Clinical conundrums in management of sepsis in the elderly

Open access

Abstract

In 2012, surviving sepsis campaign came out with updated international guidelines for management of severe sepsis and septic shock. Paradoxically, there are no specific guidelines for management of sepsis in the elderly, although the elderly are more predisposed to sepsis, and morbidity and mortality related to sepsis. Sepsis in the elderly is, more often than not, complicated by clinical conundrums such as congestive heart failure (CHF), atrial fibrillation (AF), chronic kidney disease (CKD), acute kidney injury (AKI), delirium, dementia, ambulatory dysfunction, polypharmacy, malglycemia, nutritional deficiencies, and antibiotic resistance. Also, with recurrent admissions to the hospital and widespread use of antibiotics, the elderly are more susceptible to Clostridium difficile colitis.

If the inline PDF is not rendering correctly, you can download the PDF file here.

  • 1. Levy MM Fink MP Marshall JC Abraham E Angus D Cook D et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med 2003;29:530-8.

  • 2. Starr ME Saito H. Sepsis in old age: review of human and animal studies. Aging Dis 2014;5:126-36.

  • 3. Sehgal V Bajwa SJ Bajaj A. New orally active anticoagulants in critical care and anesthesia practice: The good the bad and the ugly. Ann Card Anaesth 2013;16:193-200.

  • 4. Kalra BS. Cytochrome P450 enzyme isoforms and their therapeutic implications: an update. Indian J Med Sci 2007;61:102-16.

  • 5. Deulofeu F Cervello B Capell S Marti C Mercade V. Predictors of mortality in patients with bacteremia: the importance of functional status. J Am Geriatr Soc 1998;46:14-8.

  • 6. Martin GS Mannino DM Eaton S Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003;348:1546-54.

  • 7. Walkey AJ Wiener RS Lindenauer PK. Utilization patterns and outcomes associated with central venous catheter in septic shock: a populationbased study. Crit Care Med 2013;41:1450-7.

  • 8. Stiermaier T Herkner H Tobudic S Burgmann K Staudinger T Schellongowski P et al. Incidence and long-term outcome of sepsis on general wards and in an ICU at the General Hospital of Vienna: an observational cohort study. Wien Klin Wochenschr 2013;125:302-8.

  • 9. Lim SC Doshi V Castasus B Lim JK Mamun K. Factors causing delay in discharge of elderly patients in an acute care hospital. Ann Acad Med Singapore 2006;35:27-32.

  • 10. Bail K Berry H Grealish L Draper B Karmel R Gibson D et al. Potentially preventable complications of urinary tract infections pressure areas pneumonia and delirium in hospitalised dementia patients: retrospective cohort study. BMJ Open 2013;3:e002770.

  • 11. Eliason D. It may not be “a little dementia”. MLO Med Lab Obs 2011;43:9.

  • 12. Whittaker SA Mikkelsen ME Gaieski DF Koshy S Kean C Fuchs BD. Severe sepsis cohorts derived from claims-based strategies appear to be biased toward a more severely ill patient population. Crit Care Med 2013;41:945-53.

  • 13. Hohn A Schroeder S Gehrt A Bernhardt K Bein B Wegscheider K et al. Procalcitonin-guided algorithm to reduce length of antibiotic therapy in patients with severe sepsis and septic shock. BMC Infect Dis 2013;13:158.

  • 14. Alon D Stein GY Korenfeld R Fuchs S. Predictors and outcomes of infection-related hospital admissions of heart failure patients. PLoS One 2013;8:e72476.

  • 15. Kahl JE Calvo RY Sise MJ Sise CB Thorndike JF Shackford SR. The changing nature of death on the trauma service. J Trauma Acute Care Surg 2013;75:195-201.

  • 16. Lee A Lau TN Yeong KY. Indwelling catheters for the management of malignant ascites. Support Care Cancer 2000;8:493-9.

  • 17. Lemay AC Anzueto A Restrepo MI Mortensen EM. Predictors of long-term mortality after severe sepsis in the elderly. Am J Med Sci 2014; 347:282-8.

  • 18. Wester AL Dunlop O Melby KK Dahle UR Wyller TB. Age-related differences in symptoms diagnosis and prognosis of bacteremia. BMC Infect Dis 2013;13:346.

  • 19. Alon D Shitrit P Chowers M. Risk behaviors and spectrum of diseases among elderly travelers: a comparison of younger and older adults. J Travel Med 2010;17:250-5.

  • 20. Iakubtsevich RE Spas VV Dorokhin KM. [Clinical course and intensive therapy of sepsis in geriatric patients]. Klin Med (Mosk) 2003;81:28-32.

  • 21. Zhou M Wu R Dong W Leong J Wang P. Accelerated apoptosis contributes to aging-related hyperinflammation in endotoxemia. Int J Mol Med 2010;25:929-35.

  • 22. Potasman I Grupper M. Leukemoid reaction: spectrum and prognosis of 173 adult patients. Clin Infect Dis 2013;57:e177-81.

  • 23. Sehgal V Bajwa SJ Sehgal R Bajaj A. Clinical Conundrums in Management of Hypothyroidism in Critically Ill Geriatric Patients. Int J Endocrinol Metab 2014;12:e13759.

  • 24. Sacanella E Perez-Castejon JM Nicolas JM Masanes F Navarro M Castro P et al. Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: a prospective observational study. Crit Care 2011;15:R105.

  • 25. Al-Temimi MH Griffee M Enniss TM Preston R Vargo D Overton S et al. When is death inevitable after emergency laparotomy? Analysis of the American College of Surgeons National Surgical Quality Improvement Program database. J Am Coll Surg 2012;215:503-11.

  • 26. Andriescu L Patraşcanu E Dănilă R Bădic B Rădulescu C. [Acute surgical pathology in elderly patients]. Rev Med Chir Soc Med Nat Iasi 2005;109:286-9.

  • 27. Baldwin MR Narain WR Wunsch H Schluger NW Cooke JT Maurer MS et al. A prognostic model for 6-month mortality in elderly survivors of critical illness. Chest 2013;143:910-9.

  • 28. Liu YJ Du P Rao J. Procalcitonin as a diagnostic and prognostic marker for sepsis caused by intestinal infection: a case report. Eur Rev Med Pharmacol Sci 2013;17:1311-3.

  • 29. Magrini L Travaglino F Marino R Ferri E De Berardinis B Cardelli P et al. Procalcitonin variations after Emergency Department admission are highly predictive of hospital mortality in patients with acute infectious diseases. Eur Rev Med Pharmacol Sci 2013;17 Suppl 1:133-42.

  • 30. Park JH Wee JH Choi SP Park KN. Serum procalcitonin level for the prediction of severity in women with acute pyelonephritis in the ED: value of procalcitonin in acute pyelonephritis. Am J Emerg Med 2013;31:1092-7.

  • 31. Stucker F Herrmann F Graf JD Michel JP Krause KH Gavazzi G. Procalcitonin and infection in elderly patients. J Am Geriatr Soc 2005;53:1392-5.

  • 32. Zhao Y Li C Jia Y. Evaluation of the Mortality in Emergency Department Sepsis score combined with procalcitonin in septic patients. Am J Emerg Med 2013;31:1086-91.

  • 33. Jeong SJ Yoon SS Han SH Yong DE Kim CO Kim JM. Evaluation of humoral immune response to nosocomial pathogen and functional status in elderly patients with sepsis. Arch Gerontol Geriatr 2014; 58:10-4.

  • 34. Chen YX Li CS. Prognostic value of adrenomedullin in septic patients in the ED. Am J Emerg Med 2013;31:1017-21.

  • 35. Kuo SH Lee YT Li CR Tseng CJ Chao WN Wang PH et al. Mortality in Emergency Department Sepsis score as a prognostic indicator in patients with pyogenic liver abscess. Am J Emerg Med 2013;31:916-21.

  • 36. Shapiro NI Wolfe RE Moore RB Smith E Burdick E Bates DW. Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule. Crit Care Med 2003;31:670-5.

  • 37. Angus DC van der Poll T. Severe sepsis and septic shock. N Engl J Med. 2013;369:840-51.

  • 38. Arinzon Z Peisakh A Schrire S Berner YN. Delirium in long-term care setting: indicator to severe morbidity. Arch Gerontol Geriatr 2011;52:270-5.

  • 39. Miller RR 3rd Dong L Nelson NC Brown SM Kuttler KG Probst DR et al. Multicenter implementation of a severe sepsis and septic shock treatment bundle. Am J Respir Crit Care Med 2013;188:77-82.

  • 40. Dellinger RP Levy MM Rhodes A Annane D Gerlach H Opal SM et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580-637.

  • 41. Chronopoulos A Cruz DN Ronco C. Hospital-acquired acute kidney injury in the elderly. Nat Rev Nephrol 2010;6:141-9.

  • 42. Shah PR Gireesh MS Kute VB Vanikar AV Gumber MR Patel HV et al. Renal involvement in sepsis: a prospective single-center study of 136 cases. Saudi J Kidney Dis Transpl 2013;24:620-9.

  • 43. Romao Junior JE Haiashi AR Vidonho Junior AF Abensur H Quintaes PS Araujo MR et al. [Causes and prognosis of acute renal failure in elderly patients]. Rev Assoc Med Bras 2000;46:212-7.

  • 44. Khurana V Gambhir IS Kishore D. Evaluation of delirium in elderly: a hospital-based study. Geriatr Gerontol Int 2011;11:467-3.

  • 45. Moore EM Bellomo R Nichol AD. The meaning of acute kidney injury and its relevance to intensive care and anaesthesia. Anaesth Intensive Care 2012;40:929-48.

  • 46. Hoste EA Kellum JA Katz NM Rosner MH Haase M Ronco C. Epidemiology of acute kidney injury. Contrib Nephrol 2010;165:1-8.

  • 47. Bagshaw SM Bellomo R Kellum JA. Oliguria volume overload and loop diuretics. Crit Care Med 2008;36(4 Suppl):S172-8.

  • 48. Sehgal V Bajwa SJ Sehgal R Bajaj A Khaira U Kresse V. Polypharmacy and potentially inappropriate medication use as the precipitating factor in readmissions to the hospital. J Family Med Prim Care 2013;2:194-9.

  • 49. Collopy KT Kivlehan S Snyder SR. Acute altered mental status in elderly patients: what can cause geriatric AMS and delirium? EMS World 2013;42:31-9.

  • 50. Luitse MJ van Asch CJ Klijn CJ. Deep coma and diffuse white matter abnormalities caused by sepsis-associated encephalopathy. Lancet 2013;381:2222.

  • 51. Rutten S Schade A. [Atypical presentation of delirium: risk of misdiagnosis and undertreatment]. Ned Tijdschr Geneeskd 2013;157:A5910.

  • 52. Isfandiaty R Harimurti K Setiati S Roosheroe AG. Incidence and predictors for delirium in hospitalized elderly patients: a retrospective cohort study. Acta Med Indones 2012;44:290-7.

  • 53. Gunther ML Morandi A Ely EW. Pathophysiology of delirium in the intensive care unit. Crit Care Clin 2008;24:45-65 viii.

  • 54. Sehgal V Bajwa SS Khaira U Sehgal R Bajaj A. Challenging aspects of and solutions to diagnosis prevention and management of hypoglycemia in critically ill geriatric patients. J Sci Soc 2013;40:128-34.

  • 55. Rubenfeld GD. Does the hospital make you older faster? Am J Respir Crit Care Med 2012;185:796-8.

  • 56. Baldwin CE Bersten AD. Alterations in respiratory and limb muscle strength and size in patients with sepsis who are mechanically ventilated. Phys Ther 2014;94:68-82.

  • 57. Sehgal V Jit Singh Bajwa S Kitabchi A. Coronary artery bypass grafting: a precipitating factor for perioperative diabetic ketoacidosis. Int J Endocrinol Metab 2013;11:126-8.

  • 58. Kagansky N Levy S Rimon E Cojocaru L Fridman A Ozer Z et al. Hypoglycemia as a predictor of mortality in hospitalized elderly patients. Arch Intern Med 2003;163:1825-9.

  • 59. Suaya JA Eisenberg DF Fang C Miller LG. Skin and soft tissue infections and associated complications among commercially insured patients aged 0-64 years with and without diabetes in the U.S. PLoS One 2013;8:e60057.

  • 60. Mendoza A Kim YN Chernoff A. Hypoglycemia in hospitalized adult patients without diabetes. Endocr Pract 2005;11:91-6.

  • 61. Shilo S Berezovsky S Friedlander Y Sonnenblick M. Hypoglycemia in hospitalized nondiabetic older patients. J Am Geriatr Soc 1998;46:978-82.

  • 62. Storey S Von Ah D. Impact of malglycemia on clinical outcomes in hospitalized patients with cancer: a review of the literature. Oncol Nurs Forum 2012;39:458-65.

  • 63. Lee JS Choi HS Ko YG Yun DH. Performance of the Geriatric Nutritional Risk Index in predicting 28-day hospital mortality in older adult patients with sepsis. Clin Nutr 2013;32:843-8.

  • 64. Kagansky N Levy S Koren-Morag N Berger D Knobler H. Hypophosphataemia in old patients is associated with the refeeding syndrome and reduced survival. J Intern Med 2005;257:461-8.

  • 65. Chen J Yan J Cai GL Xu QH Gong SJ Dai HW et al. Structured lipid emulsion as nutritional therapy for the elderly patients with severe sepsis. Chin Med J (Engl). 2013;126:2329-32.

  • 66. Piagnerelli M Cotton F Herpain A Rapotec A Chatti R Gulbis B. Time course of iron metabolism in critically ill patients. Acta Clin Belg. 2013;68:22-7.

  • 67. Meyer S Schuetz P Wieland M Nusbaumer C Mueller B Christ-Crain M. Low triiodothyronine syndrome: a prognostic marker for outcome in sepsis? Endocrine 2011;39:167-74.

  • 68. Butler MS Blaskovich MA Cooper MA. Antibiotics in the clinical pipeline in 2013. J Antibiot (Tokyo) 2013;66:571-91.

  • 69. Roberts RR Hota B Ahmad I Scott RD 2nd Foster SD Abbasi F et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis 2009;49:1175-84.

  • 70. Weis S John E Lippmann N Mossner J Lubbert C. [Clostridium difficile Infection (CDI) in the Course of Time - An Issue Only for the Internist?]. Zentralbl Chir 2014;139:460-8.

  • 71. Chilton CH Crowther GS Freeman J Todhunter SL Nicholson S Longshaw CM et al. Successful treatment of simulated Clostridium difficile infection in a human gut model by fidaxomicin first line and after vancomycin or metronidazole failure. J Antimicrob Chemother 2014;69:451-62.

  • 72. Green MR Acharya UH Yeager AM. Is Fidaxomicin the Drug of Choice for Treating Clostridium difficile-Associated Diarrhea in Patients With Cancer? J Clin Oncol 2013; 31:4376-8.

  • 73. Sears P Ichikawa Y Ruiz N Gorbach S. Advances in the treatment of Clostridium difficile with fidaxomicin: a narrow spectrum antibiotic. Ann N Y Acad Sci 2013;1291:33-41.

  • 74. Chaparro-Rojas F Mullane KM. Emerging therapies for Clostridium difficile infection - focus on fidaxomicin. Infect Drug Resist 2013;6:41-53.

  • 75. Juang P Hardesty JS. Role of fidaxomicin for the treatment of clostridium difficile infection. J Pharm Pract 2013;26:491-7.

  • 76. Mullane KM Cornely OA Crook DW Golan Y Louie TJ Miller MA et al. Renal impairment and clinical outcomes of Clostridium difficile infection in two randomized trials. Am J Nephrol 2013;38:1-11.

  • 77. Scott LJ. Fidaxomicin: A Review of Its Use in Patients with Clostridium difficile Infection. Drugs 2013;73:1733-47.

  • 78. Soriano MM Liao S Danziger LH. Fidaxomicin: a minimally absorbed macrocyclic antibiotic for the treatment of Clostridium difficile infections. Expert Rev Anti Infect Ther 2013;11:767-76.

  • 79. Planquette B Timsit JF Misset BY Schwebel C Azoulay E Adrie C et al. Pseudomonas aeruginosa ventilator-associated pneumonia. predictive factors of treatment failure. Am J Respir Crit Care Med 2013;188:69-76.

  • 80. Schechner V Gottesman T Schwartz O Korem M Maor Y Rahav G et al. Pseudomonas aeruginosa bacteremia upon hospital admission: risk factors for mortality and influence of inadequate empirical antimicrobial therapy. Diagn Microbiol Infect Dis 2011;71:38-45.

  • 81. Cardoso T Ribeiro O Aragao I Costa-Pereira A Sarmento A. The impact of healthcare-associated infection on mortality: failure in clinical recognition is related with inadequate antibiotic therapy. PLoS One 2013;8:e58418.

  • 82. Mondot S de Wouters T Dore J Lepage P. The human gut microbiome and its dysfunctions. Dig Dis 2013;31:278-85.

  • 83. Griffin MR Zhu Y Moore MR Whitney CG Grijalva CG. U.S. hospitalizations for pneumonia after a decade of pneumococcal vaccination. N Engl J Med 2013;369:155-63.

  • 84. DiazGranados CA Dunning AJ Jordanov E Landolfi V Denis M Talbot HK. High-dose trivalent influenza vaccine compared to standard dose vaccine in elderly adults: safety immunogenicity and relative efficacy during the 2009-2010 season. Vaccine 2013;31:861-6.

Search
Journal information
Cited By
Metrics
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 337 204 8
PDF Downloads 124 85 2