- Email: [email protected]
Infections in the elderly
ANTIMlCR~b AND INFECTIC’ --ex7 c-r DlSEAxa NEWfsLETTEI‘“Tc-
JIL --
S
L
Editor-in-Chief Charles w. &attm,
MD
VanderbiltUniversity School of Medicine Nashville, Tennessee Full editorial board qpears on back cover
Volume 14, Number 11 November 1995
Infections in the Elderly Michael S. Gelfand, MD Memphis,
Tennessee
With improved prevention and care of infectious diseases in the 20th century, there has been a drama tic increase in general human longevity. Paradoxically, an increasingly older population, afflicted with chronic degenerative diseases and malignancies, is susceptible to many infections with resulting morbidity and mortality (Table 1). Infections in the elderly often present in an atypical fashion: fever, chills, and elevated WBC count may be absent (Table 2). A high index of suspicion must be maintained and an aggressive diagnostic and therapeutic approach is essential to avoid excessive morbidity and mortality. Fever and leukocytosis with a left shift usually indicate a serious bacterial infection in the elderly pa-
Table 1. Important infections in the elderly Pneumonia
Urinary tract infections Infected pressure ulcers, cellditis Sepsis Intmabdominal infections (dliverticulitis, appendicitis, cholecystitis, cholangitis, liver abscess) Infectious endocarditis Bacterial meningitis Tuberculosis Influenza Herpes roster
Anmx
14(11)77-84.1995
tient and in general mandate prompt hospitalization. Adequate specimens for culture are not always easy to obtain in an ill and poorly cooperative elderly patient. For example, sputum may not be produced or may be contaminated with oral flora. Obtaining an adequate urine specimen may require catheterization. Always obtain blood cultures in the elderly patient with suspected serious infection. Bacteremia is common in the elderly with other primary sites of infection (e.g., pneumonia, urinary tract infections, and cholangitis) and not infrequently is afebrile. Because of the common diagnostic difficulties and delays and limited ability of elderly patients to cope with a stress of a serious infection, broad-spectrum antibiotic therapy is a standard approach in an elderly patient with a suspected serious infection. The elderly patient has a limited capacity to cope with side-effects of antibiotics (Table 3). Diminished renal excretory capacity, decreased hearing, and decreased balance often are present. Potentially nephrotoxic and ototoxic agents such as the aminoglycosides should in general be avoided, except in special circumstances (e.g., in enterococcal endocarditis, used in combination with ampicillin, in serious P. aeruginosa infections, or against multire&ant Gram-negative bacteria). Beta-la&m agents are preferred, but if aminoglycosides, vancomycin, or intravenous erythromycin have to be used, careful dose adjustment is important in avoiding side-effects. Elderly patients often are receiving Elsevier
multiple nonantibiotic medications. Many antimicrobial agents, including such commonly given antibiotics as TMP/SMX, quinolones, and erythromytin, interact with nonantibiotic drugs and produce important side-effects. A routine review of all medications is essential when prescribing an antibiotic to an elderly patient. I will now briefly review some of the important infections commonly encountered in the elderly by a clinician. Pneumonia Pneumonia is the most common lethal infection in the elderly. Pneumonia is more common in the elderly than in young people and results in higher morbidity (including sepsis, empyema, and respiratory failure), mortality, and cost
ln This Issue
Infections in the Elderly.. . . . . . . . .77 Michael S. Gelfand
Antimicrobial Resistance and the Use of Oral Antimicrobial Agents in the Nursing Home.. . . . .80 Charles W. Stratton
corynebacterium urealJ%icum Urinary Tract Infections . . . . . . . . .83 Jocelyn A. Myers. M. Vanessa Gill, andBurkeA.Cunha
1069-417x/95/50.00 + 09.50
Table 2. Atypical presentatioosof infection in the elderly Hypothermia Change in mental status (stupor, confusion, agitation) Hyperventilation Decreased urine output Hypotension Acidosis Normal oc decreased WBC Hypoglycemia
of care. Fever, chest pain, and sputum are less common, and confusion, delirium, tachypnea, and delayed radiographicresolution are more common than in younger patients. The etiology of pneumonia is undetermined in up to 50% of patients with communityacquired pneumonia, especially when antibiotics are given prior to admission. Sputum Gram stain and culture have low sensitivity and specificity in determining the etiology of pneumonia in the elderly. Fneumococcus remains the most important cause of bacterial pneumonia in the elderly. The lack of lobar consolidation may occur when the patient is dehydrated or has bullous emphysema. A recent increase in penicillin-resistant strains in the United States is of much concern. Third-generation cephalosporins-cefotaxime and ceftriaxone-are active against the majority (but not all) of pneumococci and are popular for the treatment of serious community- and nursing home-acquired pneumonia in the elderly. Nursing home-acquired pneumonia is often caused by Gram-negative aerobic bacilli (Klebsiella, E. colt’,Pseudomonas) and methicillin-resistant S. aureus, as well as by pneumococci.
production
Familiarity with locat microbiology patterns is very helpful in selecting empiric antibiotics before the culture results are available. Legionella can cause a severe pneumonia with altered mentat status. Urinary antigen assay is the most practical way of diagnosing legionellosis. Intravenous erythromycin is the treatment of choice and in the elderly the daily dose should be limited to 3 grams to avoid toxicity. Tuberculosis is an important consideration when pneumonia fails to improve with initial therapy. Both primary and reactivation
Tuberculosis is an important consideration when pneumonia fails to improve with initial therapy. tuberculosis can occur especially in a nursing home patient.
Pseudomonas) and Gram-positive cocci
(enterococci, coagulase-negative staphylococci) increase in frequency with age, especially in patients with indwelling urinary catheters. Bacteriuria usually is asymptomatic but may also result in decreased general functional status, cognition, and urinary incontinence. A minority of the patients present with frank sepsis. Culture and sensitivity is essential because of unpredictable microbiology of UT% in the elderly. A broad-spectrum agent (a quinolone or a beta-lactam) is preferable, depending on culture results, when treating a serious UTI in an older patient. TMP/!WX is an excellent choice (p.0. or i.v.) if the pathogen is susceptible. The use of aminoglycosides is better avoided unless mandated by susceptibility results. Ten to 14 days of therapy usually is adequate except in prostatitis, where 4 to 6 weeks of therapy is advised As soon as the patient is afebrile and hemodynamitally stable, a suitable oral antibiotic can be substituted (e.g., a quinolone or ‘RWSMX). Recurrences and failures
Table 3. Antibiotic side-effects in the elderly
Urinary Tract Infections (UTI) UTI is the most frequent bacterial in-
Na or K overload from high doses of penicillins
fection in the elderly and the most common cause of bacteremia and sepsis in the geriatric population. Bacteriuria increases in frequency with age in both men and women, but especially in the former. Prostatic enlargement, pelvic floor relaxation, neurogenic bladder, and fecal impaction are some of the factors predisposing the elderly to UT&. Frequent use of indwelling urinary catheters is a major risk factor in both hospitals and nursing homes. E. coli remains the most important uropathogen in the elderly but other Gram-negative bacilli (Proteus, Klebsiella, Providenia,
Hypokalemic alkalosis from high doses of penicillins Coagulopathy-large doses of antipseudomonal penicillins, cephalosporius with M’lT sidecham (cefoperazone, cefamandole, cefotetan, cefmetazole) Neurotoxicity-large lii, imipenem, nolonea
doses of penicilceftazidime, qui-
Nephrotoxicity-aminoglycosides, vancomycin Ototoxicity-aminoglycosides, comycin, erythmmycin
van-
NOTE: No lgpcasibility is assumed by the Publisher for any injury and/or damage to persona or pmpctiy as a matter of products liability. negligence or otherwii. or fmn my use or opention of my methods, pmdu&, instrtstio~ or ideas contained in the material hemin. No ~~grstcd tast or procedure should be carried out unless. in the rudcfr judgment, its ti& k ju&fied. Because of rapid advancea in medical sciences, we mannmend that the indcpendmt verification of diagnoses and drug dosages should be made. Discussions, views. and recommaxhtio~ as to medial procedures, choice of drugs. and dmg dosages are the responsibility of the authors. Anthkrobics andf~&ctiow Diarcrprs Ncwslrttcr (ISSN 1069417X) is issued monthly in one indexed volume per year by Elsevier Science Inc, 655 Avenue of the Americas. New YorL, NY 10010. Subscription price per year: $208.00 including postage and hdlimg in the United States. Canada. and Mexico. Add $59.00 for pmtage in the rest of the wodd. Secondzlss postsge paid at New Yak NY and It additional mailing offices. Postmaster: Send addmss changes to Anhicrobics andlnfatiovs Discarcs Newskner, Else&r Science Inc., 655 Avaruc ofthe Americas. New York, NY 10010.
78
0169417X,95/so.00
+ 9.50
8 1995 Elsevier Science Inc.
Antimicrobics and Infectious Disasg
Newsletter 14(H) 1995
of therapy are not uncommon because of frequent urinary structuralabnonnalities in the elderly. Fever petsisting for more than 72 hours while the patient is on appropriatetherapy suggests possible ureteralobstruction or a perinephric abscess. An ultrasound examination or a CT scan is appropriatein evaluating persistent fever. An asymptomatic bacteriuriawith or without an indwelling utinary catheter does not result in decreased llife expectancy and need not be treated.Chronic asymptomatic bacteriuriaand pytuia is universal in patients with chronic indwelling urinary catheters and may tesult in clinical confusion when an acute febrile episode is actually due to an occult infection at another location. Always consider other possibilities before blaming the urinary catheter in a septic patient.
Biliary Tract Infections
Bacterial Meningitis An elderly patient with acute meningitis is significantly more likely to have a bacterial and less likely to have a viral infection than a young adult, Ihe usual signs of bacteiial meningitis (fever, headache, and nuchal rigidity) are not infrequently absent and confusion and coma may be the presenting features. Mortality of bacterial meningitis increaseswithage(!lOto70%intheelderly) and the most frequent pathogens include S. pncunwniue (tiringly often resistant to penicillin
andJlsectilnxIh-
Respiratay tract infections Tuberculosis Pmumoaxci Maaxdla
catarrhah
Hemophilusinfluame PdllSSiS GrwpAStrep
InfluenzaAandB Pamintluenza RSV Dianllea c1ostcidium diffkile E. coli 0157:H7
(entaohemonhagic
colitis) Salmonella Shigella Campylobacter jejmi
Silky tract disease is the most cornmon condition requiring abdominal surgery in the elderly. Cholelithiasis is common and the gallstones are colonized with bacteria in the majority of the elderly patients. A broad-spectrum antimicrobial with good biliary penetration should be administered in acute cholecystitis and cholangitis. Percutaneous or endoscopic relief of biliary obstruttion in an elderly patient with cholangitis is less invasive than immediate surgery and results in lower shortterm mortality.
Anticmbia
Tabk 4. Outbreaks ofimktlous diseases in nursing home patients
lrlmldter 14(11)1995
Rotavirus Giardia CIyptcspUidiUllI S. aureus and C. petfringens food poisoning skin infections Group A strep Methicillin-resistant S. uureus Scabies
presmeulm) numerous outbreaks of respiratory,enteric, and cutaneous infections have been reported in recent years in nursing home patients (Table 4). Nursinghomesalsohavebecomeanimportant reservoir of highly resismnt bacteria including methicillin-&stant S. aureus, vancomycin-resistant entetococci, and multiresistant Gram-negative bacilli.Acommonpractkeonthepart of the nursing homes to n&se madmission ofa hospitalized patient colonized with multiresistant bacteria is illogical because the nursing home may in fact be the original source of the infecting or colonizing organism.
Immunization Low ratesofimmunization among the elderly against the importantpath* gens have repeatedly been reported in the United States. While the seroconversion rates to most vaccines clearly are lower in the elderly, every effort must be made to immunize the susceptible patients with pneumococcal, influenza, and tetanus/diphtheria vaccines. During the outbreaks of influenza A infection, antiviral prophylaxis plays an important role in those elderly patients who have not been immunized or await the seroconversion after vaccination (10-14 days). Rimantadine may be preferable to amantadine in the elderly because of the fewer neurologic side-effects.
Bibliography results of the CSF Cram stain examination. If no micmoqanisms are seen, empiric antibiotics should be given in high doses pending results of cultures. Cefotaxime or ceftriaxone plus either ampicillin (if Lisferiu is suspected) or vancomycin (if multiresistantpneumococci are ptevalent in the community) is the cunently preferredregimen. Tuberculous meningitis may present in a subacute manner mimicking pyogenic infection. Tuberculosis is an important consideration in an elderly patient with lymphocytic meningitis.
Nursing Home-Associated Infections In addition to the more common infections (UTIs, pneumonias, infected
8 1995ElseviesScislce Inc.
Behmun RE, Meyers BR, Mendelson MH. et al.: Central navous system infections in the elderly. Arch Intern Med 149:15961599.1989. Bennett RG: Diarrhea among residents of long-term care facilities. Infect Control Hosp EpidemiollW3 14~397-404. Fein AM: Pneumonia in the elderly: special diagnostic and therapeutic cmklaations. Med Clin North Am 78:1015-1033.1594. Gleckman R, Hibert D: Afebrile bact&n.ia, a phenomenon in gaiatric patients. JAMA 248:1478-1481.1982 Meyers BR, Sherman E, Mendelson MH. et al.: Bloodstream infections in the ekly. Am J Med 863379-384.1989. Schneider EL: Infectious diseases in the elderly. Ann Intern Med 98:3W, 1983. Yoshikawa ‘IT, Norman DC: Treabnent of infections in eldezly patimts. Med Clin North Am 79:651-661,1995.
1069-417xl95/30.00 + 09.50
79
JIL --
S
L
Editor-in-Chief Charles w. &attm,
MD
VanderbiltUniversity School of Medicine Nashville, Tennessee Full editorial board qpears on back cover
Volume 14, Number 11 November 1995
Infections in the Elderly Michael S. Gelfand, MD Memphis,
Tennessee
With improved prevention and care of infectious diseases in the 20th century, there has been a drama tic increase in general human longevity. Paradoxically, an increasingly older population, afflicted with chronic degenerative diseases and malignancies, is susceptible to many infections with resulting morbidity and mortality (Table 1). Infections in the elderly often present in an atypical fashion: fever, chills, and elevated WBC count may be absent (Table 2). A high index of suspicion must be maintained and an aggressive diagnostic and therapeutic approach is essential to avoid excessive morbidity and mortality. Fever and leukocytosis with a left shift usually indicate a serious bacterial infection in the elderly pa-
Table 1. Important infections in the elderly Pneumonia
Urinary tract infections Infected pressure ulcers, cellditis Sepsis Intmabdominal infections (dliverticulitis, appendicitis, cholecystitis, cholangitis, liver abscess) Infectious endocarditis Bacterial meningitis Tuberculosis Influenza Herpes roster
Anmx
14(11)77-84.1995
tient and in general mandate prompt hospitalization. Adequate specimens for culture are not always easy to obtain in an ill and poorly cooperative elderly patient. For example, sputum may not be produced or may be contaminated with oral flora. Obtaining an adequate urine specimen may require catheterization. Always obtain blood cultures in the elderly patient with suspected serious infection. Bacteremia is common in the elderly with other primary sites of infection (e.g., pneumonia, urinary tract infections, and cholangitis) and not infrequently is afebrile. Because of the common diagnostic difficulties and delays and limited ability of elderly patients to cope with a stress of a serious infection, broad-spectrum antibiotic therapy is a standard approach in an elderly patient with a suspected serious infection. The elderly patient has a limited capacity to cope with side-effects of antibiotics (Table 3). Diminished renal excretory capacity, decreased hearing, and decreased balance often are present. Potentially nephrotoxic and ototoxic agents such as the aminoglycosides should in general be avoided, except in special circumstances (e.g., in enterococcal endocarditis, used in combination with ampicillin, in serious P. aeruginosa infections, or against multire&ant Gram-negative bacteria). Beta-la&m agents are preferred, but if aminoglycosides, vancomycin, or intravenous erythromycin have to be used, careful dose adjustment is important in avoiding side-effects. Elderly patients often are receiving Elsevier
multiple nonantibiotic medications. Many antimicrobial agents, including such commonly given antibiotics as TMP/SMX, quinolones, and erythromytin, interact with nonantibiotic drugs and produce important side-effects. A routine review of all medications is essential when prescribing an antibiotic to an elderly patient. I will now briefly review some of the important infections commonly encountered in the elderly by a clinician. Pneumonia Pneumonia is the most common lethal infection in the elderly. Pneumonia is more common in the elderly than in young people and results in higher morbidity (including sepsis, empyema, and respiratory failure), mortality, and cost
ln This Issue
Infections in the Elderly.. . . . . . . . .77 Michael S. Gelfand
Antimicrobial Resistance and the Use of Oral Antimicrobial Agents in the Nursing Home.. . . . .80 Charles W. Stratton
corynebacterium urealJ%icum Urinary Tract Infections . . . . . . . . .83 Jocelyn A. Myers. M. Vanessa Gill, andBurkeA.Cunha
1069-417x/95/50.00 + 09.50
Table 2. Atypical presentatioosof infection in the elderly Hypothermia Change in mental status (stupor, confusion, agitation) Hyperventilation Decreased urine output Hypotension Acidosis Normal oc decreased WBC Hypoglycemia
of care. Fever, chest pain, and sputum are less common, and confusion, delirium, tachypnea, and delayed radiographicresolution are more common than in younger patients. The etiology of pneumonia is undetermined in up to 50% of patients with communityacquired pneumonia, especially when antibiotics are given prior to admission. Sputum Gram stain and culture have low sensitivity and specificity in determining the etiology of pneumonia in the elderly. Fneumococcus remains the most important cause of bacterial pneumonia in the elderly. The lack of lobar consolidation may occur when the patient is dehydrated or has bullous emphysema. A recent increase in penicillin-resistant strains in the United States is of much concern. Third-generation cephalosporins-cefotaxime and ceftriaxone-are active against the majority (but not all) of pneumococci and are popular for the treatment of serious community- and nursing home-acquired pneumonia in the elderly. Nursing home-acquired pneumonia is often caused by Gram-negative aerobic bacilli (Klebsiella, E. colt’,Pseudomonas) and methicillin-resistant S. aureus, as well as by pneumococci.
production
Familiarity with locat microbiology patterns is very helpful in selecting empiric antibiotics before the culture results are available. Legionella can cause a severe pneumonia with altered mentat status. Urinary antigen assay is the most practical way of diagnosing legionellosis. Intravenous erythromycin is the treatment of choice and in the elderly the daily dose should be limited to 3 grams to avoid toxicity. Tuberculosis is an important consideration when pneumonia fails to improve with initial therapy. Both primary and reactivation
Tuberculosis is an important consideration when pneumonia fails to improve with initial therapy. tuberculosis can occur especially in a nursing home patient.
Pseudomonas) and Gram-positive cocci
(enterococci, coagulase-negative staphylococci) increase in frequency with age, especially in patients with indwelling urinary catheters. Bacteriuria usually is asymptomatic but may also result in decreased general functional status, cognition, and urinary incontinence. A minority of the patients present with frank sepsis. Culture and sensitivity is essential because of unpredictable microbiology of UT% in the elderly. A broad-spectrum agent (a quinolone or a beta-lactam) is preferable, depending on culture results, when treating a serious UTI in an older patient. TMP/!WX is an excellent choice (p.0. or i.v.) if the pathogen is susceptible. The use of aminoglycosides is better avoided unless mandated by susceptibility results. Ten to 14 days of therapy usually is adequate except in prostatitis, where 4 to 6 weeks of therapy is advised As soon as the patient is afebrile and hemodynamitally stable, a suitable oral antibiotic can be substituted (e.g., a quinolone or ‘RWSMX). Recurrences and failures
Table 3. Antibiotic side-effects in the elderly
Urinary Tract Infections (UTI) UTI is the most frequent bacterial in-
Na or K overload from high doses of penicillins
fection in the elderly and the most common cause of bacteremia and sepsis in the geriatric population. Bacteriuria increases in frequency with age in both men and women, but especially in the former. Prostatic enlargement, pelvic floor relaxation, neurogenic bladder, and fecal impaction are some of the factors predisposing the elderly to UT&. Frequent use of indwelling urinary catheters is a major risk factor in both hospitals and nursing homes. E. coli remains the most important uropathogen in the elderly but other Gram-negative bacilli (Proteus, Klebsiella, Providenia,
Hypokalemic alkalosis from high doses of penicillins Coagulopathy-large doses of antipseudomonal penicillins, cephalosporius with M’lT sidecham (cefoperazone, cefamandole, cefotetan, cefmetazole) Neurotoxicity-large lii, imipenem, nolonea
doses of penicilceftazidime, qui-
Nephrotoxicity-aminoglycosides, vancomycin Ototoxicity-aminoglycosides, comycin, erythmmycin
van-
NOTE: No lgpcasibility is assumed by the Publisher for any injury and/or damage to persona or pmpctiy as a matter of products liability. negligence or otherwii. or fmn my use or opention of my methods, pmdu&, instrtstio~ or ideas contained in the material hemin. No ~~grstcd tast or procedure should be carried out unless. in the rudcfr judgment, its ti& k ju&fied. Because of rapid advancea in medical sciences, we mannmend that the indcpendmt verification of diagnoses and drug dosages should be made. Discussions, views. and recommaxhtio~ as to medial procedures, choice of drugs. and dmg dosages are the responsibility of the authors. Anthkrobics andf~&ctiow Diarcrprs Ncwslrttcr (ISSN 1069417X) is issued monthly in one indexed volume per year by Elsevier Science Inc, 655 Avenue of the Americas. New YorL, NY 10010. Subscription price per year: $208.00 including postage and hdlimg in the United States. Canada. and Mexico. Add $59.00 for pmtage in the rest of the wodd. Secondzlss postsge paid at New Yak NY and It additional mailing offices. Postmaster: Send addmss changes to Anhicrobics andlnfatiovs Discarcs Newskner, Else&r Science Inc., 655 Avaruc ofthe Americas. New York, NY 10010.
78
0169417X,95/so.00
+ 9.50
8 1995 Elsevier Science Inc.
Antimicrobics and Infectious Disasg
Newsletter 14(H) 1995
of therapy are not uncommon because of frequent urinary structuralabnonnalities in the elderly. Fever petsisting for more than 72 hours while the patient is on appropriatetherapy suggests possible ureteralobstruction or a perinephric abscess. An ultrasound examination or a CT scan is appropriatein evaluating persistent fever. An asymptomatic bacteriuriawith or without an indwelling utinary catheter does not result in decreased llife expectancy and need not be treated.Chronic asymptomatic bacteriuriaand pytuia is universal in patients with chronic indwelling urinary catheters and may tesult in clinical confusion when an acute febrile episode is actually due to an occult infection at another location. Always consider other possibilities before blaming the urinary catheter in a septic patient.
Biliary Tract Infections
Bacterial Meningitis An elderly patient with acute meningitis is significantly more likely to have a bacterial and less likely to have a viral infection than a young adult, Ihe usual signs of bacteiial meningitis (fever, headache, and nuchal rigidity) are not infrequently absent and confusion and coma may be the presenting features. Mortality of bacterial meningitis increaseswithage(!lOto70%intheelderly) and the most frequent pathogens include S. pncunwniue (tiringly often resistant to penicillin
andJlsectilnxIh-
Respiratay tract infections Tuberculosis Pmumoaxci Maaxdla
catarrhah
Hemophilusinfluame PdllSSiS GrwpAStrep
InfluenzaAandB Pamintluenza RSV Dianllea c1ostcidium diffkile E. coli 0157:H7
(entaohemonhagic
colitis) Salmonella Shigella Campylobacter jejmi
Silky tract disease is the most cornmon condition requiring abdominal surgery in the elderly. Cholelithiasis is common and the gallstones are colonized with bacteria in the majority of the elderly patients. A broad-spectrum antimicrobial with good biliary penetration should be administered in acute cholecystitis and cholangitis. Percutaneous or endoscopic relief of biliary obstruttion in an elderly patient with cholangitis is less invasive than immediate surgery and results in lower shortterm mortality.
Anticmbia
Tabk 4. Outbreaks ofimktlous diseases in nursing home patients
lrlmldter 14(11)1995
Rotavirus Giardia CIyptcspUidiUllI S. aureus and C. petfringens food poisoning skin infections Group A strep Methicillin-resistant S. uureus Scabies
presmeulm) numerous outbreaks of respiratory,enteric, and cutaneous infections have been reported in recent years in nursing home patients (Table 4). Nursinghomesalsohavebecomeanimportant reservoir of highly resismnt bacteria including methicillin-&stant S. aureus, vancomycin-resistant entetococci, and multiresistant Gram-negative bacilli.Acommonpractkeonthepart of the nursing homes to n&se madmission ofa hospitalized patient colonized with multiresistant bacteria is illogical because the nursing home may in fact be the original source of the infecting or colonizing organism.
Immunization Low ratesofimmunization among the elderly against the importantpath* gens have repeatedly been reported in the United States. While the seroconversion rates to most vaccines clearly are lower in the elderly, every effort must be made to immunize the susceptible patients with pneumococcal, influenza, and tetanus/diphtheria vaccines. During the outbreaks of influenza A infection, antiviral prophylaxis plays an important role in those elderly patients who have not been immunized or await the seroconversion after vaccination (10-14 days). Rimantadine may be preferable to amantadine in the elderly because of the fewer neurologic side-effects.
Bibliography results of the CSF Cram stain examination. If no micmoqanisms are seen, empiric antibiotics should be given in high doses pending results of cultures. Cefotaxime or ceftriaxone plus either ampicillin (if Lisferiu is suspected) or vancomycin (if multiresistantpneumococci are ptevalent in the community) is the cunently preferredregimen. Tuberculous meningitis may present in a subacute manner mimicking pyogenic infection. Tuberculosis is an important consideration in an elderly patient with lymphocytic meningitis.
Nursing Home-Associated Infections In addition to the more common infections (UTIs, pneumonias, infected
8 1995ElseviesScislce Inc.
Behmun RE, Meyers BR, Mendelson MH. et al.: Central navous system infections in the elderly. Arch Intern Med 149:15961599.1989. Bennett RG: Diarrhea among residents of long-term care facilities. Infect Control Hosp EpidemiollW3 14~397-404. Fein AM: Pneumonia in the elderly: special diagnostic and therapeutic cmklaations. Med Clin North Am 78:1015-1033.1594. Gleckman R, Hibert D: Afebrile bact&n.ia, a phenomenon in gaiatric patients. JAMA 248:1478-1481.1982 Meyers BR, Sherman E, Mendelson MH. et al.: Bloodstream infections in the ekly. Am J Med 863379-384.1989. Schneider EL: Infectious diseases in the elderly. Ann Intern Med 98:3W, 1983. Yoshikawa ‘IT, Norman DC: Treabnent of infections in eldezly patimts. Med Clin North Am 79:651-661,1995.
1069-417xl95/30.00 + 09.50
79