ASK THE ID SPECIALIST

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1 ASK THE ID SPECIALIST Raymond E. Pontzer, MD, FACP Chief, Infectious Diseases UPMC St. Margaret Hospital Interim Medical Director of Infection Prevention for UPMC

2 I have no conflict of interest with any of the material included in this presentation.

3 COMMON INFECTIONS IN THE ELDERLY Primary cause of death > 65 y.o. 90% of pneumonia mortalities occur in elderly Elderly have three times the mortality from pneumonia and ten times the mortality from urinary tract infections Moulton, CP, et al. Am Fam Physician 2001; 63: 257 Caterino, JM. Emerg Clin N Am 2008; 26: 319

4 COMMON INFECTIONS IN THE ELDERLY Multiple biological, societal and cultural factors account for increased susceptibility to infection These factors also can alter the presentation of infections in the elderly Treatment regimens also often must be altered due to underlying factors, such as decreased renal function, drug metabolism or drug-drug interaction

5 FACTORS CONTRIBUTING TO INCREASED INFECTION RISK IN THE ELDERLY Alterations in barriers posed by skin, lung and GI tract Weakened immune system -- Immunosenescence Diminished humoral immunity Slowed proliferative capacity of immune cells Decreased cytokine production Decreased antibody response to vaccines Impaired immune function is also compromised further by the presence of comorbid medical conditions. This is more important than chronological age Castle, SC, et al. Clin Geriatr Med 2007; 23: 463

6 COMMON INFECTIONS IN THE ELDERLY EFFECTS OF INSTITUTIONALIZATION Senior day care, assisted living centers and SNF s increase risk for infection Also increase risk for developing infection with MDRO s, including MRSA, VRE and multidrug-resistant GNR,s There is a high incidence of quinolone-resistance in SNF s Indwelling devices increase risk for infection O Fallion, E. Et al. Infect Control Hosp Epidemiol 2009; 30: 1172

7 COMMON INFECTIONS IN THE ELDERLY EFFECTS OF INSTITUTIONALIZATION ABX use in chronic care facilities 8-17% taking antibiotic Rx at any given time 50-70% prescribed antibiotic Rx during any given year 22-89% of antibiotic use was inappropriate Peron EP, et al. J Am Geriatr Soc 2013; 61: 289

8 COMMON INFECTIONS IN THE ELDERLY ANTIBIOTIC STEWARDSHIP IN LONG TERM CARE Avoid treatment of asymptomatic bacteriuria Avoid unnecessary treatment in end-of-life situations Focus on giving shortest effective treatment regimen Remove any unnecessary invasive device PICC s Foley catheters Peron, EP, et al. J Am Geriatr Soc 2013; 61: 289

9 COMMON INFECTIONS IN THE ELDERLY PRESENTATION OF DISEASE Frequently present with atypical signs/symptoms Generalized malaise Falls Depressed mental status Fever and leukocytosis may be absent Frequently present with nonspecific decline in baseline function These findings can also be due to other causes than infection dehydration, mind-altering meds

10 COMMON INFECTIONS IN THE ELDERLY ANTIBIOTIC MANAGEMENT Be cognizant that creatinine clearance is decreased Metabolism may be slowed There may be other meds that pose hazard for drug-drug interaction Start with doses significant enough to quickly establish therapeutic serum/tissue levels The rule start low, go slow is not appropriate with antibiotic treatment Whenever possible, monitor drug levels Always narrow antibiotic spectrum when possible Decreases probability for development of C. difficile colitis and MDRO colonization/infection

11 CASE #1 72 yo male rehabilitation inpatient develops abrupt onset of fever (38.9C), chills and lethargy. Recent PMH significant for right hip fracture complicated by pulmonary embolism. PMH also includes hypertension, BPH and dyslipidemia. Exam pertinent for T, HR 108, RR 24, BP 110/74. Lungs are clear and cardiac regular with soft systolic murmur. Abdomen is soft & nontender. Foley catheter is present. Right hip wound is well approximated without drainage or erythema. There is a PICC at proximal left arm. Labs include creat 1.4, WBC 18,200, UA +2 leuk esterase, lactate 2.7 Blood cultures are positive for GPC in clusters in 2 of 2 sets. CXR without discreet infiltrate

12 CASE #1 What is the most likely etiology for this patient s sepsis syndrome? A. UTI B. Recurrent pulmonary embolus C. Infected PICC D. Right hip wound infection

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14 CLABSI Bloodstream infections (BSIs) are a major cause of healthcare-associated morbidity and mortality Up to 35% attributable mortality BSI leads to excess hospital length of stay of 24 days Central Line (CL) use a major risk factor for BSI More than 250,000 central line-associated BSIs (CLABSIs) in US yearly Rates of CLABSI appear to vary by type of catheter Pittet et al. JAMA 1994; Klevens et al. Public Health Reports 2007;122:160-6.

15 CLABSI PATHOGENESIS More Common Mechanisms 1. Pathogen migration along external surface - more common early (< 7days) 2. Hub contamination with intraluminal colonization -more common >10 days Less Common Mechanisms 1. Hematogenous seeding from another source 2. Contaminated infusates

16 CLABSI PREVENTION REMOVING UNNECESSARY CL In one study, 9% of CLs outside of ICU deemed inappropriate Perform daily assessment of the need for the CL and promptly discontinue CLs that are no longer required Nursing staff should be encouraged to notify physicians of CLs that are unnecessary Use peripheral catheters instead These generally have lower rates of BSIs than CL Trick et al. Infect Control Hospital Epidemiol 2004;25:266-8.

17 S. aureus Including MRSA IV CATHETER INFECTIONS MICROBIOLOGY Coagulase-negative staph majority are methicillin-resistant Gram negatives includes Pseudomonas aeruginosa Enterococcus sp. Yeast Corynebacteria

18 IV CATHETER INFECTIONS Obtain blood cultures from both existing line and peripheral blood (venipuncture). TREATMENT OPTIONS Start broad-spectrum empiric ABX Rx to include both MRSA and GNR s, including Pseudomonas. Also coverage for yeast may be indicated in certain circumstances (TPN, neutropenia, or recent/ongoing ABX Rx) Remove existing catheter No longer recommend culturing the tip

19 CASE #2 72 yo male rehabilitation inpatient develops abrupt onset of fever (38.9C), chills and lethargy. Recent PMH significant for right hip fracture complicated by pulmonary embolism. PMH also includes hypertension, BPH and dyslipidemia. Exam pertinent for T, HR 108, RR 24, BP 110/74. Lungs are clear and cardiac regular with soft systolic murmur. Abdomen is soft & nontender. Foley catheter is present. Right hip wound is well approximated without drainage or erythema. There is a PICC at proximal left arm. Labs include creat 1.4, WBC 18,200, UA +2 leuk esterase, lactate 2.7 Blood and urine cultures are positive for Morganella morganii CXR without discreet infiltrate

20 CASE #2 What is the most likely etiology for this patient s sepsis syndrome? A. UTI B. Recurrent pulmonary embolus C. Infected PICC D. Right hip wound infection

21 NOSOCOMIAL UTI 80-90% associated with catheters 10% following urologic procedure Scanning EM of bacterial biofilm within lumen of Foley catheter

22 CATHETER BACTERURIA ORGANISMS Providencia stuartii Proteus E. coli Pseudomonas Enterococcus Morganella Klebsiella S aureus incl MRSA Yeast Others

23 NOSOCOMIAL UTI TREATMENT OPTIONS Higher incidence of resistant pathogens 31% resistant to quinolones 12% resistant to advanced beta-lactams and carbapenems Suggest combination therapy for severely ill patients Betalactam + aminoglycoside Betalactam + quinolone Carbapenem where ESBL producer is suspected Avoid quinolone (cipro, levo) as empiric sole agent in view of high level of resistant organisms Fekete, T. Catheter-associated UTI s. UpToDate 2016

24 Maintain closed system CATHETER BACTERIURIA PREVENTION CAUTI IDSA GUIDELINES Minimize duration Use automated orders and nurse-driven protocols to remove catheters Avoid insertion Silver/antibiotic coated catheters may be beneficial in short-term catheterization Long-term antibiotic administration is not helpful Clin Inf Dis 2010; 50:

25 ACUTE CYSTITIS IN WOMEN Treatment for acute uncomplicated cystitis TMP/SMX 1 DS tablet bid x 3 days Nitrofurantoin 100 mg bid x 5 days Fosfomycin 3 gms po x 1 dose Alternative ampi/clav, cefpodoxime, cefdinir or cefaclor x 7 days Alternative quinolone (i.e. ciprofloxacin) x 3 days Nitrofurantoin and Fosfomycin not indicated for pyelonephritis Gupta K, et al. Clin Infect Dis 2011; 52: e103

26 NITROFURANTOIN Added to AGS Beers Criteria in 2015 as drug to use with care in elderly Has potential for pulmonary toxicity, hepatotoxicity and peripheral neuropathy esp. with long term use Avoid for long-term suppression Avoid in individuals with creat clearance < 30 ml/min American Geriatrics Society 2015 Updated Beers Criteria J. Am Geriatr Soc 2015; 63:

27 ACUTE CYSTITIS IN MEN Urologic evaluation appropriate for men with recurrent UTI Similar presentation can occur with urethritis or bacterial prostatitis Not necessary for young (age15-50) healthy men with no risk factors and no recurrence Cystitis treatment TMP/SMX and quinolones (cipro, levofloxacin) are preferred Rx Nitrofurantoin and fosfomycin not recommended in men Suggest 7 day duration Rx in absence of pyelonephritis or prostatitis 5 day duration sufficient when using quinolone Rx Persistent or recurrent symptoms warrant evaluation for prostatitis Peterson J, et al. Urology 2008: 71: 17

28 Urine cultures should be obtained More serious than cystitis, since can progress to sepsis ACUTE PYELONEPHRITIS MILD TO MODERATE Treatment recommendations for outpatients Ciprofloxacin 500 mg bid or levofloxacin 750 mg daily x 7 days Recognize potential for drug-drug interaction Possible QT prolongation Moxifloxacin is not recommended for UTI Alternate regimens include TMP/SMX for 7 to 10 days or po betalactam for 14 days preceded by IV ceftriaxone or aminoglycoside Avoid nitrofurantoin and fosfomycin Be sure to check final urine cultures to ascertain appropriateness of ABX Rx Gupta K, et al. Clin Infect Dis 2011; 52: e103

29 EFFECT OF QUINOLONES ON QT INTERVAL Oral Fluoroquinolones and Serious Arrhythmia Bi-national Cohort Study Examined population of Sweden and Denmark for incidence of serious arrhythmia during courses of therapy with quinolone versus penicillin > 900,000 courses in each group Ciprofloxacin dominated the quinolone group No statistical difference of serious arrhythmia 66 cases in quinolone and 78 cases in PCN group. Inghammar M et al. BMJ 2016;352:i843

30 ACUTE PYELONEPHRITIS INPATIENT Consider renal imaging (ultrasound or CT) to assess for urologic abnormality esp. in patients with bacteremia Initial treatment should be given intravenously Appropriate empiric agents include extended-spectrum cephalosporin or penicillin, carbapenem or aminoglycoside Quinolone OK for empiric treatment when local resistance rate is < 10% OK to transition to po treatment when there is clinical improvement and patient can tolerate oral fluids. Duration of treatment similar to patients with mild to moderate disease Clinical Infectious Diseases ; 2011 ; 52 : e103 -e120

31 IDSA GUIDELINES FOR DX AND RX OF ASYMPTOMATIC BACTERURIA IN ADULTS Population Prevalence, % Elderly persons in the community Women Men Elderly persons in a long-term care facility Women Men Patients with indwelling catheter use Short-term 9 23 Long-term 100

32 IDSA GUIDELINES FOR DX AND RX OF ASYMPTOMATIC BACTERURIA IN ADULTS Screening for treatment of ASB is not recommended for the following: Presence of pyuria Nonpregnant women Diabetic women Elderly persons, whether or not institutionalized Spinal cord injuries Catheterized patients Renal or other solid organ transplant Clinical Infectious Diseases 2005;40:643 54

33 ASYMPTOMATIC BACTERURIA IN ADULTS AND DEPRESSED MENTAL STATUS Patients in nursing homes are frequently evaluated for lethargy/stupor These patients frequently have ASB In the absence of fever and/or leukocytosis, depressed mental status is seldom due to UTI. Many other factors, including dehydration, medications and metabolic factors are common causes

34 ASYMPTOMATIC BACTERURIA IN ADULTS AND DEPRESSED MENTAL STATUS If your patient is afebrile and hemodynamically stable, recommend in most cases refrain from empiric antibiotic treatment for ASB

35 CASE #3 78 yo woman nursing home resident develops abrupt onset fever, lethargy and hypoxemic. PMH is significant for remote CVA, hypertension and 2 previous episodes of pneumonia over the past 18 months. She has a feeding gastrostomy tube because of dysphagia. Exam reveals lethargy and diaphoresis. Temp is 38.7C, RR 28, HR 96 and BP 110/72. Oral mucosa are dry, lungs with crackles at right base, irregular heart rate with 2/6 sys m. Abdomen is soft and nontender. No edema or calf tenderness. Labs: WBC 18,200, Creat 2.1, Lactate 3.5, UA +2 leuk esterase, WBC/hpf

36 CASE #3

37 ASPIRATION PNEUMONIA Most pneumonia arises following aspiration Pathogens that commonly produce pneumonia require only small inoculum True aspiration pneumonia refers to infection caused by less virulent bacteria, which are common constituents of the normal oral flora Mouth anaerobes and streptococci predominate in outpatients Multidrug-resistant organisms may be present in institutionalized patients

38 ASPIRATION PNEUMONIA TYPES Bacterial Chemical Lipoid Foreign body

39 ASPIRATION PNEUMONIA RISK FACTORS Neurologic disorders 72% hospitalized pts from SNF s with aspiration pneumonia had neurologic disorder causing dysphagia Reduced consciousness Esophageal disorders (including dysphagia and GERD) Vomiting Witnessed aspiration Taylor JK, et al. Am J Med 2013; 126: Sharaitzadeh M, et al. J Am Geriatr Soc 2006; 53: 296

40 ASPIRATION PNEUMONIA BACTERIAL Most common results from aspiration of contents containing oral/gi bacteria. Primary pathogens include oral anaerobes and streptococci Include Peptostreptococcus, Fusobacterium, Prevotella and Bacteroides May be due to multidrug-resistant organisms in institutionalized patients Periodontal disease often present Edentulous patients much less likely have bacterial aspiration More indolent onset than usual chemical aspiration May progress to lung abscess or empyema Bartlett JG. Infect Dis Clin North Am 2013; 27:

41 ASPIRATION PNEUMONIA BACTERIAL - TREATMENT Recommended antibiotic Rx Ampicillin-sulbactam (Unasyn) when no MDRO s suspected Clindamycin for PCN allergy Ertapenem Severe cases in Hospital or SNF acquired Meropenem, piperacillin-tazobactam (Zosyn) + Vancomycin, linezolid, telavancin (for suspected MRSA) Can be stopped when cultures are negative for MRSA Include negative nasal and throat cultures

42 VANCOMYCIN + PIP/TAZO ACUTE KIDNEY INJURY 2 randomized retrospective studies Compared vanco + pip/tazo (VPT) vs. vanco + cefepime (VC) Study 1: 35% VPT vs. 11% VC developed AKI Study 2: 29% VPT vs. 11% VC developed AKI Conclusion: VPT appears to be an independent predictor for AKI 1. Navalkele, B, et al Gomes, DM, et al. Pharmacotherapy 2014; 34:

43 LINEZOLID V. VANCOMYCIN FOR MRSA PNEUMONIA Prospective randomized double blind comparing 448 pts treated for MRSA HAP with vancomycin versus linezolid Linezolid Vancomycin P value Clinical cure 58% 47%.042 Microbiological cure 58% 47% Mortality at 60 days 16% 17% Renal failure 8% 18% Wunderink, RG et al. CID 2012; 54:

44 SHOULD WE BE TREATING PNEUMONIA WITH STEROIDS? Meta-analysis of 13 randomized, placebo-controlled trials >2000 hospitalized CAP patients, median age in the 60 s Doses ranged from mg prednisone/day Steroid group improvements: 5.3% vs. 7.9% in-hospital mortality 0.4% vs. 3.0% ARDS 3.1% vs. 5.7% mechanical ventilation 7.4% vs 22.0% mortality only in subgroup with severe pneumonia Shortened hospital stay by one day Hyperglycemia more common in steroid treated group

45 SHOULD WE BE TREATING PNEUMONIA WITH STEROIDS? This meta-analysis suggests that corticosteroid treatment may be a valuable adjunct in the treatment of hospitalized CAP patient. Consider a brief course (3-7 days) of daily moderate dose (20-60 mg prednisone or equivalent) corticosteroids in these patients A large randomized trial, scheduled to complete in 2018, will hopefully help clarify dose and duration. Siemieniuk RAC et al. Ann Intern Med 2015; 163:519 ( Restrepo MI et al. Ann Intern Med 2015; 163:569 (

46 ASPIRATION PNEUMONIA CHEMICAL Refers to aspiration of gastric contents Frequently associated with seizure or general anesthesia Usually abrupt onset dyspnea, hypoxemia, fever Gastric acid and/or bile are damaging to lung Usually located in one or both lower lobes Clinical course variable Large percentage improve spontaneously without ABX Rx Significant percentage progress to severe ARDS Bynum LJ, et al. Am Rev Respir Dis 1976; 114: 1129

47 ASPIRATION PNEUMONIA CHEMICAL - TREATMENT Immediate suctioning Antibiotic Rx indicated in severe cases Up to 26% patients develop bacterial superinfection If no infiltrates develop within 48 to 72 hrs, OK to stop ABX Rx Recommended antibiotic Rx same as for bacterial aspiration in severe cases Bynum LJ, et al. Am Rev Respir Dis 1976; 114: 1129

48 ASPIRATION PNEUMONIA

49 ASPIRATION PNEUMONIA PREVENTION NG and PEG feeding tubes have not been shown to reduce the incidence of aspiration pneumonia Thickened liquids have mixed results in efforts to prevent aspiration Fox DA, et al. Am J Surg. 1995; 170: 564-6