, fever, night sweats, weight loss, or anorexia, a significant number of such patients may exhibit minimal pulmonary symptoms. The radiographic manifestations and variations of pulmonary TB in older persons are briefly described in the Subheading 5. Miliary or disseminated TB...
Charles W Flowers Jr and Richard S Baker
Age-related degenerative ocular and adnexal changes predispose the elderly to eye infections. The reduction in host defenses associated with age-related degenerative changes significantly compromises the capacity of eyes of elderly people to withstand prolonged exposure to microbial pathogens. Consequently, the elderly tend to have higher rates of eye infection and poorer treatment outcomes. The poorer treatment outcomes are, in part, due to delays in diagnosis as well as delays in...
Epidemiology And Clinical Relevance Hyj
Orofacial and odontogenic infections are diverse in etiology and clinical presentation. Elderly patients are particularly at risk because of poor oral health and relatively high prevalence of dental caries and periodontal disease. Such infections in the elderly may be localized and indolent, or invasive and life-threatening. Patients with systemic underlying diseases such as diabetes mellitus are also prone to more serious infections. The increasing need for valvular and joint replacements in...
Necrotizing Skin And Softtissue Infections
Necrotizing soft-tissue infections are a group of severe, rapidly progressing, often life-threatening infections characterized by extensive tissue damage, sometimes with gas production and frequently progressing to gangrene 12 see Table 3 . Most of these Clostridial myonecrosis Non-clostridial crepitant cellulitis Peptostreptococci, Bacteroides spp., Enterobacteriaceae Local trauma, surgery Diabetes mellitus Group A streptococci, Mixed Enterobacteriaceae and anaerobes Minor trauma, abdominal...
References Ptw
1. Nicolle, L. E. and Garibaldi, R. A. 1995 Infection control in long-term-care facilities. Infect. Control Hosp. Epidemiol. 16, 348-353. 2. Nicolle, L. E., Strausbaugh, L. J., and Garibaldi, R. A. 1996 Infections and antibiotic resistance in nursing facilities. Clin. Microbiol. Rev. 9, 1-17. 3. Jackson, M. M. and Fierer, J. 1984 Infections and infection risk in residents of long-term care facilities a review of the literature, 1970-1984. Am. J. Infect. Control 13, 63-77. 4. Smith, P. W. and...
CLINICAL MANIFESTATIONS 21 Orofacial Infections
The oral cavity of older adults, especially immunocompromised persons, are susceptible to a variety of bacterial, fungal, and viral infections. The lesions are often of protracted duration, and may not be associated with a clinically significant inflammatory reaction. Palpation and percussion of the oral structures are critical as tenderness may be the only abnormal finding. 2.1.1. Vesiculobullous Gingivostomatitis and Aphthous Ulcers Vesiculobullous lesions of the oral mucosa and perioral...
Cholecystitis
2.1. Epidemiology and Clinical Relevance The most common cause for surgical intraabdominal infections in the elderly is acute cholecystitis, and the number of cholecystectomies in the elderly is increasing 6 . The incidence of this disease is higher in the female. However, the female-to-male ratio lowers from 3 1 in younger adults to 1.5 1 in patients older than 50. Cholelithiasis accounts for 95 of acute cholecystitis, with the other 5 termed acalculous cholecystitis. The incidence of...
Septic Arthritis
In the elderly, acute joint pain and swelling is much more likely to be caused by crystal-induced arthritis than septic arthritis the consequences of joint infection, however, are so serious that the possibility of infection requires a targeted diagnostic evaluation to exclude septic arthritis in most patients with acute joint pain. Immediate antibiotic treatment is necessary loss of cartilage and erosion of subchondral bone from invasion of the cartilage by bacteria and inflammatory cells,...
Appendicitis In The Elderly
3.1. Epidemiology and Clinical Relevance Appendicitis in the elderly is associated with a higher mortality rate, approximately 10 in patients 70 and older, when compared with the general population 13,14 . Although the incidence is more common in the second and third decade of life, appendicitis still accounts for 15 of all surgical emergencies in the elderly 15 . Prompt diagnosis, followed by definitive surgical treatment, reduces morbidity and mortality in this age group. The diagnosis of...
Eyelid Infections
1.1. Epidemiology and Clinical Relevance Inflammatory disorders of the eyelid constitute a major class of external eye infections affecting the elderly. The eyelid, particularly the lid margin, is a common site of ocular adnexal infection in the elderly. Staphylococcal blepharitis is by far the most common lid infection encountered. As with other forms of blepharitis, staphylococcal blepharitis is a chronic condition that has periodic exacerbations, which often leads the patient to seek medical...
Principles of Antimicrobial Therapy
From the first three chapters of this book, it is quite apparent that with aging comes a substantial susceptibility to and incidence of serious infections, as well as an increased risk of complications from these infections, including death. Moreover, subsequent chapters of this book describe in detail the most important and serious infectious disease problems of elderly people, and how these infections should be diagnosed and treated. In this chapter, the discussion focuses on general...
Conjunctival Infections
3.1. Epidemiology and Clinical Relevance Infectious conjunctivitis is primarily caused by bacteria and viruses, with viruses being the more common offending agent in the United States. Bacterial conjunctivitis may be classified as hyperacute, acute, or chronic depending on the rapidity of onset and disease progression. Hyperacute bacterial conjunctivitis is characterized by a very rapid onset a matter of hours , copious purulent discharge, and intense conjunctival swelling and redness. This...
Prevention Of Endocarditis
In the area of prevention, there is a very extensive literature and a continuing evaluation of the necessity of prophylaxis against infective endocarditis in patients with various valvular or endocardial lesions. Tables 4 and 5 show the latest American Heart Association guidelines for prophylaxis of infective endocarditis 18 . Note that post-procedure antibiotics are no longer recommended. These prophylaxis guidelines are not meant to apply to all oral-dental procedures but to procedures that...
Otitis Externa
1.1. Epidemiology and Clinical Relevance Otitis externa, an inflammatory condition involving the superficial layer of the external auditory canal, may be acute or chronic. Acute otitis externa in the elderly is generally a benign disorder, which may be localized or generalized. Chronic otitis externa is caused by the irritation due to the drainage from the middle ear in patients with chronic suppurative otitis media. An uncommon form of external otitis called malignant otitis externa is an...
Bowel Obstruction In The Elderly
Causes of bowel obstruction usually specific to the elderly include sigmoid volvulus, Ogilvie's Syndrome, colon carcinoma, and gallstone ileus. These conditions in the elderly patient can lead to gangrene with resulting perforation. Sigmoid volvulus is 20 times more likely in the patient age 60 yr and greater 19 . This age association may be due to acquired redundancy of the sigmoid colon. High-residue diets are believed to be the causative factor in developing a redundant sigmoid 20 . Other...
Orbital Infections
7.1.1. Epidemiology and Clinical Relevance Preseptal cellulitis represents a superficial cellulitis of the eyelid skin and subcutaneous tissue. This infection can arise from one of three sources paranasal sinus infections, direct extension from a localized infection of the eyelid or adjacent tissues i.e., acute dacryocystitis or hordeola , and periorbital trauma i.e., infected cuts or abrasions to the periorbital facial area . This infectious process is confined to the lid because the orbital...
Sinusitis
3.1. Epidemiology and Clinical Relevance It is estimated that sinusitis affects 16 of the United States population annually, leading to approx 16 million office visits and a yearly expenditure of approx 2 billion dollars on its medical therapy 29 . Sinusitis, an infection of one or more of the paranasal sinuses, usually begins as a complication of viral upper respiratory tract infection in the elderly population. Obstruction of sinus drainage and retention of secretions are the fundamental...
Corneal Infections
5.1.1. Epidemiology and Clinical Relevance Infectious keratitis constitutes a sight-threatening ocular emergency and requires prompt recognition and immediate referral to an ophthalmologist. Bacterial keratitis results from a breakdown in the corneal epithelial barrier and subsequent bacterial invasion of the corneal stroma. Bacterial invasion and white cell infiltration of the cornea leads to tissue destruction and may even lead to perforation if therapy is not instituted in a timely manner....
Vaginitis
Vaginal complaints are a common reason for women of all ages to visit their physician, with an estimated 3.2 million initial visits to physicians offices for this population in 1997 8 . Decreased estrogen production in the postmenopausal woman causes a number of changes in the vagina, which can lead to a variety of symptoms 21 . The amount of glycogen in the epithelial cells diminishes, leading to a reduction in the lactobacilli population that help to protect the vagina from other bacteria by...
Shunt Infections
1.1. Epidemiology and Clinical Relevance The most common indication for central nervous system CNS shunts has been to divert fluid in patients with hydrocephalus. Another indication for insertion of a CNS prosthetic device is to monitor intracranial pressure in patients who have had a variety of cerebral insults. The prevalence of infection ranges from 1.5-15 . Shunt infections often lead to an extension of the hospital stay by 2-3 wk and often require additional surgery. Risk factors for shunt...
Endemic Mycoses
3.1. Epidemiology and Clinical Relevance As the population of the United States ages, and as older adults remain in better health for a longer period of time, they travel more extensively and indulge in a variety of different outdoor avocations that are associated with increased risk of infection from endemic mycoses 19 . Endemic mycoses are found in soil or vegetation each has its own ecological niche from which it is aerosolized and subsequently inhaled see Table 2 . Older persons may become...
Otitis Media
2.1. Epidemiology and Clinical Relevance Acute otitis media has been best studied in children in whom the disease is particularly common 20-23 . Few studies have addressed the epidemiology of middle ear infections in the elderly. In 1990, there were an estimated 24.5 million visits made to offices of physicians in the United States at which the principal diagnosis was otitis media 24 . The peak incidence occurs in the first three years of life and is increased in the absence of breastfeeding...
Herpes Simplex Virus Type Ii Hsv2
Genital herpes simplex virus HSV infection is not a reportable disease but is considered to be extremely common in the U.S. with approximately 45 million adults approx 22 of the population aged 15-74 yr estimated to be infected in 1990, based on the serologic results of a random sampling of civilian adults examined as part of the National Health and Nutrition Examination Survey NHANES III 12 . This represents a 32 increase compared to 1978, when the seroprevalence of HSV-2 was 16 among the...
Unique Clinical Considerations
TB in older patients is represents a diagnostic dilemma for many clinicians. The vast majority 75 of elderly persons infected with Mtb manifest active disease in their lungs 1,14 . In addition, disseminated or miliary TB, tuberculous meningitis, and skeletal TB increase in frequency with advancing age. However, many older patients with TB disease may not exhibit the classic features of TB, i.e., cough, hemoptysis, fever, night sweats, and weight loss. TB in this population may present...
References Fmx
1. Betts, R. 1995 Influenza, in Principles and Practices of Infectious Diseases Mandell, G. L., Bennett, J. F., and Dolin, R., eds. , Churchill Livingston, New York , pp. 1546-1567. 2. Cate, T. R. 1987 Clinical manifestations and consequences of influenza. Am. J. Med. 82, 15-19. 3. Glezen, W. P. and Couch, R. B. 1978 Interpandemic influenza in the Houston area, 1974-1976. N. Engl. J. Med. 298, 587-592. 4. Perrotta, D. M., Decker, M., and Glezen, W. P. 1985 Acute respiratory disease...
Gastroenteritis Viruses
Recent studies from the CDC have described increased morbidity and mortality associated with gastroenteritis in the elderly. Although deaths related to diarrhea have traditionally been thought to be a problem of young children in developing countries, 51 of the 28,538 diarrhea-related deaths in the United States from 1979-1987 occurred in adults over age 74 compared with 11 in children lt 5 yr old 74 . The odds ratio of dying during a hospitalization involving gastroenteritis was 52.6 for...
References Sbl
1. Irvine P. W., Van Buren N., and Krossley, K. 1984 Causes for hospitalization of nursing home residents the role of infection. J. Am. Geriatr. Soc. 32, 103-107. 2. Alvarez, S., Shell, C. G., Wooley, T. W., et al. 1988 Nosocomial infections in long-term care facilities. J. Gerontol. Med. Sci. 43, M9-17. 3. Norman, D. C., Castle, S. C., and Cantrell, M. 1987 Infections in the nursing home. J. Am. Geriatr. Soc. 35, 796-805. 4. Crossley, K., Henry, K., Irvine, P., et al. 1987 Antibiotic use in...
Jack D McCue
In comparison with lower respiratory tract, urinary tract, and skin and soft tissue infections, infections of bones and joints are relatively uncommon in the elderly, accounting for no more than a few percent of the infectious diseases treated by geriatricians. However, some bone and joint infections disproportionately afflict the elderly, such as osteomyelitis contiguous to pressure ulcers, septic arthritis of joints damaged by rheumatoid arthritis, or periprosthetic hip joint septic...
Sepsis
Jirayos Chintanadilok and Bradley S. Bender 1. EPIDEMIOLOGY AND CLINICAL RELEVANCE 1.1. Definitions Sepsis is the clinical syndrome denoting systemic inflammatory response to an infection. There is some confusion over the use of the terms bacteremia and septicemia. Most studies in the United States used the term bacteremia to denote a positive blood culture with evidence of infection. Septicemia was used to denote a state of microbial invasion from a portal of entry into the bloodstream that...
References Ged
1. Fedson, D. S., for the National Vaccine Advisory Committee 1994 Adult immunization summary of the National Vaccine Advisory Committee Report. JAMA 272, 1133-1137. 2. American College of Physicians Task Force on Adult Immunization Infectious Diseases Society of America 1994 Guide for Adult Immunization, 3rd ed., Philadelphia, PA, American College of Physicians. 3. Centers for Disease Control and Prevention 1999 Health Information for International Travel 1999-2000, U.S. Pubic Health Service,...
Retinal And Vitreous Infections
6.1.1. Epidemiology and Clinical Relevance Postoperative endophthalmitis is the most significant retinal-vitreal infection encountered among the geriatric population. Endophthalmitis is defined as inflammation of the intraocular contents and develops as a result of microbial pathogens or chemical toxins gaining intraocular access. Although several etiologic mechanisms exist for the development of this infection i.e., penetrating ocular trauma, or hematog-enous spread from another infectious...
Viral Conjunctivitis
4.1. Epidemiology and Clinical Relevance Adenovirus is by far the most common cause of viral conjunctivitis and tends to be the most virulent. Herpes simplex virus HSV usually type 1 primarily causes conjunctivitis in children and usually produces a mild inflammatory response. Other viral pathogens, which can cause viral conjunctivitis in the elderly, include enterovirus, coxsackievirus, and varicella-zoster. Viral conjunctivitis classically produces a clear watery discharge, a follicular...
Gonorrhea
Gonorrhea GC can infect not only the urethra and cervix, but the rectum, pharynx, and eye as well, and may disseminate to cause arthritis and or dermatitis. Reported cases of gonorrhea in adults aged 55 and over account for approximately 1 of the nationwide total. Whereas the national rates of gonorrhea have fallen dramatically since the mid-1970s, there was a stabilization of rates between 1996 and 1997 in fact, rates in adults aged 55 and over actually increased in 1997 from 9.1-9.5 100,000...
Primary Pyodermas
Superficial skin infections, also called primary pyodermas, are the most common skin infections occurring in all age groups. These include impetigo, folliculitis, furuncles, carbuncles, and paronychia. Most of these infections are caused by group A streptococci or by Staphylococcus aureus. Pseudomonas aeruginosa is a cause of hot tub folliculitis, an infection associated with recreational use of contaminated whirlpools and hot tubs resulting in a self-limited pruritic papular eruption in a...
Chlamydia
Chlamydia infection was the most common reportable communicable disease in the U.S. in 1998, with almost 540,000 cases reported 16 . Chlamydia trachomatis is an infection predominantly of adolescents, with the highest rate of infection being in the 15-19 and 20-24 yr age groups. The prevalence of infection drops off greatly after age 35, with adults over age 55 accounting for less than 1 of the nationwide cases. The number of Chlamydia infections nationwide is increasing, possibly due to...