Septicaemia and its unacceptably high mortality in the elderly

Journal of Infection (I983) 7, I34-I38

Septicaemia and its unacceptably high mortality in the elderly B. C h a t t o p a d h y a y a n d M. A I - Z a h a w i

Public Health Laboratory and Department of Microbiology, Whipps Cross Hospital, London EII INR Summary During a period of two years the overall mortality rate among 218 patients with septicaemia was 22. 4 per cent. Mortality among patients of over 60 years of age, however, was 36"6 per cent compared with only 5" I per cent for those below that age. This difference was highly significant (P < o.oo x). For pneumococcal septicaemia the figures were particularly disturbing, the death rate being 65 per cent for the former age group, but remaining nil for the latter. Of the 49 deaths, 44 (89"8 per cent) and five (Io.2 per cent), respectively, were in those above and below that age. As death from septicaemia in the elderly seems to be unacceptably high, early institution of antibiotic therapy, even for the patient at home, is advocated so as to forestall the onset of shock. Although controversial and debatable this measure seems to be justified because it might significantly improve prognosis. Introduction Accurate information on death from septicaemia among elderly patients in the U n i t e d K i n g d o m is unobtainable. Although a recent comprehensive study from the P H L S C o m m u n i c a b l e Disease Surveillance Centre, Colindale, has estimated the overall mortality rate for septicaemia to be I7-X9 per cent, it was pointed out that this was an underestimate because when forms are completed by the reporting laboratory the final o u t c o m e is not always known. 1 A report on bacteraemia in a L o n d o n teaching hospital ( i 9 6 6 - i 9 7 5 ) ~ did not discuss mortality despite drawing attention to the steady increase in the incidence of bacteraemia and mortality in general per IOOO hospital admissions. Recently a Swedish study of p r o v e d and probable septicaemia revealed an overall figure of 20 per cent, b u t no attempt was apparently made to determine the death rate in those over 60 years of age. a

Materials and methods D u r i n g a 2-year survey (I 9 8 o / 8 I), all patients with septicaemia in the W a l t h a m F o r e s t District group of hospitals were studied prospectively. Relevant features such as age, sex, diagnosis, the underlying pathological condition giving rise to septicaemia, treatment (in particular whether the patient was receiving any antibiotic when the septicaemia developed) and the final o u t c o m e including p o s t - m o r t e m findings were recorded.

Results Results are summarised in T a b l e I, which shows the total n u m b e r of patients and the overall mortality along with the mortality rates for those over and u n d e r oi63-4453/83/o5oi34+ 05 $o2.oo/o

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I37

60 years of age. Apart from septicaemia caused by Pseudomonas aeruginosa and for which the mortality is usually high because it often arises terminally in severely ill patients, 4the mortality from pneumococcal septicaemia also was high (43 "3 per cent). However, for patients above the age of 6o years mortality rose to a striking 65 per cent. Underlying pathological conditions, many of which originated before admission to hospital, contributed to more episodes of bacteraemia (total I63) than did those in the immediate post-operative period (total 55) which could be attributed directly to surgical intervention, invasive procedures or related autogenic or nosocomial infection (Table II). Discussion

T h e elderly seem not only to be afflicted more often with septicaemia than younger persons but also to be more vulnerable because mortality was significantly higher among them than those in the younger age group. It is well known that early institution of antibiotic therapy in bacterial meningitis does not adversely affect prognosis, although, rarely, attempted isolation of the causative agent may not be successful, so leading to diagnostic difficulties. 5-7 Furthermore, the antibiotic susceptibility of the pathogen remains unknown. As patients with pneumococcal pneumonia may develop bacteraemia leading to shock and death, early administration of antibiotics should be considered in those with relatively mild respiratory tract infection. It has been shown that one-third of patients with pneumococcal bacteraemia have pneumonia.1 In our series almost half (14/3o) of the patients had pneumococcal pneumonia. Nearly all deaths in this series (44/49 i.e. 89"8 per cent), were in patients between the ages of 62 and 91 years (average age 73 years) and most succumbed within 24 to 48 hours of admission, usually before results of blood culture were known. A similar state of affairs has already been described for pneumococcal meningitis, 8 in which prognosis was significantly worse in those with a shorter rather than a longer history. Also in bacterial meningitis the prognosis was better for those who received treatment before admission than for those who did not. 6 T h e author believed that in treated patients who survived, the infective episodes ran a relatively mild and slow course compared with those without treatment, in whom the disease ran a rapid and fulminating course with high mortality. It was concluded, however, that this difference was not due to treatment. Nevertheless, it is conceivable that the early administration of antibiotics in itself modified the severity of these attacks and hence gave rise to the slow progression of the disease. Also it may be argued that this high fatality rate possibly reflects delay in initiating antibiotic therapy, leading to rapid progression of the disease with shock and deterioration, so necessitating admission to hospital. Because of the susceptibility and vulnerability to infection of this frail and ageing population, the suggestion of early institution of antibiotic therapy should not be misconstrued as the injudicious use of antibiotics. Hopefully, it should not result in an alarming increase in the emergence of resistant bacterial strains outside hospital. As the chances of survival from septicaemia are generally better when it is acquired in hospital because of ready access to rapid diagnostic facilities and early antibiotic therapy, it is tempting to

i38

B. CHATTOPADHYAY AND M. AL-ZAHAWI

speculate that the practice of early t r e a t m e n t would significantly reduce the incidence of f u l m i n a n t infection. Once a patient develops shock, antibiotic therapy has less effect, but early administration of antibiotics m a y well prevent or delay the onset of shock. Critics m a y well argue that as mortality increases exponentially after the age of 12 years, elderly patients may belong to a special group and hence the c o m m o n l y inevitable fatal outcome. In a recent and extensive survey, n e w b o r n infants below the age o f one m o n t h and patients aged 65 years and over were shown to have more episodes of bacteraemia than e x p e c t e d ) In the absence of s y m p t o m s and paucity of signs the elderly are similar to the n e w b o r n and the very y o u n g and this m a y equally well delay diagnosis. Antibiotics are prescribed early whenever infection in neonates is suspected; there is no good reason why the same principle should not apply in geriatric practice. (We are grateful to Mr R. J. H. Lobb, Epidemiological Research Laboratory, Central Public Health Laboratory, Colindale, for statistical analysis.) References I. Young SJE. Bacteraemia I975-8o: a survey of cases reported to the PHLS Communicable Disease Surveillance Centre. J Infect I982; 5: I9-26. 2. Williams GT, Houang ET, Shaw EJ, Tabaqchali S. Bacteraemia in a London teaching hospital i966-75. Lancet I976; ii: I29I-I293. 3. Svanbom MAJ. Septicaemia. I. A prospective study on etiology, underlying factors and sources of infection. ScandJ Infect Dis I979; xI: I87-I98. 4. Editorial. Pseudomonas septicaemia. Br M ed J 198o; 280: I24O-I24I. 5. Mandal BK. The dilemma of partially treated bacterial meningitis. ScandJ Infect Dis 1976; 8" I85--I88. 6. Romer FK. Difficulties in the diagnosis of bacterial meningitis. Lancet I977; ii: 345-3477. Pickens S, Sangster G, Gray JA, McC. Murdoch J. The effects of pre-admission antibiotics on the bacteriologicaldiagnosisof pyogenic meningitis. Scandff Infect Dis 1978; xo: 183-185. 8. Baird DR, Whittle HC, Greenwood BM. Mortality from pneumococcal meningitis. Lancet 1976; ii: 1343-1346.