Skip to main content
SpringerLink
Log in

Challenges to Diagnosis and Management of Infections in Older Adults

  • Chapter
  • First Online:
New Directions in Geriatric Medicine

Abstract

Infectious diseases continue to be a major cause of morbidity and mortality among adults aged 65 and older despite improvements in antibiotic therapy and vaccinations. Older adults are at increased risk for developing infections compared to younger adults because of age-associated changes in immune function, comorbidities, and repeated exposures to healthcare settings. Diagnosing infections can be challenging in older adults because common signs and symptoms of infection (e.g., fever, leukocytosis) can be absent, especially in frail adults with cognitive impairment. Pneumonia, urinary tract infection, cellulitis, and Clostridium difficile diarrheal illness are among the most common causes of infection in this age group. This chapter reviews the challenges associated with diagnosis and management of the most frequently encountered infections in older adults.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 99.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Mouton CP, Bazaldua OV, Pierce B, Espino DV. Common infections in older adults. Am Fam Physician. 2001;63(2):257–68.

    CAS  PubMed  Google Scholar 

  2. Gorina YHD, Lentzner H, Goulding M. Trends in causes of death among older persons in the United States, Aging trends, vol. 6. Hyattsville: National Center for Health Statistics; 2006.

    Google Scholar 

  3. Christensen KL, Holman RC, Steiner CA, Sejvar JJ, Stoll BJ, Schonberger LB. Infectious disease hospitalizations in the United States. Clin Infect Dis. 2009;49(7):1025–35.

    Article  PubMed  Google Scholar 

  4. Curns AT, Holman RC, Sejvar JJ, Owings MF, Schonberger LB. Infectious disease hospitalizations among older adults in the United States from 1990 through 2002. Arch Intern Med. 2005;165(21):2514–20.

    Article  PubMed  Google Scholar 

  5. Pop-Vicas A, Tacconelli E, Gravenstein S, Lu B, D’Agata EM. Influx of multidrug-resistant, gram-negative bacteria in the hospital setting and the role of elderly patients with bacterial bloodstream infection. Infect Control Hosp Epidemiol. 2009;30(4):325–31.

    Article  PubMed  Google Scholar 

  6. Yoshikawa TT. Antimicrobial resistance and aging: beginning of the end of the antibiotic era? J Am Geriatr Soc. 2002;50(7 Suppl):S226–9.

    Article  PubMed  Google Scholar 

  7. Gomez CR, Boehmer ED, Kovacs EJ. The aging innate immune system. Curr Opin Immunol. 2005;17(5):457–62.

    Article  CAS  PubMed  Google Scholar 

  8. Goodwin K, Viboud C, Simonsen L. Antibody response to influenza vaccination in the elderly: a quantitative review. Vaccine. 2006;24(8):1159–69.

    Article  CAS  PubMed  Google Scholar 

  9. Bertoni AG, Saydah S, Brancati FL. Diabetes and the risk of infection-related mortality in the U.S. Diabetes Care. 2001;24(6):1044–9.

    Article  CAS  PubMed  Google Scholar 

  10. Katona P, Katona-Apte J. The interaction between nutrition and infection. Clin Infect Dis. 2008;46(10):1582–8.

    Article  PubMed  Google Scholar 

  11. Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010;58(9):1734–8.

    Article  PubMed  Google Scholar 

  12. Compton GA. Bacterial skin and soft tissue infections in older adults. Clin Geriatr Med. 2013;29(2):443–59.

    Article  PubMed  Google Scholar 

  13. Quagliarello V, Ginter S, Han L, Van Ness P, Allore H, Tinetti M. Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis. 2005;40(1):1–6.

    Article  PubMed  Google Scholar 

  14. Donlan RM. Biofilm formation: a clinically relevant microbiological process. Clin Infect Dis. 2001;33(8):1387–92.

    Article  CAS  PubMed  Google Scholar 

  15. D’Agata E, Loeb MB, Mitchell SL. Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc. 2013;61(1):62–6.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Norman DC. Fever in the elderly. Clin Infect Dis. 2000;31(1):148–51.

    Article  CAS  PubMed  Google Scholar 

  17. Gleckman R, Hibert D. Afebrile bacteremia. A phenomenon in geriatric patients. JAMA. 1982;248(12):1478–81.

    Article  CAS  PubMed  Google Scholar 

  18. High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48(2):149–71.

    Article  PubMed  Google Scholar 

  19. Ahkee S, Srinath L, Ramirez J. Community-acquired pneumonia in the elderly: association of mortality with lack of fever and leukocytosis. South Med J. 1997;90(3):296–8.

    Article  CAS  PubMed  Google Scholar 

  20. Faulkner CM, Cox HL, Williamson JC. Unique aspects of antimicrobial use in older adults. Clin Infect Dis. 2005;40(7):997–1004.

    Article  PubMed  Google Scholar 

  21. Drusano GL, Munice Jr HL, Hoopes JM, Damron DJ, Warren JW. Commonly used methods of estimating creatinine clearance are inadequate for elderly debilitated nursing home patients. J Am Geriatr Soc. 1988;36(5):437–41.

    Article  CAS  PubMed  Google Scholar 

  22. Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147(11):755–65.

    Article  PubMed  Google Scholar 

  23. Shehab N, Patel PR, Srinivasan A, Budnitz DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis. 2008;47(6):735–43.

    Article  PubMed  Google Scholar 

  24. Strausbaugh LJ, Joseph CL. The burden of infection in long-term care. Infect Control Hosp Epidemiol. 2000;21(10):674–9.

    Article  CAS  PubMed  Google Scholar 

  25. Anand N, Kollef MH. The alphabet soup of pneumonia: CAP, HAP, HCAP, NHAP, and VAP. Semin Respir Crit Care Med. 2009;30(1):3–9.

    Article  PubMed  Google Scholar 

  26. Kaplan V, Angus DC, Griffin MF, Clermont G, Scott Watson R, Linde-Zwirble WT. Hospitalized community-acquired pneumonia in the elderly: age- and sex-related patterns of care and outcome in the United States. Am J Respir Crit Care Med. 2002;165(6):766–72.

    Article  PubMed  Google Scholar 

  27. Loeb M. Pneumonia in older persons. Clin Infect Dis. 2003;37(10):1335–9.

    Article  PubMed  Google Scholar 

  28. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344(9):665–71.

    Article  CAS  PubMed  Google Scholar 

  29. Smith MD, Derrington P, Evans R, Creek M, Morris R, Dance DA, et al. Rapid diagnosis of bacteremic pneumococcal infections in adults by using the Binax NOW Streptococcus pneumoniae urinary antigen test: a prospective, controlled clinical evaluation. J Clin Microbiol. 2003;41(7):2810–3.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Jackson ML, Neuzil KM, Thompson WW, Shay DK, Yu O, Hanson CA, et al. The burden of community-acquired pneumonia in seniors: results of a population-based study. Clin Infect Dis. 2004;39(11):1642–50.

    Article  PubMed  Google Scholar 

  31. Vergis EN, Brennen C, Wagener M, Muder RR. Pneumonia in long-term care: a prospective case–control study of risk factors and impact on survival. Arch Intern Med. 2001;161(19):2378–81.

    Article  CAS  PubMed  Google Scholar 

  32. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27–72.

    Article  CAS  PubMed  Google Scholar 

  33. Juthani-Mehta M, De Rekeneire N, Allore H, Chen S, O’Leary JR, Bauer DC, et al. Modifiable risk factors for pneumonia requiring hospitalization of community-dwelling older adults: the Health, Aging, and Body Composition Study. J Am Geriatr Soc. 2013;61(7):1111–8.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Moberley S, Holden J, Tatham DP, Andrews RM. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev. 2013;(1):CD000422.

    Google Scholar 

  35. Bonten MJ, Huijts SM, Bolkenbaas M, Webber C, Patterson S, Gault S, et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med. 2015;372(12):1114–25.

    Article  CAS  PubMed  Google Scholar 

  36. Lexau CA, Lynfield R, Danila R, Pilishvili T, Facklam R, Farley MM, et al. Changing epidemiology of invasive pneumococcal disease among older adults in the era of pediatric pneumococcal conjugate vaccine. JAMA. 2005;294(16):2043–51.

    Article  CAS  PubMed  Google Scholar 

  37. DiazGranados CA, Dunning AJ, Kimmel M, Kirby D, Treanor J, Collins A, et al. Efficacy of high-dose versus standard-dose influenza vaccine in older adults. N Engl J Med. 2014;371(7):635–45.

    Article  PubMed  Google Scholar 

  38. Fiore AE, Uyeki TM, Broder K, Finelli L, Euler GL, Singleton JA, et al. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Recomm Rep. 2010;59(RR-8):1–62.

    PubMed  Google Scholar 

  39. 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(6):861–6.

    Article  CAS  PubMed  Google Scholar 

  40. Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2007. Vital Health Stat 13, Data from the National Health Survey. 2011;(169):1–38.

    Google Scholar 

  41. Juthani-Mehta M. Asymptomatic bacteriuria and urinary tract infection in older adults. Clin Geriatr Med. 2007;23(3):585–94.

    Article  PubMed  Google Scholar 

  42. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643–54.

    Article  PubMed  Google Scholar 

  43. Das R, Perrelli E, Towle V, Van Ness PH, Juthani-Mehta M. Antimicrobial susceptibility of bacteria isolated from urine samples obtained from nursing home residents. Infect Control Hosp Epidemiol. 2009;30(11):1116–9.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Jackson SL, Boyko EJ, Scholes D, Abraham L, Gupta K, Fihn SD. Predictors of urinary tract infection after menopause: a prospective study. Am J Med. 2004;117(12):903–11.

    Article  PubMed  Google Scholar 

  45. Caljouw MA, den Elzen WP, Cools HJ, Gussekloo J. Predictive factors of urinary tract infections among the oldest old in the general population. A population-based prospective follow-up study. BMC Med. 2011;9:57.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Nicolle LE. Urinary tract infections in the elderly. Clin Geriatr Med. 2009;25(3):423–36.

    Article  CAS  PubMed  Google Scholar 

  47. Hooton TM. Clinical practice. Uncomplicated urinary tract infection. N Engl J Med. 2012;366(11):1028–37.

    Article  CAS  PubMed  Google Scholar 

  48. Stone ND, Ashraf MS, Calder J, Crnich CJ, Crossley K, Drinka PJ, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol. 2012;33(10):965–77.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Juthani-Mehta M, Drickamer MA, Towle V, Zhang Y, Tinetti ME, Quagliarello VJ. Nursing home practitioner survey of diagnostic criteria for urinary tract infections. J Am Geriatr Soc. 2005;53(11):1986–90.

    Article  PubMed  Google Scholar 

  50. Olsho LE, Bertrand RM, Edwards AS, Hadden LS, Morefield GB, Hurd D, et al. Does adherence to the Loeb minimum criteria reduce antibiotic prescribing rates in nursing homes? J Am Med Dir Assoc. 2013;14(4):309.e1–7.

    Article  Google Scholar 

  51. Juthani-Mehta M, Tinetti M, Perrelli E, Towle V, Quagliarello V. Role of dipstick testing in the evaluation of urinary tract infection in nursing home residents. Infect Control Hosp Epidemiol. 2007;28(7):889–91.

    Article  PubMed  Google Scholar 

  52. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103–20.

    Article  PubMed  Google Scholar 

  53. Oplinger M, Andrews CO. Nitrofurantoin contraindication in patients with a creatinine clearance below 60 mL/min: looking for the evidence. Ann Pharmacother. 2013;47(1):106–11.

    Article  PubMed  Google Scholar 

  54. Gupta K, Sahm DF, Mayfield D, Stamm WE. Antimicrobial resistance among uropathogens that cause community-acquired urinary tract infections in women: a nationwide analysis. Clin Infect Dis. 2001;33(1):89–94.

    Article  CAS  PubMed  Google Scholar 

  55. Perrotta C, Aznar M, Mejia R, Albert X, Ng CW. Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database of Systematic Reviews. 2008;(2).

    Google Scholar 

  56. Bianco L, Perrelli E, Towle V, Van Ness PH, Juthani-Mehta M. Pilot randomized controlled dosing study of cranberry capsules for reduction of bacteriuria plus pyuria in female nursing home residents. J Am Geriatr Soc. 2012;60(6):1180–1.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2012;(10):CD001321.

    Google Scholar 

  58. Hersh AL, Chambers HF, Maselli JH, Gonzales R. National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections. Arch Intern Med. 2008;168(14):1585–91.

    Article  PubMed  Google Scholar 

  59. Edelsberg J, Taneja C, Zervos M, Haque N, Moore C, Reyes K, et al. Trends in US hospital admissions for skin and soft tissue infections. Emerg Infect Dis. 2009;15(9):1516–8.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10–52.

    Article  PubMed  Google Scholar 

  61. Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis and erysipelas. J Infect. 2012;64(2):148–55.

    Article  PubMed  Google Scholar 

  62. Gunderson CG. Cellulitis: definition, etiology, and clinical features. Am J Med. 2011;124(12):1113–22.

    Article  PubMed  Google Scholar 

  63. Whitley RJ. A 70-year-old woman with shingles: review of herpes zoster. JAMA. 2009;302(1):73–80.

    Article  CAS  PubMed  Google Scholar 

  64. Cohen JI. Clinical practice: herpes zoster. N Engl J Med. 2013;369(3):255–63.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  65. Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005;352(22):2271–84.

    Article  CAS  PubMed  Google Scholar 

  66. Schmader KE, Oxman MN, Levin MJ, Johnson G, Zhang JH, Betts R, et al. Persistence of the efficacy of zoster vaccine in the shingles prevention study and the short-term persistence substudy. Clin Infect Dis. 2012;55(10):1320–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Lessa FC, Mu Y, Bamberg WM, Beldavs ZG, Dumyati GK, Dunn JR, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372(9):825–34.

    Article  CAS  PubMed  Google Scholar 

  68. Henrich TJ, Krakower D, Bitton A, Yokoe DS. Clinical risk factors for severe Clostridium difficile-associated disease. Emerg Infect Dis. 2009;15(3):415–22.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Pawar D, Tsay R, Nelson DS, Elumalai MK, Lessa FC, Clifford McDonald L, et al. Burden of Clostridium difficile infection in long-term care facilities in Monroe County, New York. Infect Control Hosp Epidemiol. 2012;33(11):1107–12.

    Article  PubMed  Google Scholar 

  70. Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431–55.

    Article  PubMed  Google Scholar 

  71. Koo HL, Koo DC, Musher DM, DuPont HL. Antimotility agents for the treatment of Clostridium difficile diarrhea and colitis. Clin Infect Dis. 2009;48(5):598–605.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA

    Theresa Rowe

  2. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615, N Wolfe Street, Baltimore, MD, 21205, USA

    Geetha Iyer

Authors
  1. Theresa Rowe
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Geetha Iyer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Theresa Rowe .

Editor information

Editors and Affiliations

  1. 10th Fl, CHICAGO, Illinois, USA

    Lee Ann Lindquist

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Rowe, T., Iyer, G. (2016). Challenges to Diagnosis and Management of Infections in Older Adults. In: Lindquist, L. (eds) New Directions in Geriatric Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-28137-7_3

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-28137-7_3

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-28135-3

  • Online ISBN: 978-3-319-28137-7

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation