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Managing Infectious Disease in the Critically Ill Elderly Patient

  • Surgical Care (F Luchette and R Gonzalez, Section Editors)
  • Published:
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Abstract

Purpose of the Review

Infections and subsequent sepsis are an increasing cause of hospital admission and critical illness in the elderly population. The risk factors that predispose elderly patients to infections, such as comorbidities and frailty, also contribute to prolonged recovery times and subsequent mortality.

Recent Findings

Elderly patients may present with atypical symptoms such as delirium and remain afebrile thus delaying the diagnosis of infections. White blood cell count is not as useful in the diagnosis of infection as other biomarkers such as procalcitonin. Once an infection has begun, the elderly patient has less physiologic cardiac and respiratory reserve and develops end organ damage more rapidly. Frailty itself is strongly associated with high rates of first time sepsis. Mortality risk from sepsis clearly increases with age. Appropriate antibiotics and source control are necessary components of sepsis management as is early fluid resuscitation. Fluid resuscitation must be performed judiciously with appropriate endpoints utilizing bedside cardiac ultrasound and IVC collapsibility to avoid fluid overload. Acute kidney injury (AKI) occurs in 1/3–2/3 of elderly septic patients and increases mortality. AKI is potentially preventable with appropriate and timely fluid resuscitation and avoiding nephrotoxic medications including loading doses of vancomycin, limiting aminoglycoside exposure to < 3 days, and minimizing colistin use. Source control within 12 h when appropriate improves outcome. Specific infections, including Clostridium difficile, community-acquired pneumonia, and urinary tract infection, pose unique challenges in the elderly. Early goals-of-care discussions emphasizing potential complications and undesirable outcomes must be discussed when caring for critically ill elderly patients.

Summary

Early recognition of sepsis via identification of atypical signs and symptoms in elderly patients is critical. This allows for timely and appropriate therapy to decrease the incidence of end organ damage and mortality in high-risk elderly patients.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Vergidis P, Hamer DH, Meydani SN, Dallal GE, Barlam TF. Patterns of antimicrobial use for respiratory tract infections in older residents of long-term care facilities. J Am Geriatr Soc. 2011;59(6):1093–8. https://doi.org/10.1111/j.1532-5415.2011.03406.x.

    Article  PubMed  PubMed Central  Google Scholar 

  2. National Center for Health Statistics. Table 20. Leading causes of death and numbers of deaths, by age: United States, 1980 and 2016. April 2018:1–3.

  3. Rubens M, Saxena A, Ramamoorthy V, Das S, Khera R, Hong J, et al. Increasing sepsis rates in the United States: results from National Inpatient Sample, 2005 to 2014. J Intensive Care Med. 2018;115(6):088506661879413–1. https://doi.org/10.1177/0885066618794136.

    Article  Google Scholar 

  4. Lee S-H, Hsu T-C, Lee M-TG, et al. Nationwide trend of sepsis: a comparison among octogenarians, elderly, and young adults. Crit Care Med. 2018;46(6):926–34. https://doi.org/10.1097/CCM.0000000000003085.

    Article  PubMed  Google Scholar 

  5. Kopczynska M, Sharif B, Cleaver S, Spencer N, Kurani A, Lee C, et al. Red-flag sepsis and SOFA identifies different patient population at risk of sepsis-related deaths on the general ward. Medicine (Baltimore). 2018;97(49):e13238–7. https://doi.org/10.1097/MD.0000000000013238.

    Article  Google Scholar 

  6. Caterino JM. Evaluation and management of geriatric infections in the emergency department. Emerg Med Clin North Am. 2008;26(2):319–43. https://doi.org/10.1016/j.emc.2008.01.002.

    Article  PubMed  Google Scholar 

  7. •• Maxwell CA, Patel MB, Suarez-Rodriguez LC, Miller RS. Frailty and prognostication in geriatric surgery and trauma. Clin Geriatr Med. 2019;35(1):13–26. https://doi.org/10.1016/j.cger.2018.08.002 This article presents a review of the concept of frailty and its role for prognostication among geriatric trauma and surgery patients, as well as best practices for the delivery of prognostic information in acute care settings and specific recommendations for trauma and surgical care settings.

    Article  PubMed  Google Scholar 

  8. Mahalingam M, Moore JX, Donnelly JP, Safford MM, Wang HE. Frailty syndrome and risk of sepsis in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort. J Intensive Care Med. 2019;34(4):292–300. https://doi.org/10.1177/0885066617715251.

    Article  PubMed  Google Scholar 

  9. Heyland DK, Garland A, Bagshaw SM, Cook D, Rockwood K, Stelfox HT, et al. Recovery after critical illness in patients aged 80 years or older: a multi-center prospective observational cohort study. Intensive Care Med. 2015;41(11):1911–20. https://doi.org/10.1007/s00134-015-4028-2.

    Article  PubMed  Google Scholar 

  10. Chassagne P, Perol MB, Doucet J, Trivalle C, Ménard JF, Manchon ND, et al. Is presentation of bacteremia in the elderly the same as in younger patients? Am J Med. 1996;100(1):65–70.

    Article  CAS  PubMed  Google Scholar 

  11. Waalen J, Buxbaum JN. Is older colder or colder older? The association of age with body temperature in 18,630 individuals. J Gerontol A Biol Sci Med Sci. 2011;66A(5):487–92. https://doi.org/10.1093/gerona/glr001.

    Article  PubMed Central  Google Scholar 

  12. Gomolin IH, Aung MM, Wolf-Klein G, Auerbach C. Older is colder: temperature range and variation in older people. J Am Geriatr Soc. 2005;53(12):2170–2. https://doi.org/10.1111/j.1532-5415.2005.00500.x.

    Article  PubMed  Google Scholar 

  13. Khodorkovsky B, Youssef E, Adamakos F, Cina T, Falco A, LaMura L, et al. Does initial temperature in the emergency department predict outcomes in patients admitted for sepsis? J Emerg Med. 2018;55(3):372–7. https://doi.org/10.1016/j.jemermed.2018.06.008.

    Article  PubMed  Google Scholar 

  14. • Chou H-L, Han S-T, Yeh C-F, et al. Systemic inflammatory response syndrome is more associated with bacteremia in elderly patients with suspected sepsis in emergency departments. Medicine (Baltimore). 2016;95(49):e5634–7. https://doi.org/10.1097/MD.0000000000005634 Elderly patients present with atypical symptoms of infection making early and accurate diagnosis challenging. Elderly patients presenting with bacteremia are more likely to have tachypnea with overall SIRS criteria more likely to predict bacteremia among elderly patients, compared to young patients.

    Article  CAS  Google Scholar 

  15. Brooks SE, Peetz AB. Evidence-based care of geriatric trauma patients. Surg Clin North Am. 2017;97(5):1157–74. https://doi.org/10.1016/j.suc.2017.06.006.

    Article  PubMed  Google Scholar 

  16. Kuswardhani RAT, Sugi YS. Factors related to the severity of delirium in the elderly patients with infection. Gerontol Geriatr Med. 2017;3:2333721417739188. https://doi.org/10.1177/2333721417739188.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Ebersoldt M, Sharshar T, Annane D. Sepsis-associated delirium. Intensive Care Med. 2007;33(6):941–50. https://doi.org/10.1007/s00134-007-0622-2.

    Article  PubMed  Google Scholar 

  18. Guthrie PF, Rayborn S, Butcher HK. Evidence-based practice guideline: delirium. J Gerontol Nurs. 2018;44(2):14–24. https://doi.org/10.3928/00989134-20180110-04.

    Article  PubMed  Google Scholar 

  19. Moraga AV, Rodriguez-Pascual C. Acurate diagnosis of delirium in elderly patients. Curr Opin Psychiatry. 2007;20(3):262–7. https://doi.org/10.1097/YCO.0b013e3280ec52e5.

    Article  PubMed  Google Scholar 

  20. Chae JHJ, Miller BJ. Beyond urinary tract infections (UTIs) and delirium. J Psychiatr Pract. 2015;21(6):402–11. https://doi.org/10.1097/PRA.0000000000000105.

    Article  PubMed  Google Scholar 

  21. Balogun SA, Philbrick JT. Delirium, a symptom of UTI in the elderly: fact or fable? A systematic review*. Can Geri J. 2014;17(1):1–5. https://doi.org/10.5770/cgj.17.90.

    Article  Google Scholar 

  22. Mattox K, Moore E, Feliciano D. Trauma, Seventh Edition. McGraw Hill Professional; 2012.

  23. Ramly E, Kaafarani HMA, Velmahos GC. The effect of aging on pulmonary function: implications for monitoring and support of the surgical and trauma patient. Surg Clin North Am. 2015;95(1):53–69. https://doi.org/10.1016/j.suc.2014.09.009.

    Article  PubMed  Google Scholar 

  24. Culham EG, Jimenez HA, King CE. Thoracic kyphosis, rib mobility, and lung volumes in normal women and women with osteoporosis. Spine. 1994;19(11):1250–5.

    Article  CAS  PubMed  Google Scholar 

  25. Janssens J-P. Aging of the respiratory system: impact on pulmonary function tests and adaptation to exertion. Clin Chest Med. 2005;26(3):469–84–vi–vii–84. https://doi.org/10.1016/j.ccm.2005.05.004.

    Article  PubMed  Google Scholar 

  26. Ticinesi A, Milani C, Lauretani F, Nouvenne A, Mancabelli L, Lugli GA, et al. Gut microbiota composition is associated with polypharmacy in elderly hospitalized patients. Sci Rep. 2017;7(1):11102. https://doi.org/10.1038/s41598-017-10734-y.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Vischer UM, Frangos E, Graf C, Gold G, Weiss L, Herrmann FR, et al. The prognostic significance of malnutrition as assessed by the Mini Nutritional Assessment (MNA) in older hospitalized patients with a heavy disease burden. Clin Nutr. 2012;31(1):113–7. https://doi.org/10.1016/j.clnu.2011.09.010.

    Article  PubMed  Google Scholar 

  28. Almeida AI, Correia M, Camilo M, Ravasco P. Nutritional risk screening in surgery: valid, feasible, easy! Clin Nutr. 2012;31(2):206–11. https://doi.org/10.1016/j.clnu.2011.10.003.

    Article  PubMed  Google Scholar 

  29. Abdel-Kader K, Palevsky PM. Acute kidney injury in the elderly. Clin Geriatr Med. 2009;25(3):331–58. https://doi.org/10.1016/j.cger.2009.04.001.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Musso CG, Oreopoulos DG. Aging and physiological changes of the kidneys including changes in glomerular filtration rate. Nephron Physiol. 2011;119(Suppl 1):p1–5. https://doi.org/10.1159/000328010.

    Article  CAS  PubMed  Google Scholar 

  31. Schmitt R, Coca S, Kanbay M, Tinetti ME, Cantley LG, Parikh CR. Recovery of kidney function after acute kidney injury in the elderly: a systematic review and meta-analysis. Am J Kidney Dis. 2008;52(2):262–71. https://doi.org/10.1053/j.ajkd.2008.03.005.

    Article  PubMed  Google Scholar 

  32. Caterino JM, Scheatzle MD, Forbes ML, D'Antonio JA. Bacteremic elder emergency department patients: procalcitonin and white count. Acad Emerg Med. 2004;11(4):393–6. https://doi.org/10.1197/j.aem.2003.10.027.

    Article  PubMed  Google Scholar 

  33. Martin-Loeches I, Guia MC, Vallecoccia MS, Suarez D, Ibarz M, Irazabal M, et al. Risk factors for mortality in elderly and very elderly critically ill patients with sepsis: a prospective, observational, multicenter cohort study. Ann Intensive Care. 2019;9:1–9. https://doi.org/10.1186/s13613-019-0495-x.

    Article  Google Scholar 

  34. Thiery-Antier N, Binquet C, Vinault S, Meziani F, Boisramé-Helms J, Quenot JP. Is thrombocytopenia an early prognostic marker in septic shock? Crit Care Med. 2016;44(4):764–72. https://doi.org/10.1097/CCM.0000000000001520.

    Article  PubMed  Google Scholar 

  35. Yildiz A, Yigit A, Benli AR. The impact of nutritional status and complete blood count parameters on clinical outcome in geriatric critically ill patients. J Clin Med Res. 2018;10(7):588–92. https://doi.org/10.14740/jocmr3461w.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Arnau-Barrés I, Güerri-Fernández R, Luque S, Sorli L, Vázquez O, Miralles R. Serum albumin is a strong predictor of sepsis outcome in elderly patients. Eur J Clin Microbiol Infect Dis. 2019;1(1):23–4. https://doi.org/10.1007/s10096-019-03478-2.

    Article  Google Scholar 

  37. Yin M, Si L, Qin W, Li C, Zhang J, Yang H, et al. Predictive value of serum albumin level for the prognosis of severe sepsis without exogenous human albumin administration: a prospective cohort study. J Intensive Care Med. 2018;33(12):687–94. https://doi.org/10.1177/0885066616685300.

    Article  PubMed  Google Scholar 

  38. Self WH, Balk RA, Grijalva CG, Williams DJ, Zhu Y, Anderson EJ, et al. Procalcitonin as a marker of etiology in adults hospitalized with community-acquired pneumonia. Clin Infect Dis. 2017;65(2):183–90. https://doi.org/10.1093/cid/cix317.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Wang Y, Zhang S, Li L, Xie J. The usefulness of serum procalcitonin, C-reactive protein, soluble triggering receptor expressed on myeloid cells 1 and Clinical Pulmonary Infection Score for evaluation of severity and prognosis of community-acquired pneumonia in elderly patients. Arch Gerontol Geriatr. 2019;80:53–7. https://doi.org/10.1016/j.archger.2018.10.005.

    Article  CAS  PubMed  Google Scholar 

  40. Nakamura Y, Murai A, Mizunuma M, Ohta D, Kawano Y, Matsumoto N, et al. Potential use of procalcitonin as biomarker for bacterial sepsis in patients with or without acute kidney injury. J Infect Chemother. 2015;21(4):257–63. https://doi.org/10.1016/j.jiac.2014.12.001.

    Article  CAS  PubMed  Google Scholar 

  41. Zhang H, Wang X, Zhang Q, Xia Y, Liu D. Comparison of procalcitonin and high-sensitivity C-reactive protein for the diagnosis of sepsis and septic shock in the oldest old patients. BMC Geriatr. 2017;17(1):173. https://doi.org/10.1186/s12877-017-0566-5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–56.

    Article  CAS  PubMed  Google Scholar 

  43. •• Cesari M, Araujo de Carvalho I, Amuthavalli Thiyagarajan J, et al. Evidence for the domains supporting the construct of intrinsic capacity. J Gerontol A Biol Sci Med Sci. 2018;73(12):1653–60. https://doi.org/10.1093/gerona/gly011 This innovative model recently proposed by the World Health Organization has the potential to substantially modify the way in which clinical practice is currently conducted, shifting from disease-centered toward function-centered paradigms.

    Article  PubMed  Google Scholar 

  44. Tang M, Quanstrom K, Jin C, Suskind AM. Recurrent urinary tract infections are associated with frailty in older adults. Urology. 2019;123:24–7. https://doi.org/10.1016/j.urology.2018.09.025.

    Article  PubMed  Google Scholar 

  45. Tannou T, Koeberle S, Manckoundia P, Aubry R. Multifactorial immunodeficiency in frail elderly patients: contributing factors and management. Med Mal Infect. February 2019;49:167–72. https://doi.org/10.1016/j.medmal.2019.01.012.

    Article  CAS  PubMed  Google Scholar 

  46. Wikby A, Ferguson F, Forsey R, Thompson J, Strindhall J, Lofgren S, et al. An immune risk phenotype, cognitive impairment, and survival in very late life: impact of allostatic load in Swedish octogenarian and nonagenarian humans. J Gerontol A Biol Sci Med Sci. 2005;60(5):556–65.

    Article  PubMed  Google Scholar 

  47. De Pauw B, Walsh TJ, Donnelly JP, et al. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis. 2008;46(12):1813–21. https://doi.org/10.1086/588660.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Hatfield KM, Dantes RB, Baggs J, Sapiano MRP, Fiore AE, Jernigan JA, et al. Assessing variability in hospital-level mortality among U.S. Medicare beneficiaries with hospitalizations for severe sepsis and septic shock. Crit Care Med. 2018;46(11):1753–60. https://doi.org/10.1097/CCM.0000000000003324.

    Article  PubMed  Google Scholar 

  49. Shankar-Hari M, Phillips GS, Levy ML, Seymour CW, Liu VX, Deutschman CS, et al. Developing a new definition and assessing new clinical criteria for septic shock. JAMA. 2016;315(8):775–13. https://doi.org/10.1001/jama.2016.0289.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Freund Y, Lemachatti N, Krastinova E, van Laer M, Claessens YE, Avondo A, et al. Prognostic accuracy of Sepsis-3 criteria for in-hospital mortality among patients with suspected infection presenting to the emergency department. JAMA. 2017;317(3):301–8. https://doi.org/10.1001/jama.2016.20329.

    Article  PubMed  Google Scholar 

  51. •• Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801–10. https://doi.org/10.1001/jama.2016.0287 This manuscript outlines the rationale for overhauling the diagnostic criteria for sepsis and septic shock and outlines the importance of qSOFA.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Cheng H-H, Chen F-C, Change M-W, Kung CT, Cheng CY, Tsai TC, et al. Difference between elderly and non-elderly patients in using serum lactate level to predict mortality caused by sepsis in the emergency department. Medicine (Baltimore). 2018;97(13):e0209. https://doi.org/10.1097/MD.0000000000010209.

    Article  CAS  PubMed Central  Google Scholar 

  53. Francisco J, Aragão I, Cardoso T. Risk factors for long-term mortality in patients admitted with severe infection. BMC Infect Dis. 2018;18(1):161. https://doi.org/10.1186/s12879-018-3054-4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Leisman D, Wie B, Doerfler M, Bianculli A, Ward MF, Akerman M, et al. Association of fluid resuscitation initiation within 30 minutes of severe sepsis and septic shock recognition with reduced mortality and length of stay. Ann Emerg Med. 2016;68(3):298–311. https://doi.org/10.1016/j.annemergmed.2016.02.044.

    Article  PubMed  Google Scholar 

  55. Leisman DE, Goldman C, Doerfler ME, Masick KD, Dries S, Hamilton E, et al. Patterns and outcomes associated with timeliness of initial crystalloid resuscitation in a prospective sepsis and septic shock cohort*. Crit Care Med. 2017;45(10):1596–606. https://doi.org/10.1097/CCM.0000000000002574.

    Article  PubMed  Google Scholar 

  56. Kelm DJ, Perrin JT, Cartin-Ceba R, Gajic O, Schenck L, Kennedy CC. Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock. 2015;43(1):68–73. https://doi.org/10.1097/SHK.0000000000000268.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. Mitchell KH, Carlbom D, Caldwell E, Leary PJ, Himmelfarb J, Hough CL. Volume overload: prevalence, risk factors, and functional outcome in survivors of septic shock. Ann Am Thorac Soc. 2015;12(12):1837–44. https://doi.org/10.1513/AnnalsATS.201504-187OC.

    Article  PubMed  PubMed Central  Google Scholar 

  58. de Oliveira FSV, Freitas FGR, Ferreira EM, de Castro I, Bafi AT, de Azevedo LCP, et al. Positive fluid balance as a prognostic factor for mortality and acute kidney injury in severe sepsis and septic shock. J Crit Care. 2015;30(1):97–101. https://doi.org/10.1016/j.jcrc.2014.09.002.

    Article  PubMed  Google Scholar 

  59. Neyra JA, Li X, Canepa-Escaro F, Adams-Huet B, Toto RD, Yee J, et al. Cumulative fluid balance and mortality in septic patients with or without acute kidney injury and chronic kidney disease. Crit Care Med. 2016;44(10):1891–900. https://doi.org/10.1097/CCM.0000000000001835.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Zhao J, Wang G. Inferior vena cava collapsibility index is a valuable and non-invasive index for elevated general heart end-diastolic volume index estimation in septic shock patients. Med Sci Monit. 2016;22:3843–8. https://doi.org/10.12659/MSM.897406.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Coen D, Cortellaro F, Pasini S, Tombini V, Vaccaro A, Montalbetti L, et al. Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED. Am J Emerg Med. 2014;32(6):563–8. https://doi.org/10.1016/j.ajem.2014.02.011.

    Article  PubMed  Google Scholar 

  62. Oord M, Olgers TJ, Doff-Holman M, Harms MPM, Ligtenberg JJM, ter Maaten JC. Ultrasound and NICOM in the assessment of fluid responsiveness in patients with mild sepsis in the emergency department: a pilot study. BMJ Open. 2017;7(1):e013465. https://doi.org/10.1136/bmjopen-2016-013465.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Ng NYY, Ang HHE, Tan JCL, Ho WH, Kuan WS, Chua MT. Evaluation for occult sepsis incorporating NIRS and emergency sonography. Am J Emerg Med. 2018;36(11):1957–63. https://doi.org/10.1016/j.ajem.2018.02.020.

    Article  PubMed  Google Scholar 

  64. Long E, Oakley E, Duke T, Babl FE. Paediatric Research in Emergency Departments International Collaborative (PREDICT). Does respiratory variation in inferior vena cava diameter predict fluid responsiveness: a systematic review and meta-analysis. Shock. 2017;47(5):550–9. https://doi.org/10.1097/SHK.0000000000000801.

    Article  PubMed  Google Scholar 

  65. •• Levitov A, Frankel HL, Blaivas M, et al. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-part II: cardiac ultrasonography. Crit Care Med. 2016;44(6):1206–27. https://doi.org/10.1097/CCM.0000000000001847 Levitov provides an extensive set of evidence-based guidelines for the use of critical care ultrasonography.

    Article  PubMed  Google Scholar 

  66. Guarracino F, Ferro B, Forfori F, Bertini P, Magliacano L, Pinsky MR. Jugular vein distensibility predicts fluid responsiveness in septic patients. Crit Care. 2014;18(6):647. https://doi.org/10.1186/s13054-014-0647-1.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Nedel WL, Simas DM, Marin LG, Morais VD, Friedman G. Respiratory variation in femoral vein diameter has moderate accuracy as a marker of fluid responsivity in mechanically ventilated septic shock patients. Ultrasound Med Biol. 2017;43(11):2713–7. https://doi.org/10.1016/j.ultrasmedbio.2017.06.023.

    Article  PubMed  Google Scholar 

  68. Charbonneau H, Riu B, Faron M, Mari A, Kurrek MM, Ruiz J, et al. Predicting preload responsiveness using simultaneous recordings of inferior and superior vena cavae diameters. Crit Care. 2014;18(5):473. https://doi.org/10.1186/s13054-014-0473-5.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Rodrigo E, Suberviola B, Albines Z, Castellanos Á, Heras M, Rodriguez-Borregán JC, et al. A comparison of acute kidney injury classification systems in sepsis. Nefrologia. 2016;36(5):530–4. https://doi.org/10.1016/j.nefro.2016.03.021.

    Article  PubMed  Google Scholar 

  70. Medeiros P, Nga HS, Menezes P, Bridi R, Balbi A, Ponce D. Acute kidney injury in septic patients admitted to emergency clinical room: risk factors and outcome. Clin Exp Nephrol. 2015;19(5):859–66. https://doi.org/10.1007/s10157-014-1076-9.

    Article  PubMed  Google Scholar 

  71. Siew ED, Fissell WH, Tripp CM, Blume JD, Wilson MD, Clark AJ, et al. Acute kidney injury as a risk factor for delirium and coma during critical illness. Am J Respir Crit Care Med. 2017;195(12):1597–607. https://doi.org/10.1164/rccm.201603-0476OC.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  72. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753–62. https://doi.org/10.1001/jama.291.14.1753.

    Article  CAS  PubMed  Google Scholar 

  73. Girard TD, Jackson JC, Pandharipande PP, Pun BT, Thompson JL, Shintani AK, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med. 2010;38(7):1513–20. https://doi.org/10.1097/CCM.0b013e3181e47be1.

    Article  PubMed  PubMed Central  Google Scholar 

  74. Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306–16. https://doi.org/10.1056/NEJMoa1301372.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  75. Heung M, Steffick DE, Zivin K, Gillespie BW, Banerjee T, Hsu CY, et al. Acute kidney injury recovery pattern and subsequent risk of CKD: an analysis of veterans health administration data. Am J Kidney Dis. 2016;67(5):742–52. https://doi.org/10.1053/j.ajkd.2015.10.019.

    Article  PubMed  Google Scholar 

  76. Fiorentino M, Tohme FA, Wang S, Murugan R, Angus DC, Kellum JA. Long-term survival in patients with septic acute kidney injury is strongly influenced by renal recovery. PLoS One. 2018;13(6):e0198269. https://doi.org/10.1371/journal.pone.0198269.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  77. Kane-Gill SL, Sileanu FE, Murugan R, Trietley GS, Handler SM, Kellum JA. Risk factors for acute kidney injury in older adults with critical illness: a retrospective cohort study. Am J Kidney Dis. 2015;65(6):860–9. https://doi.org/10.1053/j.ajkd.2014.10.018.

    Article  PubMed  Google Scholar 

  78. Shao M, Wang S, Parameswaran PK. Hypoalbuminemia: a risk factor for acute kidney injury development and progression to chronic kidney disease in critically ill patients. Int Urol Nephrol. 2017;49(2):295–302. https://doi.org/10.1007/s11255-016-1453-2.

    Article  CAS  PubMed  Google Scholar 

  79. Venot M, Weis L, Clec'h C, et al. Acute kidney injury in severe sepsis and septic shock in patients with and without diabetes mellitus: a multicenter study. PLoS One. 2015;10(5):e0127411. https://doi.org/10.1371/journal.pone.0127411.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  80. Leedahl DD, Frazee EN, Schramm GE, Dierkhising RA, Bergstralh EJ, Chawla LS, et al. Derivation of urine output thresholds that identify a very high risk of AKI in patients with septic shock. Clin J Am Soc Nephrol. 2014;9(7):1168–74. https://doi.org/10.2215/CJN.09360913.

    Article  PubMed  PubMed Central  Google Scholar 

  81. Loftus TJ, Bihorac A, Ozrazgat-Baslanti T, Jordan JR, Croft CA, Smith RS, et al. Acute kidney injury following exploratory laparotomy and temporary abdominal closure. Shock. 2017;48(1):5–10. https://doi.org/10.1097/SHK.0000000000000825.

    Article  PubMed  PubMed Central  Google Scholar 

  82. Karino S, Kaye KS, Navalkele B, Nishan B, Salim M, Solanki S, et al. Epidemiology of acute kidney injury among patients receiving concomitant vancomycin and piperacillin-tazobactam: opportunities for antimicrobial stewardship. Antimicrob Agents Chemother. 2016;60(6):3743–50. https://doi.org/10.1128/AAC.03011-15.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  83. Navalkele B, Pogue JM, Karino S, Nishan B, Salim M, Solanki S, et al. Risk of acute kidney injury in patients on concomitant vancomycin and piperacillin-tazobactam compared to those on vancomycin and cefepime. Clin Infect Dis. 2017;64(2):116–23. https://doi.org/10.1093/cid/ciw709.

    Article  CAS  PubMed  Google Scholar 

  84. Peyko V, Smalley S, Cohen H. Prospective comparison of acute kidney injury during treatment with the combination of piperacillin-tazobactam and vancomycin versus the combination of cefepime or meropenem and vancomycin. J Pharm Pract. 2017;30(2):209–13. https://doi.org/10.1177/0897190016628960.

    Article  PubMed  Google Scholar 

  85. Otto GP, Sossdorf M, Breuel H, Schlattmann P, Bayer O, Claus RA, et al. Renal outcome after vancomycin treatment and renal replacement therapy in patients with severe sepsis and septic shock: a retrospective study. J Crit Care. 2014;29(4):656–61. https://doi.org/10.1016/j.jcrc.2014.03.015.

    Article  CAS  PubMed  Google Scholar 

  86. Ong L-Z, Tambyah PA, Lum LH, Low ZJ, Cheng I, Murali TM, et al. Aminoglycoside-associated acute kidney injury in elderly patients with and without shock. J Antimicrob Chemother. 2016;71(11):3250–7. https://doi.org/10.1093/jac/dkw296.

    Article  CAS  PubMed  Google Scholar 

  87. Picard W, Bazin F, Clouzeau B, Bui HN, Soulat M, Guilhon E, et al. Propensity-based study of aminoglycoside nephrotoxicity in patients with severe sepsis or septic shock. Antimicrob Agents Chemother. 2014;58(12):7468–74. https://doi.org/10.1128/AAC.03750-14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  88. Johnston C, Hilmer SN, McLachlan AJ, Matthews ST, Carroll PR, Kirkpatrick CM. The impact of frailty on pharmacokinetics in older people: using gentamicin population pharmacokinetic modeling to investigate changes in renal drug clearance by glomerular filtration. Eur J Clin Pharmacol. 2014;70(5):549–55. https://doi.org/10.1007/s00228-014-1652-7.

    Article  CAS  PubMed  Google Scholar 

  89. Aydoğan BB, Yıldırım F, Zerman A, Gönderen K, Türkoğlu M, Aygencel G. Colistin nephrotoxicity in the ICU: is it different in the geriatric patients? Aging Clin Exp Res. 2018;30(6):573–80. https://doi.org/10.1007/s40520-017-0827-3.

    Article  PubMed  Google Scholar 

  90. Dalfino L, Puntillo F, Ondok MJM, Mosca A, Monno R, Coppolecchia S, et al. Colistin-associated acute kidney injury in severely ill patients: a step toward a better renal care? A prospective cohort study. Clin Infect Dis. 2015;61(12):1771–7. https://doi.org/10.1093/cid/civ717.

    Article  CAS  PubMed  Google Scholar 

  91. • Joannidis M, Druml W, Forni LG, et al. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017: Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Med. 2017;43(6):730–49. https://doi.org/10.1007/s00134-017-4832-y Joannidis and colleagues provide a compilation of expert opinion and guidelines for the prevention of acute kidney injury.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  92. Kellum JA, Chawla LS, Keener C, Singbartl K, Palevsky PM, Pike FL, et al. The effects of alternative resuscitation strategies on acute kidney injury in patients with septic shock. Am J Respir Crit Care Med. 2016;193(3):281–7. https://doi.org/10.1164/rccm.201505-0995OC.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  93. Moman RN, Ostby SA, Akhoundi A, Kashyap R, Kashani K. Impact of individualized target mean arterial pressure for septic shock resuscitation on the incidence of acute kidney injury: a retrospective cohort study. Ann Intensive Care. 2018;8(1):124. https://doi.org/10.1186/s13613-018-0468-5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  94. • Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378(9):829–39. https://doi.org/10.1056/NEJMoa1711584 This manuscript contains the results of the SMART trial, indicating the importance of resuscitation with balanced crystalloids rather than normal saline for patients with sepsis.

    Article  PubMed  PubMed Central  Google Scholar 

  95. Xue M, Zhang X, Liu F, Chang W, Xie J, Xu J, et al. Effects of chloride content of intravenous crystalloid solutions in critically ill adult patients: a meta-analysis with trial sequential analysis of randomized trials. Ann Intensive Care. 2019;9(1):30. https://doi.org/10.1186/s13613-019-0506-y.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  96. Raghunathan K, Shaw A, Nathanson B, Stürmer T, Brookhart A, Stefan MS, et al. Association between the choice of IV crystalloid and in-hospital mortality among critically ill adults with sepsis*. Crit Care Med. 2014;42(7):1585–91. https://doi.org/10.1097/CCM.0000000000000305.

    Article  CAS  PubMed  Google Scholar 

  97. Suetrong B, Pisitsak C, Boyd JH, Russell JA, Walley KR. Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients. Crit Care. 2016;20(1):315. https://doi.org/10.1186/s13054-016-1499-7.

    Article  PubMed  PubMed Central  Google Scholar 

  98. Pfortmueller CA, Fleischmann E. Acetate-buffered crystalloid fluids: current knowledge, a systematic review. J Crit Care. 2016;35:96–104. https://doi.org/10.1016/j.jcrc.2016.05.006.

    Article  CAS  PubMed  Google Scholar 

  99. Park JY, An JN, Jhee JH, Kim DK, Oh HJ, Kim S, et al. Early initiation of continuous renal replacement therapy improves survival of elderly patients with acute kidney injury: a multicenter prospective cohort study. Crit Care. 2016;20(1):260. https://doi.org/10.1186/s13054-016-1437-8.

    Article  PubMed  PubMed Central  Google Scholar 

  100. Pérez-Fernández X, Sabater-Riera J, Sileanu FE, Vázquez-Reverón J, Ballús-Noguera J, Cárdenas-Campos P, et al. Clinical variables associated with poor outcome from sepsis-associated acute kidney injury and the relationship with timing of initiation of renal replacement therapy. J Crit Care. 2017;40:154–60. https://doi.org/10.1016/j.jcrc.2017.03.022.

    Article  PubMed  Google Scholar 

  101. Gaudry S, Hajage D, Schortgen F, Martin-Lefevre L, Pons B, Boulet E, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016;375(2):122–33. https://doi.org/10.1056/NEJMoa1603017.

    Article  PubMed  Google Scholar 

  102. Barbar SD, Clere-Jehl R, Bourredjem A, Hernu R, Montini F, Bruyère R, et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med. 2018;379(15):1431–42. https://doi.org/10.1056/NEJMoa1803213.

    Article  CAS  PubMed  Google Scholar 

  103. Lessa FC, Gould CV, McDonald LC. Current status of Clostridium difficile infection epidemiology. Clin Infect Dis. 2012;55(Suppl 2):S65–70. https://doi.org/10.1093/cid/cis319.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  104. Steiner C, Barrett M, Weiss A. HCUP projections: Clostridium difficile hospitalizations 2001 to 2013.

  105. Pépin J, Valiquette L, Cossette B. Mortality attributable to nosocomial Clostridium difficile-associated disease during an epidemic caused by a hypervirulent strain in Quebec. CMAJ. 2005;173(9):1037–42. https://doi.org/10.1503/cmaj.050978.

    Article  PubMed  PubMed Central  Google Scholar 

  106. Rao K, Micic D, Chenoweth E, Deng L, Galecki AT, Ring C, et al. Poor functional status as a risk factor for severe clostridium difficile infection in hospitalized older adults. J Am Geriatr Soc. 2013;61(10):1738–42. https://doi.org/10.1111/jgs.12442.

    Article  PubMed  PubMed Central  Google Scholar 

  107. Kaiser AM, Hogen R, Bordeianou L, et al. Clostridium difficile infection from a surgical perspective. J Gastrointest Surg. 2015;19(7):1363–77. https://doi.org/10.1007/s11605-015-2785-4.

    Article  PubMed  Google Scholar 

  108. Bovonratwet P, Bohl DD, Russo GS, Ondeck NT, Nam D, Della Valle CJ, et al. How common-and how serious—is Clostridium difficile colitis after geriatric hip fracture? Findings from the NSQIP dataset. Clin Orthop Relat Res. 2018;476(3):453–62. https://doi.org/10.1007/s11999.0000000000000099.

    Article  PubMed  PubMed Central  Google Scholar 

  109. 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. https://doi.org/10.1056/NEJMoa1408913.

    Article  CAS  PubMed  Google Scholar 

  110. Loo VG, Bourgault A-M, Poirier L, Lamothe F, Michaud S, Turgeon N, et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med. 2011;365(18):1693–703. https://doi.org/10.1056/NEJMoa1012413.

    Article  CAS  PubMed  Google Scholar 

  111. Dial S, Delaney JAC, Barkun AN, Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA. 2005;294(23):2989–95. https://doi.org/10.1001/jama.294.23.2989.

    Article  CAS  PubMed  Google Scholar 

  112. Center for Health Care Quality Healthcare-Associated Infections Program.

  113. Jump RLP, Olds DM, Seifi N, Kypriotakis G, Jury LA, Peron EP, et al. Effective antimicrobial stewardship in a long-term care facility through an infectious disease consultation service: keeping a LID on antibiotic use. Infect Control Hosp Epidemiol. 2015;33(12):1185–92. https://doi.org/10.1086/668429.

    Article  Google Scholar 

  114. • McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):987–94. https://doi.org/10.1093/cid/ciy149 This is the gold-standard set of guidelines for diagnosis and treatment of Clostridium difficile infections.

    Article  CAS  PubMed  Google Scholar 

  115. Vardakas KZ, Polyzos KA, Patouni K, Rafailidis PI, Samonis G, Falagas ME. Treatment failure and recurrence of Clostridium difficile infection following treatment with vancomycin or metronidazole: a systematic review of the evidence. Int J Antimicrob Agents. 2012;40(1):1–8. https://doi.org/10.1016/j.ijantimicag.2012.01.004.

    Article  CAS  PubMed  Google Scholar 

  116. Cobo J, Merino E, Martínez C, Cózar-Llistó A, Shaw E, Marrodán T, et al. Prediction of recurrent clostridium difficile infection at the bedside: the GEIH-CDI score. Int J Antimicrob Agents. 2018;51(3):393–8. https://doi.org/10.1016/j.ijantimicag.2017.09.010.

    Article  CAS  PubMed  Google Scholar 

  117. Jeon K, Yoo H, Jeong B-H, Park HY, Koh WJ, Suh GY, et al. Functional status and mortality prediction in community-acquired pneumonia. Respirology. 2017;22(7):1400–6. https://doi.org/10.1111/resp.13072.

    Article  PubMed  Google Scholar 

  118. Fernandez-Sierra MA, Rueda-Domingo MT, Rodriguez-Del-Aguila MM, et al. Adaptation of antibiotic treatment to clinical practice guidelines in patients aged ⩾65 years hospitalised due to community-acquired pneumonia. Epidemiol Infect. 2018;146(14):1870–7. https://doi.org/10.1017/S0950268818002121.

    Article  CAS  PubMed  Google Scholar 

  119. Garrouste-Orgeas M, Azoulay E, Ruckly S, Schwebel C, de Montmollin E, Bedos JP, et al. Diabetes was the only comorbid condition associated with mortality of invasive pneumococcal infection in ICU patients: a multicenter observational study from the Outcomerea research group. Infection. 2018;46(5):669–77. https://doi.org/10.1007/s15010-018-1169-6.

    Article  PubMed  Google Scholar 

  120. Ahmed H, Farewell D, Francis NA, Paranjothy S, Butler CC. Risk of adverse outcomes following urinary tract infection in older people with renal impairment: retrospective cohort study using linked health record data. PLoS Med. 2018;15(9):e1002652. https://doi.org/10.1371/journal.pmed.1002652.

    Article  PubMed  PubMed Central  Google Scholar 

  121. Toyas C, Aspiroz C, Martínez-Álvarez RM, Ezpeleta AI, Arazo P, Ferrando JC. Differential characteristics of bacteraemias according to age in a community hospital. Rev Clin Esp. 2017;217(1):15–20. https://doi.org/10.1016/j.rce.2016.09.003.

    Article  CAS  PubMed  Google Scholar 

  122. Ruiz-Mesa JD, Marquez-Gomez I, Sena G, Buonaiuto VA, Mora-Ordoñez J, Salido M, et al. Factors associated with severe sepsis or septic shock in complicated pyelonephritis. Medicine (Baltimore). 2017;96(43):e8371. https://doi.org/10.1097/MD.0000000000008371.

    Article  Google Scholar 

  123. Martínez ML, Ferrer R, Torrents E, Guillamat-Prats R, Gomà G, Suárez D, et al. Impact of source control in patients with severe sepsis and septic shock. Crit Care Med. 2017;45(1):11–9. https://doi.org/10.1097/CCM.0000000000002011.

    Article  PubMed  Google Scholar 

  124. Moran-Atkin E, Stem M, Lidor AO. Surgery for diverticulitis is associated with high risk of in-hospital mortality and morbidity in older patients with end-stage renal disease. Surgery. 2014;156(2):361–70. https://doi.org/10.1016/j.surg.2014.03.034.

    Article  PubMed  Google Scholar 

  125. Akyar S, Armenia SJ, Ratnani P, Merchant AM. The impact of frailty on postoperative cardiopulmonary complications in the emergency general surgery population. Surg J (N Y). 2018;4(2):e66–77. https://doi.org/10.1055/s-0038-1655756.

    Article  Google Scholar 

  126. Lees MC, Merani S, Tauh K, Khadaroo RG. Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis. Can J Surg. 2015;58(5):312–7. https://doi.org/10.1503/cjs.011614.

    Article  PubMed  PubMed Central  Google Scholar 

  127. Bertsimas D, Dunn J, Velmahos GC, Kaafarani HMA. Surgical risk is not linear: derivation and validation of a novel, user-friendly, and machine-learning-based Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) calculator. Ann Surg. 2018;268(4):574–83. https://doi.org/10.1097/SLA.0000000000002956.

    Article  PubMed  Google Scholar 

  128. Heyland DK, Dodek P, Mehta S, Cook D, Garland A, Stelfox HT, et al. Admission of the very elderly to the intensive care unit: family members’ perspectives on clinical decision-making from a multicenter cohort study. Palliat Med. 2015;29(4):324–35. https://doi.org/10.1177/0269216314566060.

    Article  PubMed  Google Scholar 

  129. • Guidet B, Vallet H, Boddaert J, et al. Caring for the critically ill patients over 80: a narrative review. Ann Intensive Care. 2018:1–15. doi:https://doi.org/10.1186/s13613-018-0458-7. The care of the critically ill elderly patient requires recognition of frailty and other risk factors that affect the patient’s outcome, involvement of the patient and family in defining goals of care and providing geriatric expertise or care in a geriatric unit when possible.

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  1. Loma Linda University Medical Center, 11175 Campus Street, CP 21111, Loma Linda, CA, 92350, USA

    Kaushik Mukherjee & Sigrid K. Burruss

  2. Texas Tech University Health Sciences Center, Lubbock, TX, USA

    Steven E. Brooks

  3. Carolinas Medical Center, Charlotte, NC, USA

    Addison K. May

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Mukherjee, K., Burruss, S.K., Brooks, S.E. et al. Managing Infectious Disease in the Critically Ill Elderly Patient. Curr Geri Rep 8, 180–193 (2019). https://doi.org/10.1007/s13670-019-00291-9

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