Infect Dis Clin N Am 18 (2004) 533549

Antibiotic agents in the elderly

Malini Stalam, MDa,*, Donald Kaye, MDb
a

Southeastern Veterans Center, 1 Veterans Drive, Spring City, PA 19475, USA

b
Department of Medicine, Drexel University College of Medicine,
3300 Henry Avenue, Philadelphia, PA 19129, USA

In the year 2002 people over 60 years constituted 16% of the population,
and people 65 years and older represented 12% of the population (US
Census Bureau \http//www.census.gov>). By the year 2050, the number of
Americans over 65 years of age is estimated to double to reach nearly 80
million. Despite the many advances that have occurred in the prevention,
diagnosis, and treatment of infectious diseases, infections still cause severe
morbidity and mortality in the elderly and are the most frequent cause of
hospitalization in this population.
Managing infections in the elderly is a challenge for a number of reasons.
Diagnosis of infections can be problematic, because elderly patients
frequently lack classical signs and symptoms of infection, such as fever
and leukocytosis. When infection occurs, the elderly often present with
unusual symptoms, such as poor appetite, dehydration, functional impairment, and changes in cognition. Physical ndings and laboratory results
are often dicult to interpret because many of the elderly have baseline
pulmonary, urinary tract, and laboratory abnormalities (eg, rales, bacteriuria, and pyuria). Therapy is problematic in the elderly because of the
increased potential for toxicity of antimicrobial agents and adverse drug
reactions caused by polypharmacy.
The following sections discuss some of the important physiologic
changes, drug-drug interactions, compliance issues, and reasons for increased adverse eects that aect use of antimicrobial agents in the elderly.
There is also a review of the most frequently encountered bacterial
infections in the elderly and recommendations for therapy.
It is estimated that more than 40% of the persons aged 65 years require
care in a long-term care facility (LTCF) or skilled nursing facility at some
point in their lifetime [1]. Special comments about patients in LTCF are
* Corresponding author. 1305 Cooper Circle, Audubon, PA 19403.
E-mail address: malastalam@aol.com (M. Stalam).
0891-5520/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.idc.2004.04.004

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incorporated in the discussion of frequently encountered infections in the

elderly. In addition, there is a brief discussion of colonization of LTCF
residents with resistant pathogens.
Pharmacologic issues in the elderly
Physiologic changes
Oral absorption
With aging there is a reduction in rate of gastric acid output with
a concomitant rise in gastric pH. There is a reduced rate of gastric emptying,
a decline in blood ow to the small intestine, and an increased incidence of
duodenal diverticula [2]. Despite these changes, orally administered antibiotics are generally absorbed well with only a modest slowing of absorption
rate [3]. Information is lacking on how drug absorption may be altered in
the elderly who are receiving histamine receptor-2 blockers or proton pump
inhibitors or in those with enteral feeding tubes.
Renal function
The number of intact nephrons and hence renal function declines with
normal aging [2]. In addition, chronic illnesses common in the elderly, such
as diabetes mellitus, congestive heart failure, and hypertension, contribute
to a decrease in renal function. The Cockcroft-Gault equation, based on
age, body weight, and a single serum creatinine value (Cr), closely correlates
with creatinine clearance (CLcr) measured by a 24-hour urine collection [2]:

CLcr

140
age y  weight kg
 0:85 in women
Cr mg=dL  72

The major drawback to using this equation is that it requires using the
patients ideal body weight. This may be dicult to determine, especially in
morbidly obese or edematous patients. Furthermore, the serum creatinine
value may be spuriously low in the elderly because of malnutrition and
decreased muscle mass. Often creatinine values within normal limits indicate
varying degrees of renal insuciency. For example, a serum creatinine of
1 in a frail 85-year-old woman weighing 86 lb may represent a creatinine
clearance as low as 25 mL/min.
Drugdrug interactions
Elderly patients are frequently taking a number of medications, such as
anticoagulants, antiarrhythmics, antihypertensives, antidepressants, and
antiseizure agents. Residents of LTCF receive an average of 5 to 10 prescribed drugs each day [4]. Table 1 lists some of the antibiotics commonly
used in the elderly and examples of drug-drug interactions that can occur.

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535

Table 1
Selected drug- drug interactions
Antibiotic

Drugs

Interaction

Aminoglycosides

Loop diuretics
NSAIDS
Radiographic
contrast
Vancomycin
Allopurinol
Anticoagulants
Theophylline
Antiarrhythmics

Increase in ototoxicity
Increase in nephrotoxicity

Adrenergic agents
Serotonergic drugs
Cisapride Pimozide

Increased blood pressure

Serotonin syndrome
Increased Q-T interval and
arrhythmias
Increased risk of rhabdomyolysis

Ampicillin, amoxicillin
Some cephalosporinsa
Ciprooxacin
Gatioxacin, levooxacin,
moxioxacin
Linezolid
Macrolides
Erythromycin,
clarithromycin
Metronidazole
Tetracyclines
Trimethoprim

Lovastatin
Simvastatin
Warfarin
Digoxin
Digoxin
Potassium-sparing diuretics

Increased frequency of rash

Potentiate anticoagulant eect
Increases theophylline levels
Increased Q-T interval (torsades)

Increased anticoagulant eect

Increased digoxin levels
Increased digoxin levels
Hyperkalemia

Abbreviations: NSAIDS, nonsteroidal anti-inammatory drugs.

Cephalosporins with methyltetrathiazole side-chain: cefamandole, cefotetan, cefmetazole,
cefoperazone.
a

Compliance
Elderly patients have been perceived as being noncompliant with drug
regimens. Compliance remains a challenge especially in view of frequent
polypharmacy and may drop to 50% for oral therapy [5]. Some of the
reasons for noncompliance in this population are as follows:
1. Inability to follow directions (ie, to be taken on empty stomach or 1
hour before meals or to avoid antacids)
2. Fear of drug-drug interactions
3. Attributing unrelated symptoms as secondary to antibiotic intake (eg,
diaphoresis, palpitations, dizziness)
4. Improvement of symptoms and return to sense of well being
5. Symptoms did not improve despite several doses
6. Difculty in opening child-resistant containers
7. High cost of medications
8. Perceived need to save medication in case infection recurs
9. Impaired vision or difculty in hearing
10. Poor memory
Compliance can be improved by better communication between patient
and caregiver (eg, providing the patient with written and oral instructions);

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assistance from relatives who can help administer medications; and by

keeping the regimen as simple as possible (eg, single daily doses) [6,7].
Adverse eects
Adverse eects from drugs are more frequent and more severe in the
elderly with antibiotics being an important cause [3,8,9]. Some of this excess
toxicity is related to decreased renal function and decreased excretion of
many drugs, and some is related to more potential for drug-drug
interactions. In addition there may be an increased susceptibility of the
end organs to drugs. For example, the elderly have fewer functional
nephrons and cochlear hair cells than younger individuals. Hearing loss
or renal insuciency from aminoglycosides may be observed at a much
earlier point in time of therapy than in a younger individual.
Pneumonia
Epidemiology
Pneumonia, inuenza, and complications of bacteremia are major causes
of death in the elderly [10]. Silent aspiration and atypical pathogens have
been increasingly recognized in the pathogenesis of lower respiratory tract
infection [1113]. Whether or not infection develops depends on the
quantity and virulence of the bacteria aspirated and the eectiveness of
host defense mechanisms. Silent aspiration also occurs in patients with
enteral feeding tubes and the incidence of aspiration pneumonia is not
reduced by use of these measures [14].
Microbiology
The frequency of infecting organisms varies depending on the setting in
which pneumonia was acquired. Bacterial culture results and other microbiologic studies are positive in less than 50% of hospitalized patients,
however, even in carefully conducted prospective studies [1518]. Table 2
categorizes the sites as (1) community-acquired pneumonia, (2) LTCFTable 2
Bacterial pneumonia
Site of acquisition

Etiologic bacteria

Community-acquired pneumonia
in otherwise healthy

S pneumoniae, H inuenzae, M catarrhalis,

S aureus, GNB, atypical agents
(Mycoplasma, Chlamydia Legionella),
anaerobes
S pneumoniae, GNB, S aureus, H inuenzae,
anaerobes, atypical agents
GNB, P aeruginosa, S aureus, polymicrobial

Long-term care facility acquired

pneumonia
Hospital-acquired pneumonia

Abbreviations: GNB, gram-negative enteric bacilli.

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537

acquired pneumonia, and (3) hospital-acquired pneumonia and lists the

usual infecting microorganisms.
In the healthy elderly residing in the community, the spectrum of
infecting organisms is similar to that seen in younger patients. In LTCF,
Streptococcus pneumoniae remains a frequent cause of pneumonia. In
addition in LTCF and especially in hospitalized geriatric patients with poor
functional status and co-existing medical illness, gram-negative bacilli (eg,
Klebsiella pneumoniae and Pseudomonas aeruginosa) and Staphylococcus
aureus play an important role. Aspiration pneumonia caused by a mixed
ora of anaerobic and aerobic bacteria may be seen in community-acquired
and LTCF-acquired pneumonia in the elderly.
Therapy
Recommendations are based on selecting eective coverage of the most
likely pathogens in a given clinical situation. The regimens listed are for
empiric therapy and until a microbiologic diagnosis can be obtained.
Community-acquired pneumonia
In the otherwise healthy elderly who do not require hospitalization, the
recommended antibiotics for empiric therapy are (1) a respiratory uoroquinolone, which is active against more than 98% of S pneumoniae,
including penicillin-resistant S pneumoniae [19,20]; (2) a macrolide; or (3)
doxycycline [21]. These agents have a high level of activity against the major
causative organisms of community-acquired pneumonia.
Currently available respiratory uoroquinolones are levooxacin, moxioxacin, gatioxacin, and gemioxacin; only an oral formulation of
gemioxacin is available. These agents are active in vitro against most
clinically signicant respiratory gram-positive cocci; aerobic gram-negative
bacilli; Hemophilus inuenzae; Moraxella catarrhalis; and atypical agents
(Mycoplasma, Chlamydia, and Legionella) [22]. Because of its minimal
adverse side eects, its relative lack of drug-drug interactions, and the
extensive experience with the drug, the authors preferred uoroquinolone
for outpatient therapy of community-acquired pneumonia is levooxacin.
Moxioxacin and gatioxacin are more active against S pneumoniae than
levooxacin; moxioxacin is more active than gatioxacin. These agents
may replace levooxacin as uoroquinolones of choice after there has been
more experience with them in the elderly. Gemioxacin, the most active of
these uoroquinolones against S pneumoniae, has the problem of frequently
causing a rash.
The advanced macrolides, azithromycin and clarithromycin, are better
tolerated than erythromycin and easier to administer because of reduced
dosage frequency. They are active against most S pneumoniae and virtually
all atypical agents. They have much better activity against H inuenzae than
erythromycin. Despite greater expense, they are used more frequently than

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erythromycin. Approximately 20% of S pneumoniae isolates are resistant

to macrolides in vitro, however, and the rate is higher among
penicillin-resistant strains [2224]. The macrolides have little activity against
gram-negative bacilli (other than H inuenzae) and unreliable activity
against staphylococci.
Doxycycline is active in vitro against most S pneumoniae, H inuenzae,
and atypical pathogens. Its advantages are low price, convenient dosing, and
good tolerability. Resistance of S pneumoniae has been reported in 5% to
8% of isolates [25]. The activity against gram-negative bacilli and staphylococci is unreliable.
Other antibiotics that have been recommended for community-acquired
pneumonia are amoxicillinclavulanic acid or second- or third-generation
oral cephalosporins. Amoxicillinclavulanic acid is active against virtually
all H inuenzae, M catarrhalis, penicillin-susceptible S pneumoniae, and
anaerobes. It lacks activity against some of the Enterobacteriaceae and has
little activity against atypical agents [26]. Whereas many penicillin-resistant
S pneumoniae are also resistant to amoxicillin, failures of therapy of
pneumonia with a penicillin have been dicult to demonstrate. A signicant
problem with amoxicillinclavulanic acid is a 9% to 10% occurrence of
diarrhea and an increased predisposition to develop Clostridium dicile
associated diarrhea (CDAD).
Most second- and third-generation cephalosporins have good activity
against H inuenzae and M catarrhalis. Of the cephalosporins suitable for
outpatient therapy, ceftriaxone (which can be injected once daily) is the
most active against strains of S pneumoniae and may be used in cases of
S pneumoniae pneumonia with intermediate penicillin resistance (mean
inhibitory concentration, 0.11 lg/mL). In fact, because of the high serum
levels achieved, ceftriaxone is probably eective in many cases of pneumonia
caused by S pneumoniae highly resistant to penicillin. Cefditoren, cefpodoxime, cefprozil, and cefuroxime are the oral cephalosporins that are most
active against pneumococci [26,27]. Third-generation cephalosporins are
more reliable than second-generation cephalosporins against gram-negative
enteric bacilli. These agents all lack activity against the atypical agents and
are not eective in treatment of methicillin-resistant S aureus (MRSA)
infections.
Clindamycin is another therapeutic possibility, especially if aspiration
pneumonia caused by anaerobes is suspected [28,29]. It has excellent activity
against anaerobes and exhibits good in vitro activity against gram-positive
cocci including most strains of S pneumoniae (both penicillin-resistant and
macrolide-resistant strains) and most isolates of methicillin-sensitive S
aureus [30]. Clindamycin is not active against H inuenzae and erythromycin-resistant S aureus. Signicant adverse eects are diarrhea and predisposition to CDAD.
Although all of the previously mentioned antimicrobial agents constitute
appropriate therapy for the outpatient, the authors preferred antimicrobial

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539

agent for empiric treatment of community-acquired pneumonia in the

elderly outpatient is levooxacin. The usual course of therapy for typical
bacterial pneumonia is 7 to 10 days. Ten to 14 days is used for Mycoplasma
or Chlamydia and 14 to 21 days for Legionella [22]. If a uoroquinolone
cannot be used, the authors recommend a macrolide with or without a
b-lactam.
If hospitalization becomes necessary, pending examination of a Gram
stain of the sputum and results of sputum culture, the authors recommend
intravenous therapy with levooxacin or with ceftriaxone plus a macrolide
in the non-ICU patient. In the seriously ill patient, the recommended
therapy is a combination of levooxacin or a macrolide plus ceftriaxone or
piperacillin-tazobactam [31]. If aspiration pneumonia caused by anaerobes
is suspected, clindamycin or another agent active against anaerobes should
be included in the regimen. Levooxacin and ceftriaxone have poor activity
against anaerobes. Vancomycin must be included in the regimen when
MRSA is a likely infecting organism.
Long-term care facilityacquired pneumonia
Empiric therapy in the LTCF must include excellent activity against
enteric gram-negative bacilli and pneumococci. The authors preference is for
levooxacin, or if levooxacin cannot be used, a macrolide with a b-lactam
[22,32]. Vancomycin or linezolid or quinupristin-dalfopristin must be added
when MRSA is a consideration. Linezolid has the advantage of being
available in oral form. At least 10 days of therapy are usually required.
Hospital-acquired pneumonia
Hospital-acquired pneumonia is dened as development of pneumonia at
least 48 hours after hospitalization and not incubating at time of admission.
Hospital-acquired pneumonia is the second most frequent cause of hospitalacquired infection and the leading cause of morbidity and mortality from
nosocomial infection [33,34].
The initial antibiotic therapy is selected based on the setting in which the
infection occurs and the results of Gram stain of sputum if available.
Empiric therapy must be sucient to treat pneumonia caused by gramnegative bacilli (including P aeruginosa) and MRSA. P aeruginosa and other
hospital-associated multiresistant gram-negative bacilli become increasingly
important in patients in an ICU, especially if the patient is on a respirator.
Other important factors that predispose to infections caused by these
bacteria are prior use of antibiotics and a hospital stay of 5 or more days
[35]. The antibiotic regimen chosen varies depending on the identity and
susceptibility of the bacteria causing hospital-associated pneumonia in that
facility. In general, two agents from dierent classes active against gramnegative bacilli should be included in the initial regimen to be certain of
adequate coverage. Ciprooxacin or the following b-lactam antibiotics are
recommended for their broad coverage of gram-negative bacilli (including P

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aeruginosa): piperacillin-tazobactam, ceftazidime, cefepime, imipenem, meropenem, and aztreonam. An aminoglycoside, such as gentamicin, is added
to the b-lactam antibiotics for its synergistic killing eect especially for
infections caused by P aeruginosa. If there is a history of hypersensitivity to
b-lactam antibiotics, aztreonam is the b-lactam least likely to result in
a reaction. If ciprooxacin is not included in the regimen, a macrolide may
be added for activity against atypical bacteria, such as Legionella. Aminoglycosides must be used with care, and peak and trough levels followed,
because of the increased occurrence of nephrotoxicity and ototoxicity in the
elderly. If an aminoglycoside is contraindicated, a uoroquinolone active
against P aeruginosa (ie, ciprooxacin) may be added to a b-lactam
antibiotic. As an alternative to use of b-lactam antibiotics, ciprooxacin
can be used together with an aminoglycoside. Vancomycin should be added
to the regimen unless MRSA is ruled out. Nafcillin is preferred for
methicillin-susceptible S aureus. Therapy is modied when results of
cultures and sensitivity studies are available. Hospital-acquired pneumonia
usually requires at least 10 to 14 days of therapy [35]. A recent study,
however, suggested that 8 days of appropriate therapy may be sucient in
some cases [36].
Prevention
Pneumonia and inuenza are the fourth leading cause of death among the
elderly [37]. Many cases of pneumonia can be prevented in the elderly by the
simple adherence to universal administration of pneumococcal vaccine and
yearly immunization against inuenza. Although the ecacy of inuenza
vaccine is reduced in the elderly, even in residents of LTCF it prevents 70%
to 80% of deaths from pneumonia following inuenza [38].
Pneumococcal polysaccharide vaccine is a 23-valent vaccine containing
the polysaccharide antigens of pneumococcal serotypes that cause more
than 90% of invasive pneumococcal infections. Case control and indirect
cohort studies indicate an ecacy of 60% to 70% in preventing invasive
pneumococcal infections [39,40]. Pneumococcal vaccine should be administered to patients 65 years of age and older if their prior vaccine history is
not known, because the incidence of adverse events is as low following
revaccination as it is following initial vaccination [41]. Despite of its ecacy
and safety, many people aged 65 years and older do not get vaccinated.

Urinary tract infection

Epidemiology
Urinary tract infection is the most common bacterial infection in the
elderly [37,42]. The prevalence of asymptomatic bacteriuria is about 20% in
the female population over age 65 and about 10% in the male population

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541

over age 65 [43]. The ratio of prevalence of bacteriuria in women to men

decreases from approximately 30:1 in a young adult population to about 2:1
in the elderly [44,45]. Factors contributing to the high frequency of
bacteriuria in the elderly are listed in Table 3. In LTCF the prevalence of
bacteriuria in elderly men without indwelling catheters varies from 15% to
40% and in women from 25% to 50% [44].
Microbiology
Escherichia coli is the most frequently isolated organism from the urine of
elderly women both in the ambulatory and LTCF settings. For men,
however, Proteus mirabilis has been reported to be the most frequently
isolated organism in LTCF [46]. Other frequently isolated gram-negative
bacilli are K pneumoniae and multidrug-resistant gram-negative bacilli
including Enterobacter cloacae, Citrobacter freundii, P aeruginosa, and
Providencia stuartii [42]. Among gram-positive organisms, coagulasenegative staphylococci, enterococci, and group B streptococci are most
frequently isolated [42]. Catheter-associated bacteriuria is usually polymicrobial with the presence of two or more of the previously mentioned and
other organisms [47].
Therapy
Upper tract infections
Clinical pyelonephritis or bacteremia of suspected urinary tract origin
must be treated. Initial therapy is almost always empiric and should be
guided by urine Gram stain whenever possible [45]. If enterococcal infection
is suspected, ampicillin (amoxicillin if given orally) or an ureidopenicillin (eg,
piperacillin) with or without an aminoglycoside is appropriate therapy [45].
If gram-negative bacillary infection is suspected, a third-generation cephalosporin or piperacillin-tazobactam (with or without an aminoglycoside) or

Table 3
Factors contributing to bacteriuria
Women

Men

Neurogenic bladder caused by

Medications (may impair bladder
emptying)
Long-term care facility

Loss of estrogen eect on female genital

mucosa resulting in loss of lactobacilli
Outlet obstruction from pelvic oor laxity
Decrease in antibacterial prostatic secretions
Prostatic hypertrophy resulting in incomplete
bladder emptying
Diabetes, cerebrovascular disease, Parkinsons
disease, Alzheimers disease
Sedatives, antidepressants
Prolonged bed rest, indwelling catheters,
bowel incontinence, condom catheter

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a uoroquinolone (eg, ciprooxacin or levooxacin) is recommended. Once

culture data are available, the antibiotic therapy can be adjusted accordingly. Failure to observe an adequate clinical response by 72 hours after
initiating appropriate antimicrobial therapy should raise the possibility of
urinary tract obstruction (eg, from a calculus) or intrarenal or perinephric
abscess [45]. If prompt clinical response occurs and there are no complications, the appropriate duration of therapy should be a total of 14 days for
men and women [48,49].
Lower tract infections
In women with symptoms restricted to the lower urinary tract, 3 days
of antimicrobial therapy is adequate. Elderly men with lower tract symptoms should be treated for 7 to 10 days [43]. The most commonly used
antimicrobial agents have been amoxicillin, trimethoprim-sulfamethoxazole,
trimethoprim alone, or a uoroquinolone. Up to 40% of E coli infections
acquired in the community are now resistant to amoxicillin, however, and
resistance to trimethoprim-sulfamethoxazole is approaching 20% [43,50].
Fluoroquinolones should probably be the preferred empiric therapy.
Resistance to uoroquinolones among E coli isolates has been low, although
increasing resistance has been noted in recent years [50].
Asymptomatic bacteriuria
Asymptomatic bacteriuria in the elderly (with or without an indwelling
catheter) should not be treated [43]. Recent studies have shown that there is
no benet in screening for or treating female diabetics with asymptomatic
bacteriuria [51]. The major exception to the general rule of screening the
elderly for bacteriuria is if the patient is to have an invasive urologic
procedure, such as a cystoscopy or a prostatectomy. Under these circumstances, antimicrobial therapy active against the infecting organisms should
be started 12 hours before the procedure. The purpose is to lower the level of
bacteriuria at the time of the procedure and reduce the incidence of
bacteremia associated with the procedure [52]. Similarly, treating candiduria
in the asymptomatic elderly with or without an indwelling catheter has not
proved to be benecial [53]. The exception is in patients who are to undergo
renal transplantation or elective urinary tract procedures [43].

Soft tissue infections

Infected pressure ulcers
Epidemiology
Pressure ulcers are a frequent complication in chronically ill and
debilitated patients. The probable contributing factors are decreased blood
ow, dry thin skin, malnutrition, obesity, and immobility. The incidence in
LTCF varies from 17% to 35% [54]. All pressure ulcers become colonized

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543

with multiple microorganisms. In LTCF residents increased MRSA

colonization is seen in presence of decubitus ulcers [55]. The rate of
occurrence of clinically apparent infection in the pressure ulcer population
is not well documented. Results from one study suggest that osteomyelitis
may occur in nearly one third of patients with nonhealing pressure ulcers
[56]. Classical signs of pressure ulcer infection include fever or local
erythema, edema, pain, changes in wound odor, purulent drainage, and
the presence of necrotic tissue [54].
Diagnosis
Tissue biopsy (bone in the case of osteomyelitis) and irrigation-aspiration
techniques help dierentiate between organisms that are causing deeper
infection as opposed to just colonizing the surface. Although tissue biopsy
with culture is the gold standard for identication of infecting organisms, it
is an expensive technique and not practical for most LTCF. The irrigationaspiration technique and similar methods used for culturing have been
shown to be specic and sensitive for recovery of infecting aerobic and
anaerobic bacteria [54,57]. These methods consist of irrigating with saline
after removing eschar, necrotic tissue, and brin slough. After irrigation the
wound is massaged with a swab and the uid produced is used for culture.
Therapy
Antimicrobial therapy is recommended when bacteremia, cellulitis, or
osteomyelitis is present or when fever is thought to be caused by an infected
pressure ulcer. The aerobic organisms most commonly isolated from
infected pressure ulcers include staphylococci, enterococci, P mirabilis, E
coli, and P aeruginosa; anaerobic bacteria include peptostreptococci,
Bacillus fragilis, and Clostridium spp [58]. Bacteremia resulting from
pressure ulcers is usually caused by P mirabilis, E coli, P aeruginosa,
Klebsiella spp, S aureus, or B fragilis [59]. Bacteremia in the presence of
pressure ulcers has been associated with a mortality rate of 50% [60]. When
bacteremia is suspected in the absence of adequate cultures, broad-spectrum
antibiotic therapy is necessary with coverage of gram-positive and gramnegative aerobes and anaerobes. Examples of potentially eective regimens
are piperacillin-tazobactam or a carbapenem as single-agent therapy or
ciprooxacin or ceftazidime in combination with metronidazole (all with an
antistaphylococcal agent added; vancomycin if MRSA are suspected). In
cases of deep wound infection and osteomyelitis, adequate surgical debridement is essential for cure.
Cellulitis
Cellulitis in the community and in LTCF is usually caused by S aureus or
group A or B b-hemolytic streptococci. Supercial diabetic foot ulcers and
those from peripheral vascular disease are commonly infected with

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streptococci or staphylococci. Antistaphylococcal penicillins, rst-generation cephalosporins (eg, cefazolin or cephalexin) or clindamycin are
commonly used to treat cellulitis caused by methicillin-susceptible S aureus
and streptococci. With deeper diabetic foot ulcers or ulcers caused by
peripheral vascular disease, however, polymicrobial infection with staphylococci, aerobic gram-negative bacilli, or anaerobes is common [61]. Broadspectrum antibiotic therapy is necessary for empirical treatment of cellulitis
in the presence of deep diabetic ulcers or ulcers from peripheral vascular
disease. Patients with these types of cellulitis should receive therapy active
against gram-positive and gram-negative aerobes and anaerobes. Vancomycin, linezolid, or quinupristin-dalfopristin must be used when serious
infection with MRSA is suspected. Linezolid has the advantage of being
available in oral form, which can be used after initial clinical response. In
cases of deep wound infection and osteomyelitis adequate surgical debridement is essential for cure.
Clostridium dicileassociated diarrhea
Epidemiology
Clostridium dicileassociated diarrhea is usually a complication of
antibiotic therapy and is a major cause of nosocomial infectious diarrhea
and common cause of acute diarrheal illness in LTCF [6264]. It is most
likely to occur in hospitals and less frequently in LTCF. Older age is a risk
factor for CDAD because the incidence increases dramatically in those over
60 years of age [65]. Although virtually any antimicrobial agent can be
associated with CDAD, most cases have occurred as a complication of use
of clindamycin or b-lactam antibiotics. C dicile colonization and CDAD
occur commonly in elderly LTCF residents. Contributing factors in LTCF
are thought to be the closed environment; contaminated inanimate objects
(eg, commodes); fecal incontinence; and a higher rate of exposure to
antibiotics [66].
Therapy
Metronidazole is the antibiotic of choice and should be given orally or by
a feeding tube. It can be used parenterally, if necessary, because adequate
amounts of drug reach the gastrointestinal tract when it is injected.
Vancomycin, which is much more expensive, should be avoided because
of the potential for facilitating the spread of vancomycin-resistant enterococci [67]. If used for CDAD, vancomycin must be given orally or by
a feeding tube. Parenterally administered vancomycin does not reach the
gastrointestinal tract and is of no value in treating CDAD. Therapy should
be continued for 7 to 10 days.
Prevention and control of CDAD in LTCF involves prudent use of
antimicrobials; providing a private room if possible for residents with fecal

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545

incontinence; avoiding sharing patient care items (eg, stethoscope and blood
pressure cus); and disinfecting room surfaces of residents with CDAD
using dilute hypochlorite solution [68].
Resistant pathogens in long-term care facilities
The most frequently encountered resistant pathogens in LTCF are
MRSA, vancomycin-resistant enterococci, and multidrug-resistant gramnegative bacilli. Up to 25% of patients with MRSA colonization can
develop MRSA infections [69]. In residents with vancomycin-resistant
enterococci colonization, however, the rate of infection caused by vancomycin-resistant enterococci is low [70].
Predisposing factors for colonization with resistant pathogens are
frequent hospitalizations, decreased functional capacity, presence of urinary
catheter, tracheostomy, feeding tube, decubitus ulcer, and use of antibiotics
[55,71].
It is dicult to implement infection control guidelines in LTCF similar to
those in acute care facilities. Some of the limitations are a limited number of
single rooms; the cost of performing surveillance cultures; and the negative
aspects of isolation of LTCF residents, which restricts their functional
capacity and quality of life. Quality of life is an important priority in LTCF.
To prevent spread of these resistant pathogens, keeping decubiti (and other
colonized lesions) covered, judicious use of antibiotics, use of gloves by
caregivers, and using alcohol-based hand antisepsis are preventive methods
that can be implemented [55].
Summary
Changes that occur in the pharmacology of drugs in the elderly must be
considered in the use of antimicrobial agents. Although absorption of orally
administered drugs is not aected in a signicant way, renal function
decreases, drug-drug interactions increase, compliance with regimens may
be decreased, and drug toxicity is increased. The most frequent infections
occurring in the elderly are pneumonia, urinary tract infection, and soft
tissue infection. CDAD is usually a complication of antibiotic therapy.
Pneumonia can be categorized as community-acquired, LTCF acquired, and
hospital-acquired. Therapeutic approaches vary according to which of these
sites is involved. Urinary tract infection is divided into upper tract infection,
lower tract infection, and asymptomatic bacteriuria. Upper tract infection is
treated for a longer period of time than lower tract infection and
asymptomatic bacteriuria is usually not treated. Soft tissue infection is
usually caused by an infected pressure ulcer or cellulitis (which may be
a complication of a diabetic foot ulcer or an ulcer caused by peripheral
vascular disease) and may be supercial or deep. These infections have
dierent microbial causes and require dierent therapeutic approaches.

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