1. Infections in Elderly Care Dr Lucia Pareja-Cebrian Microbiology Consultant 12 th March 2014

2. Who Why What

3. WHO Difficult cutoff point: ?65, ?70 ?85 Aging population – 1900s: 1% of world’s population (15 m) >65yo – 1992: 6% of population (342 m) >65 yo – 2020: 20% of population (6b) >65 yo >85 are high risk group

4. WHY Decline in host defences – Inmune senescence – Changes in non adaptive inmunity – Chronic illness – Medication – Malnutrition – Functional impairments

5. Immunity T-cell production decreases with age Antibody production decrease Malnutrition affects cell mediated immunity

6. Non adaptive immunity Thining skin, chronic ulcers Enlarged prostate Impaired cough reflex Functional impairments: – Dysphagia – Inmobility – Incontinence

7. Chronic illness and intervention Diabetes Hypertension Dementia Decreased gastric acid Indwelling devices, medication,

8. Lifestyle Leisure: travelling, gardening, sports? Contact with healthcare: Outpatients, inpatients? Living arrangements: nursing homes, residential care?

9. Sitting ducks or sentinel chickens?

10. WHAT? Skin and soft tissue UTIs and the “new kids on the block” – ESBLs – Carbapenemases GI Respiratory HCAI Vaccine preventable

11. The trouble with infections… …is it a bird, is it a plane…? …is it a UTI, is it a chest infection…?!

12. Challenges in diagnosis Temperature response Communication Immune response Pain Confusion

13. Skin and soft Tissue Thining skin Chronic ulcers Colonisation vs infection? Organisms involved: – Streptococcus (A,B,G, C) – Staph aureus (MRSA)

14. UTI No benefit in treating asymptomatic UTI …symptoms are hard to spot! How long to treat: – 3 days for uncomplicated UTI – 5-7 days in males – 10-14 days pyelonephritis

15. Ecoli Urinary tract infections Catheterised (not exclusively) Preventable? – Peak in summer – The role of primary care – Symptoms

16. ESBLs Extended spectrum betalactamases Resistant to coamox, amox, cephalosporins, piptazo Usually associated resistance to quinolones and gentamycin Usually urines, many in the community What’s left: Temocilin, fosfomycin, meropenem, ertapenem

17. Carbapenemase producing enterobacteria CPE Urines, pneumonia, wounds and ulcers Travel to South Europe, India… and Manchester What’s left: fosfomycin, colystin…or nothing!

18. Respiratory: challenges Existing pathology: COPD, bronchiectasis Decreased cough reflex Dysphagia, stroke The trouble with CXR!

19. Respiratory Seasonal illness – Influenza – Parainfluenza – RSV Non seasonal illness – Pneumococcal – Haemophilus Aspiration pneumonia Legionella-not just for travellers!

20. GI Norovirus – Not just winter vomiting! – Pre-admission management PEG Cryptosporidium, Salmonella, Campylobacter Listeria Hepatitis (A, B and E, also C)

21. Cdiff Colonisation increases with age PPIs and antibiotics predispose NG feeding, GI pathology, malnutrition Recurrence is common Length of stay

22. HCAI MRSA, MSSA, Cdiff and Ecoli Other: ESBLs,Carbapenemases Contact with healthcare and interventions >50% HCAI in >65yo

23. MRSA, MSSA 30% population colonised with Staph aureus Skin and soft tissue Pneumonia Endocarditis 20-30% mortality risk Decolonisation difficult in elderly population

24. Vaccine preventable Influenza Pneumococcus Varicella Meningococcus Haemophilus Pertussis

25. Summary Predisposing factors Care beyond hospitals HCAIs and resistance Education Prevention