Annals of Long-Term Care: Clinical Care and Aging. 2015;23(7):13
Imagine an enemy significantly smaller than even the average human cell. It travels seemingly undetected by air, land, and sea. Once it attacks, it can cause billions of dollars worth of damage per year and can lead to 15,000 preventable deaths in the same timespan. Strange as it may sound, it’s not a foe that’s hard to imagine at all: it’s Clostridium difficile (C. difficile).
C. difficile is one of several common bacterial pathogens that can be particularly worrisome in long-term care (LTC) environments. The US Centers for Disease Control and Prevention estimate that this single bacterial strain is responsible for 0.5 million illnesses annually (with 80% occurring in older adults) and that 1 in 11 people aged 65 years or older will die within 1 month of a C. difficile diagnosis. Although antibiotic treatment has revolutionized our approach to these and other infections, including urinary tract infections (UTIs) and pneumonia, effective antibiotic stewardship can be equally problematic if overlooked. These considerations were the genesis for a special symposium, “Updates on Common Infections in Older Adults,” at the 2015 American Geriatrics Society Annual Scientific Meeting (AGS15). Led by David A. Nace, MD, MPH; Verna R. Sellers, MD, MPH, CMD, AGSF; and Robin L.P. Jump, MD, PhD, the session focused on managing common infections in older patients, with an eye toward helping participants identify cases, choose appropriate therapies, and incorporate the same into other infection-control strategies in LTC contexts.
These practices are essential for cases of C. difficile, as Dr. Jump explained, because antibiotic use remains the most important risk factor for acquiring the pathogen. Some studies suggest that it can put an entire patient population at risk, including those who are not receiving antibiotics themselves. This scenario can be even more problematic for populations of older adults: advanced age is the next most important risk factor for infection with C. difficile, and, in 2010, more than 90% of deaths due to C. difficile occurred in people aged 65 years or older.
Because of this elevated risk, Dr. Jump reinforced the importance of taking appropriate measures on a case-by-case basis where C. difficile is concerned. These include discontinuing the inciting antibiotics when possible, but also choosing appropriate treatment options based on case severity. From a public health perspective, it also means being conscious of proper hygiene, early patient isolation, education of housekeeping staff, and new technologies for cleaning “hard to reach” places.
Many of these principles extend beyond cases of C. difficile. Reviewing common decision-making errors when approaching suspected UTIs, Dr. Nace noted that these suspected cases remain the most common condition for antibiotic use in the LTC setting, but that such treatment may ultimately be unnecessary in up to 75% of cases. Dr. Nace reiterated the importance of distinguishing between actual UTIs and asymptomatic bacteriuria and of not using antibiotic treatment inappropriately for the latter as a “harmless” catch-all for infection. Similarly, Dr. Sellers addressed how the myriad “alphabet soup” of pneumonias originating in healthcare contexts (CAP, HCAP, HAP, VAP, etc.) has increased as much as 10-fold in recent years and can account for almost half of all infections in some nursing homes. However, here too must effective therapy be tied to local resistance patterns, take into consideration a patient’s risk for treatment resistance, and incorporate early communication—particularly with a patient and his or her family—as an integral part of the treatment paradigm.
Several other resources exist to help healthcare professionals effectively identify and control bacterial infections. The latest edition of Geriatrics At Your Fingertips (GAYF), for example, provides an easy-to-access synthesis of treatment guidance for pneumonia, urinary tract infections, methicillin-resistant Staphylococcus aureus (MRSA) infections, and other such conditions, and also reviews classes of antimicrobials and principles for antimicrobial stewardship. These include:
• Collaborating with local antimicrobial stewardship teams;
• Becoming more familiar with formulary restrictions and pre-authorization requirements;
• Participating in educational offerings;
• Streamlining/de-escalating empirical treatment, when appropriate;
• Optimizing/individualizing antibiotic doses; and
• Switching eligible patients to oral antimicrobials, when available.
GAYF and other resources—including speaker handouts from the AGS15 symposium—are available from GeriatricsCareOnline.org.