Ethical Issues Relating to the Use of Antimicrobial Therapy in Older Adults

Marcus, Esther‐Lee; Clarfield, A. Mark; Moses, Allon E.

doi:10.1086/323757

Cited by 75 publications

(34 citation statements)

References 81 publications

(75 reference statements)

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“…Age has been shown to play an important role in infection associated mortality in many studies. 12,14,21 This was also shown in our study in that the mortality rate for those aged >85 was 1.9-fold higher than for those aged between 75 and 84 years. However, its significance decreased when other confounders were included, which is consistent with previous reports.…”

Section: Discussionsupporting

confidence: 86%

“…Moreover, infection is the major cause of death in the end stage of many diseases, such as malignancy,or heart, liver, or renal disease. 21 Mortality in the elderly with severe infection is even higher with rates ranging from 21% to 37% for bacteremia, 10% to 53% for pneumonia, and 6% for urinary tract infections. 5 The lower respiratory tract and urinary tract were the most common sources of infection in our study, consistent with epidemiological surveys on elderly populations.…”

Section: Discussionmentioning

confidence: 99%

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A scoring system to predict in-hospital death in oldest-old patients with infections in Taiwan

Chen

Hwang

Tjung

et al. 2012

Journal of Clinical Gerontology and Geriatrics

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a b s t r a c tBackground: The elderly population has the highest number of in-patient claims accounting for over 40% of in-patient medical expenses in Taiwan, and infectious diseases are one of the most common causes of hospitalization in elderly patients. The aims of the study were to identify independent predictors of mortality, and to develop a simple scoring system for use in a busy clinical medical setting. Methods: All patients aged 75 years and older presenting to our emergency department or outpatient clinics who were subsequently admitted due to infections between March and July 2009 were enrolled. Results: A total of 981 patients were included, and the mortality rate was 9.2%. Logistic regression revealed seven independent predictors of mortality [odds ratio (95% confidence interval)]: albumin <3 g/ dL [3.72 (1.97e7.00)], creatinine >1.5 mg/dL [2.94 (1.69e5.09)], total dependence on admission [1.64 (1.11e2.43)], systolic blood pressure <100 mmHg [4.46 (2.02e9.84)], white blood cell count !10 or 4 Â 10 9 /L [2.23 (1.23e4.04)], total bilirubin >1.2 mg/dL [2.37 (1.31e4.31)], and malignancy history [2.73 (1. 4e5.30)]. These were given weighting by discriminant analysis and used to create a receiver operating curve with an area under the curve of 0.820. The model was simplified and each variable was assigned scores of 3 or 4 to form an index predicting in-hospital mortality. Mortality increased with score: 0.9% for score <5; 6.9% for 6 to 11; 21.4% for 12 to15, 53.7% for 16 to 19, and all three subjects whose score was >19 died during hospitalization. Conclusion: Our scoring system derived from seven readily available variables including activity level, malignancy history, systolic blood pressure, and a small number of laboratory parameters predicted inhospital mortality in oldest-old patients with infections. This system may allow for the identification of high-risk patients soon after admission.

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Section: Discussionsupporting

confidence: 86%

Section: Discussionmentioning

confidence: 99%

A scoring system to predict in-hospital death in oldest-old patients with infections in Taiwan

Chen

Hwang

Tjung

et al. 2012

Journal of Clinical Gerontology and Geriatrics

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“…In a non-randomized prospective study, patients with severe dementia receiving antibiotics had no survival benefits compared to those without antibiotic for fever episode (21). It was different for patients with mild dementia: the estimated mortality rate was 7 times higher in the group that did not receive antibiotics (22). In the literature, there is no data for antifungal therapies.…”

Section: Discussionmentioning

confidence: 99%

Candiduria in Those over 85 Years Old: A Retrospective Study of 73 Patients

Fraisse¹,

Crouzet

Lachaud³

et al. 2011

Intern. Med.

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Objective Candiduria is a common finding in the growing population of very old patients that has not been previously studied. The objective was to study candiduria in the population aged 85 and over, including an estimation of the incidence, factor of acquisition, and evaluation of treatment and mortality. Methods retrospective monocentric study. Materials medical charts of patients aged of 85 and over who have candiduria diagnosed at Nimes University Hospital. Results The prevalence of candiduria in the hospitalized very old patients was 8.9%. More than half of strains isolated were C. albicans (59%). Mean age was 89.7 years old with 53 women and 20 men. Urinary catheter (55%) and prior antibiotic use (67%) were commonly found. Fifteen patients with candiduria were treated, consistently with fluconazole. Patients treated had higher Mini Mental Test score than the others. A high C-reactive protein level, Mac Cabe score or Charlson's score >7 were associated with 6 months mortality. Conclusion Episodes of candiduria in oldest old were associated with frailty and vulnerability of the patient. The medical decision for antifungal treatment is usually difficult to make but it did not seem to influence mortality.

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“…6–9 This may entail withholding of antibiotics or combining antibiotics with symptom relief. 10,11 From a population point of view, appropriate antibiotic use is important because of concerns regarding increased antimicrobial resistance.…”

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confidence: 99%

Antibiotics and Mortality in Patients with Lower Respiratory Infection and Advanced Dementia

Steen

Lane

Kowall

et al. 2012

Journal of the American Medical Directors Association

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Objectives: To describe long-term mortality rate and to assess associations between mortality rate and antibiotic treatment of lower respiratory infection in patients with advanced dementia; antibiotic treatment allocation was independent of mortality risk—leaving less room for biased associations than in previous multicenter observational studies. Design: Prospective study (2004–2009). Multilevel Cox proportional hazard analyses with adjustment for mortality risk were used to assess associations between antibiotics and mortality using time-dependent covariates. Setting: A US Department of Veterans Affairs nursing home. Participants: Ninety-four residents with advanced dementia who developed 109 episodes. Measurements: Survival, treatment, mortality risk, illness severity, fluid intake, and several other patient characteristics. Results: Ten-day mortality was 48%, and 6-month mortality was 74%. Antibiotics were used in 77% of episodes. Overall, antibiotics were not associated with mortality rate (Hazard Ratio [HR] 0.70, Confidence Interval [CI] 0.38–1.30); however, antibiotics were associated with reduced 10-day mortality rate (HR 0.51, CI, 0.30–0.87; rate after 10 days: 1.5, CI 0.42–5.2). Benefit from antibiotics was less likely with inadequate fluid intake, and when experiencing the first episode. Conclusion: In our sample of male nursing home residents with advanced dementia and lower respiratory infection, mortality was substantial despite antibiotic treatment. Antibiotics prolonged life but in many cases only for several days. Treatment decisions should take into account that antibiotics may delay death but may also prolong the dying process, indicating a need for accurate prediction of mortality and study of characteristics that may alter effectiveness of antibiotics.

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Ethical Issues Relating to the Use of Antimicrobial Therapy in Older Adults

Cited by 75 publications

References 81 publications

A scoring system to predict in-hospital death in oldest-old patients with infections in Taiwan

A scoring system to predict in-hospital death in oldest-old patients with infections in Taiwan

Candiduria in Those over 85 Years Old: A Retrospective Study of 73 Patients

Antibiotics and Mortality in Patients with Lower Respiratory Infection and Advanced Dementia

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