Treating elderly patients with infections represents one of the greatest challenges to health-care providers. Older adults are the largest growing sector of the population and suffer excessively from infectious diseases such as pneumonia, urinary tract infections (UTIs), and skin and soft-tissue infections. Often because of disabilities, the elderly require treatment of infectious diseases in long-term care facilities (LTCFs). As a result of antibiotic use, LTCFs have become “reservoirs of resistance” and multi-drug resistant (MDR) pathogens are frequently recovered. Clinicians also need to be aware of the impairment of immune function and other emerging chronic infections (HIV, HCV) that are now present in the elderly. Despite vigilance regarding this issue, delays in diagnosis and initiation of therapy are common. This article reviews the changing landscape of infections in the elderly and the challenge these syndromes present in the context of an increasing older population that requires dedicated resources.
1. T.T. Yoshikawa 2002 Resistant pathogens: considerations in geriatrics and infectious disease J Am Geriatr Soc 50 7Suppl S225.
2. Yoshikawa TT : Antimicrobial resistance and aging: beginning of the end of the antibiotic era? JAm Geriatr Soc 50 (7 Suppl), S226–S229 (2002).
3. K. Dorshkind E. Montecino-Rodriguez R.A. Signer 2009 The ageing immune system: is it ever too old to become young again? Nat Rev Immunol 9 1 57–62.
4. B. Capitano D.P. Nicolau 2003 Evolving epidemiology and cost of resistance to antimicrobial agents in long-term care facilities J Am Med Dir Assoc 4 3Suppl S90–S99.
5. L.J. Strausbaugh 2000 Prevention and control of infection in long-term-care facilities: an overview J Am Med Dir Assoc 1 2 62–68.
6. Strausbaugh LJ : Anxiety on the Watchtower: The hospital epidemiologist and emerging infectious diseases. Curr Infect Dis Rep 5 (6), 451–453 (2003).
7. L.J. Strausbaugh C.L. Joseph 2000 The burden of infection in long-term care Infect Control Hosp Epidemiol 21 10 674–679.
8. L.J. Strausbaugh S.R. Sukumar C.L. Joseph 2003 Infectious disease outbreaks in nursing homes: an unappreciated hazard for frail elderly persons Clin Infect Dis 36 7 870–876.
9. R.A. Bonomo L.B. Rice 1999 Emerging issues in antibiotic resistant infections in long-term care facilities J Gerontol A Biol Sci Med Sci 54 6 B260–B267.
10. M.G. Figueiro J.D. Bullough R.H. Parsons M.S. Rea 2005 Preliminary evidence for a change in spectral sensitivity of the circadian system at night J Circadian Rhythms 3 14.
11. K.P. High S.F. Bradley S. Gravenstein 2009 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 48 2 149–171.
12. R.A. Bonomo C.J. Donskey J.L. Blumer 2003 Cefotaxime-resistant bacteria colonizing older people admitted to an acute care hospital J Am Geriatr Soc 51 4 519–522.
13. S.F. Bradley 1999 Issues in the management of resistant bacteria in long-term-care facilities Infect Control Hosp Epidemiol 20 5 362–366.
14. S.F. Bradley 1997 Methicillin-resistant Staphylococcus aureus in nursing homes. Epidemiology, prevention and management Drugs Aging 10 3 185–198.
15. M.B. Loeb S. Craven A.J. McGeer 2003 Risk factors for resistance to antimicrobial agents among nursing home residents Am J Epidemiol 157 1 40–47.
16. L. Mody C.A. Kauffman S. Donabedian M. Zervos S.F. Bradley 2008 Epidemiology of Staphylococcus aureus colonization in nursing home residents Clin Infect Dis 46 9 1368–1373.
17. C. Sandoval S.D. Walter A. McGeer 2004 Nursing home residents and Enterobacteriaceae resistant to third-generation cephalosporins Emerg Infect Dis 10 6 1050–1055.
18. L. Tsan C. Davis R. Langberg 2008 Prevalence of nursing home-associated infections in the Department of Veterans Affairs nursing home care units Am J Infect Control 36 3 173–179.
19. D. Marchaim T. Chopra J.M. Pogue 2011 Outbreak of colistin-resistant, carbapenem-resistant Klebsiella pneumoniae in metropolitan Detroit, Michigan Antimicrob Agents Chemother 55 2 593–599.
20. F. Perez A. Endimiani A.J. Ray 2010 Carbapenem-resistant Acinetobacter baumannii and Klebsiella pneumoniae across a hospital system: impact of post-acute care facilities on dissemination J Antimicrob Chemother 65 8 1807–1818.
21. A. Endimiani J.M. Depasquale S. Forero 2009 Emergence of blaKPC-containing Klebsiella pneumoniae in a long-term acute care hospital: a new challenge to our healthcare system J Antimicrob Chemother 64 5 1102–1110.
22. N.L. Crogan B.C. Evans 2007 Clostridium difficile: an emerging epidemic in nursing homes Geriatr Nurs 28 3 161–164.
23. R.A. Garibaldi 1999 Residential care and the elderly: the burden of infection J Hosp Infect 43 Suppl S9–S18.
24. A. Goorhuis T. Van der Kooi N. Vaessen 2007 Spread and epidemiology of Clostridium difficile polymerase chain reaction ribotype 027/toxinotype III in The Netherlands Clin Infect Dis 45 6 695–703.
25. A.M. Laffan M.F. Bellantoni W.B. Greenough 3rd J.M. Zenilman 2006 Burden of Clostridium difficile-associated diarrhea in a long-term care facility J Am Geriatr Soc 54 7 1068–1073.
26. B.S. Bender 2003 Infectious disease risk in the elderly Immunol Allergy Clin North Am 23 1 57–64.
27. G. Gavazzi K.H. Krause 2002 Ageing and infection Lancet Infect Dis 2 11 659–666.
28. G. Gavazzi M.R. Mallaret P. Couturier A. Iffenecker A. Franco 2002 Bloodstream infection: differences between young-old, old, and old-old patients J Am Geriatr Soc 50 10 1667–1673.
29. S.Y. Liang P.A. Mackowiak 2007 Infections in the elderly Clin Geriatr Med 23 2 441–456.
30. R. Aspinall G. Del Giudice R.B. Effros B. Grubeck-Loebenstein S. Sambhara 2007 Challenges for vaccination in the elderly Immun Ageing 4 9.
31. M. Czesnikiewicz-Guzik W.W. Lee D. Cui 2008 T cell subset-specific susceptibility to aging Clin Immunol 127 1 107–118.
32. J.J. Goronzy W.W. Lee C.M. Weyand 2007 Aging and T-cell diversity Exp Gerontol 42 5 400–406.
33. A.L. Gruver L.L. Hudson G.D. Sempowski 2007 Immunosenescence of ageing J Pathol 211 2 144–156.
34. J.P. Viard A. Mocroft A. Chiesi 2001 Influence of age on CD4 cell recovery in human immunodeficiency virus-infected patients receiving highly active antiretroviral therapy: evidence from the EuroSIDA study J Infect Dis 183 8 1290–1294.
35. A.G. Babiker T. Peto K. Porter A.S. Walker J.H. Darbyshire 2001 Age as a determinant of survival in HIV infection J Clin Epidemiol 54 Suppl1 S16–S21.
36. K. Porter A. Babiker K. Bhaskaran 2003 Determinants of survival following HIV-1 seroconversion after the introduction of HAART Lancet 362 9392 1267–1274.
37. G. Touloumi N. Pantazis A. Antoniou H.A. Stirnadel S.A. Walker K. Porter 2006 Highly active antiretroviral therapy interruption: predictors and virological and immunologic consequences J Acquir Immune Defic Syndr 42 5 554–561.
38. G. Touloumi N. Pantazis H.A. Stirnadel 2008 Rates and determinants of virologic and immunological response to HAART resumption after treatment interruption in HIV-1 clinical practice J Acquir Immune Defic Syndr 49 5 492–498.
39. V. Appay J.R. Almeida D. Sauce B. Autran L. Papagno 2007 Accelerated immune senescence and HIV-1 infection Exp Gerontol 42 5 432–437.
40. V. Appay F. Boutboul B. Autran 2005 The HIV infection and immune activation: “to fight and burn” Curr Infect Dis Rep 7 6 473–479.
41. V. Appay S.L. Rowland-Jones 2002 Premature ageing of the immune system: the cause of AIDS? Trends Immunol 23 12 580–585.
42. M.A. Bachus 1998 HIV and the older adult J Gerontol Nurs 24 11 41–46.
43. B.S. Bender 1997 HIV and aging as a model for immunosenescence J Gerontol A Biol Sci Med Sci 52 5 M261–M263.
44. R.B. Effros C.V. Fletcher K. Gebo 2008 Aging and infectious diseases: workshop on HIV infection and aging: what is known and future research directions Clin Infect Dis 47 4 542–553.
45. M.J. Simone J. Appelbaum 2008 HIV in older adults Geriatrics 63 12 6–12.
46. D.J. Skiest 2003 The importance of co-morbidity in older HIV-infected patients Aids 17 10 1577.
47. D.J. Skiest P. Keiser 1997 Human immunodeficiency virus infection in patients older than 50 years. A survey of primary care physicians’ beliefs, practices, and knowledge Arch Fam Med 6 3 289–294.
48. A.R. Tenorio J. Spritzler J. Martinson 2008 The effect of aging on T-regulatory cell frequency in HIV infection Clin Immunol 130 3 298–303.
49. R.C. Kalayjian A. Landay R.B. Pollard 2003 Age-related immune dysfunction in health and in human immunodeficiency virus (HIV) disease: association of age and HIV infection with naive CD8+ cell depletion, reduced expression of CD28 on CD8+ cells, and reduced thymic volumes J Infect Dis 187 12 1924–1933.
50. R.C. Kalayjian J. Spritzler M. Pu 2005 Distinct mechanisms of T cell reconstitution can be identified by estimating thymic volume in adult HIV-1 disease J Infect Dis 192 9 1577–1587.
51. F. Cainelli 2008 Hepatitis C virus infection in the elderly: epidemiology, natural history and management Drugs Aging 25 1 9–18.
52. T. Serste N. Bourgeois 2006 Ageing and the liver Acta Gastroenterol Belg 69 3 296–298.
53. A.M. Arvin 1996 Varicella-zoster virus Clin Microbiol Rev 9 3 361–381.
54. R.H. Dworkin F.M. Perkins E.M. Nagasako 2000 Prospects for the prevention of postherpetic neuralgia in herpes zoster patients Clin J Pain 16 2Suppl S90–S100.
55. R. Harpaz I.R. Ortega-Sanchez J.F. Seward 2008 Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Recomm Rep 57 RR-5 1–30.
56. J.A. Stewart S.E. Reef P.E. Pellett L. Corey R.J. Whitley 1995 Herpesvirus infections in persons infected with human immunodeficiency virus Clin Infect Dis 21 Suppl1 S114–S120.
57. K. Terada S. Kawano K. Yoshihiro T. Morita 1994 Varicella-zoster virus (VZV) reactivation is related to the low response of VZV-specific immunity after chickenpox in infancy J Infect Dis 169 3 650–652.
58. M.N. Oxman M.J. Levin G.R. Johnson 2005 A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults N Engl J Med 352 22 2271–2284.
59. G. Dimopoulos 2007 Antibiotics selection for bacteremic pneumonia Chest 132 1 360–361.
60. G. Dimopoulos D.K. Matthaiou D.E. Karageorgopoulos A.P. Grammatikos Z. Athanassa M.E. Falagas 2008 Short-versus longcourse antibacterial therapy for community-acquired pneumonia: a meta-analysis Drugs 68 13 1841–1854.
61. C.P. Chong P.R. Street 2008 Pneumonia in the elderly: a review of the epidemiology, pathogenesis, microbiology, and clinical features South Med J 101 11 1141–1145.
62. J.P. Janssens K.H. Krause 2008 Pneumonia in the very old Lancet Infect Dis 4 2 112–124.
63. J.M. Katz J. Plowden M. Renshaw-Hoelscher X. Lu T.M. Tumpey S. Sambhara 2004 Immunity to influenza: the challenges of protecting an aging population Immunol Res 29 1–3 113–124.
64. T. Kumagai K. Nagai T. Okui 2004 Poor immune responses to influenza vaccination in infants Vaccine 22 25–26 3404–3410.
65. L. Simonsen T.A. Reichert C. Viboud W.C. Blackwelder R.J. Taylor M.A. Miller 2005 Impact of influenza vaccination on seasonal mortality in the US elderly population Arch Intern Med 165 3 265–272.
66. L.C. McDonald G.E. Killgore A. Thompson 2005 An epidemic, toxin gene-variant strain of Clostridium difficile N Engl J Med 353 23 2433–2441.
67. P. Gardner T. Eickhoff G.A. Poland 1996 Adult immunizations Ann Intern Med 124 1Pt1 35–40.
68. P.A. Gross A.W. Hermogenes H.S. Sacks J. Lau R.A. Levandowski 1995 The efficacy of influenza vaccine in elderly persons. A meta-analysis and review of the literature Ann Intern Med 123 7 518–527.
69. E.A. Belongia D.K. Shay 2008 Influenza vaccine for community-acquired pneumonia Lancet 372 9636 352–354.
70. M.L. Jackson J.C. Nelson N.S. Weiss K.M. Neuzil W. Barlow L.A. Jackson 2008 Influenza vaccination and risk of communityacquired pneumonia in immunocompetent elderly people: a population-based, nested case-control study Lancet 372 9636 398–405.
71. K.L. Nichol J.D. Nordin D.B. Nelson J.P. Mullooly E. Hak 2007 Effectiveness of influenza vaccine in the community-dwelling elderly N Engl J Med 357 14 1373–1381.
72. C. Thijs A. Knottnerus 2008 Influenza vaccination and risk of community-acquired pneumonia Lancet 372 9656 2112.
73. P.A. Bradford C. Urban A. Jaiswal 1995 SHV-7, a novel cefotaxime-hydrolyzing beta-lactamase, identified in Escherichia coli isolates from hospitalized nursing home patients Antimicrob Agents Chemother 39 4 899–905.
74. L.B. Rice E.C. Eckstein J. DeVente D.M. Shlaes 1996 Ceftazidimeresistant Klebsiella pneumoniae isolates recovered at the Cleveland Department of Veterans Affairs Medical Center Clin Infect Dis 23 1 118–124.
75. L.B. Rice S.H. Willey G.A. Papanicolaou 1990 Outbreak of ceftazidime resistance caused by extended-spectrum beta-lactamases at a Massachusetts chronic-care facility Antimicrob Agents Chemother 34 11 2193–2199.
76. L. Niclaes F. Buntinx F. Banuro E. Lesaffre J. Heyrman 1999 Consequences of MRSA carriage in nursing home residents Epidemiol Infect 122 2 235–239.
77. J. Oteo C. Navarro E. Cercenado 2006 Spread of Escherichia coli strains with high-level cefotaxime and ceftazidime resistance between the community, long-term care facilities, and hospital institutions J Clin Microbiol 44 7 2359–2366.