Download Signs and symtoms of infection are atypical

ESICM, Barcelona, Tuesday September 26th
The elderly patients need specific care after surgery
Signs and symtoms of infection
are atypical
Jean-François TIMSIT, MD, PhD
INSERM U578
Medical ICU
Grenoble, France
Altered
clinical
manifestations
Altered
biological
response
Altered
immunity
Infections
in the
elderly
Adverse
events
Frailty
Chronic
diseases
Due to ABx
Poly-pharmacy
Renal fonct.
Multi-resistant
bacterias
6
Pneumonia
UTI
5
Failure to wean >48h
4
Reintubation
3
Systemic SIRS
2
AMI
Cardiac arrest
Renal insufficiency
1
Pulmonary embolism
0
<65 y
65-74y
75-84y
>84y
Incidence of post-operative complications (% patients)
ACS Surgery 2004, Web MD Inc.
 Relative mortality
High KP Ageing Research Reviews 2004;1-14
J Trauma 2001; 50:612
Elderly is an immunocompromized
patient
Delayed cutaneous hypersensitivity
 T lymphocytes, T helper, NK Lymphocytes
 proliferative response to Ag
Normal neutrophilia is more frequent
 phagocyte fonction
Impaired production of pro-inflammatory
cytokines
Change in Complement system
Chandra RK - Ageing Research Reviews 2004;91-104
Decline of non-immune host defences
Lung:
-blunting of protective reflexes in the airway
-decrease in the mucociliary clearance
-loss of local immunity ( IgA,  acid production by the
stomach)
Urinary:
-  asymtomatic bacteruria
- reduction in the bladder capacity
- urothelial change ( bacterial adherence)
- prostatic hypertrophy, hormonal changes
Gastro-intestinal tract
-  gastric acidity
-  intestinal mobility
- modification of the intestinal flora
Thermal homeostasis and old age
Homeostatic mechanism
Defects
Thermogenesis
Decreased metabolic rate
Decreased efficiency of shivering
Vasomotor response
Lack of vasoconstriction on cooling
Temp. Perception
Decreased ability to recognize temp
differences
Lack of precision in environmental control
CNS control
Desynchronization of sheep-wake and
thermal circadian cycles
Jones SR- In « Fever Basic mechanisms and management » Raven press NY 1991
Age-related differences in the metabolic
response to injury - Frankenfield et al J Trauma 2000; 49
Reduced incidence of fever (48% vs.
77%,p = 0.027).
8 % decrease in oxygen
consumption (p = 0.0032).
(independent of fever, severity of
injury)
Same catabolic rate
(*) Young: <60 y
Elderly were more often
hyperglycemic (38% vs. 0%, p <
0.0001) and azotemic (62% vs. 22%,
p = 0.004) despite similar intake,
% of apyrexia in bacteremia
Defining
temp.
Age (y)
N (%
apyrexia)
Reference
<38°C
20-49
50-64
>65
<60
>60
<65
>=65
85 (9%)
47 (15%)
55 (29%)
12 (0%)
36 (31%)
128 (4%)
192 (13%)
Finkelstein 83
<38.5°C
<37.8
Murphy 84
Gleckman 82
Fever may be absent…
• Exagerated discrepancy between core and
rectal temperature:
– 52% > 0.5°C
– 19% > 1°C
Downton JH Age & Ageing 1987
Change in acute pain perception
Rosenthal – Crit Care Med 2004; 32:S92
•  silent myocardial infarction
<20% for 45-54 y vs >40% for 75-84y
• >35% duodenal ulcers without pain vs 8%
of younger pts
Clinch 1985
• Slight increase in pain thresholds with
increasing age
Gibson 2001
Intraabdominal infection: differences in presentation and
outcome between younger patients and the elderly.
Cooper et al Clin Infect Dis 1994; 1:146
• Patients > 65 y have less
– abdominal pain
– nausea, vomiting
– Diarrhea
– fever
and
• have symptoms for a longer period than
patients < 65y
Clinical Presentation and Delayed Treatment
of Cholangitis in Older People
Rahman SH -
Digestive Diseases and Sciences, 2005;50, pp. 2207–2210
Presence of functional symptoms delayed diagnosis and
treatment…
Delirium in elderly patients
• Infections….
But also…
•
•
•
•
•
Metabolic disturbances
Stroke
Cardiac insufficiency
Drugs
Intervention itself
Clinical Infectious Diseases 2002; 35:1390–6
• Pressure ulcers could preceed ICU admission
(1 to 11% of elderly in LTCF)
• 11.2% of 70-79y and 34% of > 90y would
develop pressure ulcers after admission to the
hospital
• Ulcers can have extensive deep-tissue necrosis
much worse than external inspection may
suggest
– Osteomyelitis without serious manifestations
– Sepsis, severe sepsis or bacteremia
Staphylococcal bacteremia
McClelland R 1999; 159:1244-1247
(*) OR of >65 y vs 18-60 y
Presentation of bacteremia is different…
Chassagne et al – Am J Med 1996; 100:65
Elderly
Young
3 groups:
(rectal <36°C or > 38.4°C)
71 Bacteremic elderly
187 Non bacteremic elderly
34 Bacteremic young
(>1.5°C)
3/16 clinical findings found
in at least 70% of the
bacteremic elderly patients
New markers of infection…
218 patients admitted in an acute geriatric unit
Stucker et al - J Am Geriatr Soc 53:1392–1395, 2005.
Clinical presentation of infection
• Comorbidities
• Aging
– Cognitive impairement, delirium
– Subtle manifestation: anorexia, decreased
functional status, change in cognition
–  fever due to infection:
• 0.1 to 0.2 °C for each decade over 30
• One third of infected patients > 65 are afebrile
• <50% of fever > 38.3°C after 80
« Delayed diagnosis may account for much of
the over risk of death »
MRSA is frequent on hospital admission
Lucet et al - Infect Control Hosp Epidemiol 2005; 26:121126
• Systematic nasal screening of > 75 y at
admission
• Pe 7.9% (63/797)
• ¾ are missed by clinical samples
Older adults particularely in longterm care facilities are a reservoir
for antibiotic resistance
100
80
60
% LTCF
40
% of patients
20
0
MRSA
VRE
R-GNRs
*: LTCF long-term care facilities
Pooled data from:
Bradley 1999
Trausbaugh 1996
Trik 2001
Muto 2003
Antibiotic resistant infections on patients
transfered from Long-term care facilites
153 infected patients
Resistance to levofloxacin 69
Resitance to cefotaxime 20
Resistance to both drugs 9
Toubes et al – Clin Infect Dis 2003; 36:724
Poor prognosis
 % patients
from LTC facilities
Elderly
Inappropriate
initial ABx
Resistant
bacteria
Conclusion
• Atypical presentation
• Delayed diagnosis
• Initial large antimicrobial treatment
followed by a subsequent de-esqualation
• Very early and Aggressive ressucitation