Infection Control for Elderlybamras.ddc.moph.go.th/userfiles/Infectious control.pdf · 2018-03-29 · Infection Control for the Elderly ... TB, atypical ... postural drainage

Dept. Preventive & Social Med. Siriraj Hospital

Infection Control for the Elderly

ศ.นพ. ประเสริฐ อัสสันตชัย

สาขาวิชาเวชศาสตร์ผู้สูงอายุ

ภาควิชาเวชศาสตร์ป้องกันและสังคม

คณะแพทยศาสตร์ศริิราชพยาบาล


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


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


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


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


Polymorphonuclear leucocyte

Number, adherence to epithelial surface,

chemotactic and random migration

all no changes

Rate of migration into skin abrasion


Local defense mechanism

Abnormal gag response

Incontinence

Immobility

Respiratory excursion





& mortality



Atypical presentation : geriatric syndrome,

absence of fever, nonspecific presentation


Polypharmacy

Social adversity


อาการแสดงที่ไม่แน่นอน__โรคชรา ?

ภาวะหกล้ม Instability (Fall)

สูญเสียความสามารถในการเดิน Immobility

สติปัญญาเสื่อมถอย Intellectual impairment

ปัสสาวะอุจจาระราด Incontinence

เบื่ออาหาร Inanition

เกิดภาวะแทรกซ้อนได้ง่าย Iatrogenesis


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





& mortality






Polypharmacy

Social adversity


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





& mortality






Polypharmacy

Social adversity


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


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


SEPTICEMIA IN THE ELDERLY

Epidemiologic point:

increased frail elderly

more invasive intervention

increased gram negative organism

increased morbidity & mortality



Clinical:

geriatric giants “5 I’s”

fever, tachycardia, tachypnea, hypotension

unreliable local signs

hypoalbuminemia, hyponatremia,

no leucocytosis



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.


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



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.



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%



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


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.


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


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.


A Clinical Study


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


A Clinical Study


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.


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%



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



Pathogenesis:

Aspiration of oropharyngeal pathogen

Community: S. pneumoniae, H. influenza,

S. aureus, gram-ve bacilli

Nosocomial: mixed flora of gr-ve bacilli,

anaerobes



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%


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



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


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. !!


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


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.


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


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


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



1. Host factors


Resource limitation

Suboptimal full-time equivalents for registered nurse,

nursing aids, high caregiver turnover

Limited availability of information system & lab.

3. Care process factor



1. Host factors


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.


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


ขอขอบคุณทุกท่าน ที่ให้ความเอื้ออาทรต่อผู้สูงอายุนะ

Documents

Infection Control for Elderlybamras.ddc.moph.go.th/userfiles/Infectious control.pdf · 2018-03-29 · Infection Control for the Elderly ... TB, atypical ... postural drainage