Sepsis in Geriatric Patient

Sepsis is especially dangerous for elderly patients 

People over 65 are 13 times more likely to be hospitalized with sepsis than adults younger than 65, and the mortality rates for elderly patients with severe sepsis and septic shock are around 50 –60%.1- 4 These high death rates occur because the elderly often experience co-morbidities, frequent and extended hospitalizations, weakened immune systems, functional limitations, and general effects of aging like thinning skin, frailty, and a sedentary lifestyle.1

People over 65 are 13x more likely to be hospitalized with sepsis2-5

The mortality rates for elderly patients with sepsis and septic shock are around 50-60%.

Making a timely and accurate diagnosis is essential 

Diagnosis of infection is often difficult and delayed.5 For example, the first symptom of a UTI, a leading cause of infection, is typically confusion and disorientation, making it hard for the patient to describe his or her symptoms. In addition, the presentation of symptoms can be ambiguous or atypical. Moreover, elderly patients may not exhibit fever or other clinical signs of infection or inflammation seen in younger patients, even though seniors are at higher mortality risk.

Additionally, the bladder is often colonized in many elderly people leading to false positive results of the urinalysis that show colonization and not infection. This leads to an over prescription of antibiotics in this patient population.6

The decline in immune function often observed in elderly patients7-9 can result in atypical and frequently subtle (e.g., mild fever or even apyrexia) clinical presentations of bacteremia,7,8,10-12 further increasing the risk of under diagnosis and subsequent delays in the treatment of sepsis.

Given these challenges to diagnosis, and the vulnerability of the geriatric population to infection, having a diagnostic test with high specificity and predictive value is essential. Procalcitonin (PCT) can meet this need. With PCT testing, physicians gain timely information specific to systemic bacterial infection, including its presence, course, and severity.13


PCT is sensitive and specific

One meta-analysis of four studies (760 patients, aged 65 years and older) evaluated the accuracy of procalcitonin in diagnosing systemic bacterial infections in elderly patients.11 It was found that procalcitonin is both specific and sensitive in the diagnosis of severe bacterial infection in elderly patients. As shown in randomized controlled trials, very elderly patients can benefit from the use of PCT as a means of lowering antibiotic exposure. While kidney function in many older patients may be impaired, which can affect biomarker kinetics, there is no evidence that it impacts the usefulness of PCT as a diagnostic tool. As always, test results should be interpreted in the context of clinical findings.

Learn more about implementing optimized procalcitonin testing in your hospital.

References
  1. Nasa P, Juneja D, Singh O, Dang R, Arora V. Severe sepsis and its impact on outcome in elderly and very elderly patients admitted in intensive care unit. J Intensive Care Med. 2012 May;27(3):179-83.
  2. Hall MJ, Williams SN, DeFrances CJ, Golosinskiy A. Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS data brief. 2011;(62): 1–8.
  3. Martin GS, Mannino DM, Moss M. The effect of age on the development and outcome of adult sepsis. Crit Care Med. 2006;34:15–21.
  4. Vosylius S, Sipylaite J, Ivaskevicius J. Determinants of outcome in elderly patients admitted to the intensive care unit. Age Ageing. 2005;34:157–162.
  5. Girard TD, Ely EW. Bacteremia and sepsis in older adults. Clin Geriatr Med. 2007;23:633–47.
  6. Pallin DJ, Ronan C, Montazeri K, Wai K, Gold A, Parmar S, et al. Urinalysis in acute care of adults: Pitfalls in testing and interpreting results. Open Forum Infect Dis. 2014 Mar 1 (Vol. 1, No. 1). Oxford University Press.
  7. Ackermann RJ, Monroe PW. Bacteremic urinary tract infection in older people. J Am Geriatr Soc. 1996 Aug;44(8):927-33.
  8. Lee CC, Chang IJ, Lai YC, Chen SY, Chen SC. Epidemiology and prognostic determinants of patients with bacteremic cholecystitis or cholangitis. Am J Gastroenterol. 2007 Mar 1;102(3):563-9.
  9. Gutierrez F, Masia M. Improving outcomes of elderly patients with community-acquired pneumonia. Drugs Aging 2008;25:585-610.
  10. Van Duin D. Diagnostic challenges and opportunities in older adults with infectious diseases. Clin Infect Dis. 2012;54:973–8.
  11. Lee SH, Chan RC, Wu JY, et al. Diagnostic value of procalcitonin for bacterial infection in elderly patients - A systemic review and meta-analysis. Int J Clin Pract. 2013;67:1350-1357.
  12. Fernández-Sabé N, Carratalà J, Rosón B, Dorca J, Verdaguer R, Manresa F, et al. Community-acquired pneumonia in very elderly patients: Causative organisms, clinical characteristics, and outcomes. Medicine. 2003 May 1;82(3):159-69.
  13. Karzai W, Oberhoffer M, Meier-Hellmann A, Reinhart K. Procalcitonin—A new indicator of the systemic response to severe infections. Infection. 1997 Nov 1;25(6):329-34.
  14. Gómez-Cerquera JM, Daroca-Pérez R, Baeza-Trinidad R, Casañas-Martinez M, Mosquera-Lozano JD, Ramalle-Gómara E. Validity of procalcitonin for the diagnosis of bacterial infection in elderly patients. Enferm Infecc Microbiol Clin. 2015 Oct;33(8):521-4.
  15. Fuentes E, Fuentes M, Alarcon M, Palomo I. Immune System Dysfunction in the Elderly. An Acad Bras Cienc. 2017;89(1):285-299.
  16. Guertler C, Wirz B, Christ-Crain M, Zimmerli W, Mueller B, Schuetz P. Inflammatory responses predict long-term mortality risk in community-acquired pneumonia. Eur Respir J. 2011;37(6):1439-1446.  
  17. Schuetz P, Christ-Crain M, Muller B. Biomarkers to improve diagnostic and prognostic accuracy in systemic infections. Current opinion in critical care. 2007;13(5):578-585.