Editors

JoukoLaurila

Infections in Old Age

Essentials

Changes related to ageing make people susceptible to infections and complicate diagnosis.
- Diminished cell-mediated immunity and partly also humoral immunity
- Long-term diseases, age-related physiological changes and many medications
Typical symptoms of infections (such as fever) are often absent or are non-specific (e.g. difficulty walking, confusion). Even a mild infection may cause some organ decompensation.

Pneumonia

Predisposing factors for pneumonia Pneumonia in old age include impaired cough reflex, impaired functioning of the pharynx, obstructive pulmonary diseases, immobilization and heart failure.
The temperature of a patient with pneumonia may be normal and cough may be completely absent. Pneumonia may manifest as impaired general condition and functioning, confusion, or chest pain.
Drug therapy
- The most common causative agent is Streptococcus pneumoniae (pneumococci), and the first-line antimicrobial drug for this in outpatients is amoxicillin http://www.dynamed.com/condition/community-acquired-pneumonia-in-adults#ANTIBIOTICS_FOR_ADULT_OUTPATIENTS and in hospitalised patients cefuroxime or penicillin G http://www.dynamed.com/condition/community-acquired-pneumonia-in-adults#ANTIBIOTICS_FOR_ADULT_INPATIENTS.
- During an influenza epidemic secondary bacterial pneumonia, often caused by staphylococci, is common. In this case cefuroxime is a justifiable antimicrobial choice.
- The length of treatment for pneumonia is usually 10 days.
Preventing pneumonia by yearly influenza vaccination http://www.dynamed.com/prevention/seasonal-influenza-vaccination#TOPIC_CRL_3LM_CNB is worthwhile Vaccines for Preventing Influenza in the Elderly. The same applies to pneumococcal vaccine http://www.dynamed.com/prevention/pneumococcal-vaccination#EFFICACY_OF_PNEUMOCOCCAL_VACCINE_IN_ADULTS, which has also been shown to be effective in the elderly population Vaccines for Preventing Pneumococcal Infection in Adults.
In prolonged lung infection, the possibility of malignancy as well as of tuberculosis should be kept in mind (Mycobacterium tuberculosis, nucleic acid detection).

Urinary tract infections and pyelonephritis

Women are predisposed to urinary tract infections Urinary Tract Infections because of factors such as age-related atrophy of the mucosa or prolapses, men because of prostate hyperplasia. The most important external factor predisposing for urinary tract infection is cathetrization. An indwelling catheter should always be removed as soon as possible.
The cause of recurrent infections should be defined and treated.
- Prophylactic pharmacotherapy should be avoided. In exceptional cases it can be considered for a specific period with, e.g., trimethoprim as single dose at night for 6-12 weeks. Nitrofurantoin and quinolones are not used for prophylactic treatment.
- Use of cranberry juice is probably beneficial.
- Strengthening of the mucosal membranes with local oestrogen (oestriol, oestradiol) is often effective Vaginal Oestrogens for Preventing Recurrent Urinary Tract Infection in Postmenopausal Women.
Treatment should always be based on symptoms and a bacterial culture of an appropriately collected sample. Treatment should not be started only on the basis of a smell combined with suspicion of an infection.
Symptomless bacteriuria of the elderly is common and should not be treated without some specific (dysuria, frequency) symptoms suggestive of an infection. Symptomless bacteriuria should not be accepted as the reason for the patient's weakened general condition either.
Drug therapy
- In the elderly, single dose antimicrobial treatment is less effective than courses lasting for more than 3 days Antibiotic Duration for Lower Urinary Tract Infections in Elderly Women http://www.dynamed.com/condition/uncomplicated-urinary-tract-infection-uti-pyelonephritis-and-cystitis#DURATION_OF_ANTIBIOTICS
- Cefuroxime intravenously is the first-line management of pyelonephritis. When the temperature normalizes or when the general condition improves, oral medication based on sensitivity testing may be substituted for the i.v. drug. The length of treatment is at least 10 days http://www.dynamed.com/condition/uncomplicated-urinary-tract-infection-uti-pyelonephritis-and-cystitis#ANTIBIOTIC_SELECTION_FOR_ACUTE_PYELONEPHRITIS.
Patients with an indwelling catheter should not be given prophylactic medication, and taking follow-up samples from the catheter is not worthwhile. Chronic bacteriuria (e.g. Pseudomonas) is common among elderly people wearing catheters, and it should only be treated if there are general symptoms http://www.dynamed.com/condition/catheter-associated-urinary-tract-infection-cauti#TREATMENT_OVERVIEW.

Gastrointestinal and intra-abdominal infections

Because the sense of visceral pain decreases with ageing, acute appendicitis and cholecystitis, for example, may be difficult to diagnose. They may silently lead to perforation or acute abdominal catastrophe.
Diverticulosis and diverticulitis are most often age-related diseases.
Plasma CRP and blood leukocyte count, repeated clinical examination and exclusion of infections affecting other organs and eventually abdominal CT scan help to reach the correct diagnosis.

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Information

Editors

Infections in Old Age

Essentials

Pneumonia

Urinary tract infections and pyelonephritis

Gastrointestinal and intra-abdominal infections