REVIEW

Special considerations of antibiotic prescription in the geriatric population

C. L. Beckett1, S. Harbarth2 and B. Huttner2

1) Infectious Diseases Department, Eastern Health, Victoria, Australia and 2) Infection Control Programme and Faculty of Medicine, Geneva, Switzerland

Abstract

Infectious diseases pose a major challenge in the elderly for two reasons: on the one hand the susceptibility to infection increases with age and
when infections occur they often present atypically—on the other hand diagnostic uncertainty is much more pronounced in the geriatric
population. Reconciling the opposing aspects of optimizing patient outcomes while avoiding antibiotic overuse requires significant
expertise that can be provided by an infectious diseases consultant. In addition, geriatric facilities are reservoirs for multidrug-resistant
organisms and other nosocomial pathogens, and infectious diseases consultants also play a vital role in assuring appropriate infection
control measures. In this review we outline the challenges of diagnosis and management of infectious diseases in the elderly, and discuss
the importance of appropriate antibiotic use in the elderly in order to demonstrate the value of the infectious diseases consultant in this
special setting.
Clinical Microbiology and Infection © 2014 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All
rights reserved.

Keywords: Antibiotic stewardship, antimicrobials, elderly, geriatrics, infectious diseases, prudent antibiotic use
Original Submission: 7 August 2014; Accepted: 29 August 2014
Article published online: 13 October 2014

in this area of medicine. In addition, ID consultants also have a

Corresponding author: B. Huttner, Infection Control Programme,
major role in promoting the judicious use of antibiotics in this
Geneva University Hospitals, Geneva, Switzerland
E-mail: benedikt.huttner@hcuge.ch population, since it is also particularly vulnerable to the dele-
terious effects of inappropriate antibiotic use, such as adverse
drug reactions, antimicrobial resistance and Clostridium difficile
infection [7].
The aging population

The high risk of infectious diseases in the

Over half of all deaths in many countries now occur in hospi-
tals, even without taking into account deaths occurring in res-
idential aged care institutions [1]. The vast majority of in-
hospital deaths occur among the elderly and the very old. In
the USA for example, in 2010 75% of inpatients who died in a
hospital were aged 65 years and over and 27% were aged 85
years and over [2]. Infections, such as pneumonia, often directly
contribute to the mortality in these patients, as suggested by
the term ‘end-of-life pneumonia’ [3]. This poses challenges with
regard to the use of ‘end-of-life’ antibiotics, which may lower
suffering but also may exacerbate selection pressure for anti-
microbial resistance [4–6]. The prevention, diagnosis and
management of infections in geriatric patients, requires the
expertise of infectious diseases (ID) consultants with an interest
elderly
While aging is a normal process, and not in itself a disease, age-
related physiological changes place the elderly at high risk for
infectious diseases [8]. These diseases are therefore a leading
cause of hospital admission and cause of death in this patient
population [9]. Susceptibility to infectious diseases in the elderly
is increased by a combination of factors, including immune
senescence (such as changes in B-cell and T-cell function, innate
immune responses and effector functions), as well as altered
skin and mucosal barrier function, degenerative changes in bone
and cartilage and reduction in respiratory capacity [9–11].
Urinary catheters are often used in geriatrics facilities and

Clin Microbiol Infect 2015; 21: 3–9

Clinical Microbiology and Infection © 2014 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved
http://dx.doi.org/10.1016/j.cmi.2014.08.018
4 Clinical Microbiology and Infection, Volume 21 Number 1, January 2015
prevalence estimates of these devices range between 6 and
40%, depending on the population studied [12]. Approximately
3–7% of nursing home residents with an indwelling urinary
catheter will acquire a urinary tract infection with each day that
the catheter remains in place. The changes in immune system
function in the elderly lead to reduced responsiveness to
vaccination, and increased susceptibility to systemic infection by
specific pathogens such as Listeria monocytogenes. Additionally,
reactivation of latent infection such as Mycobacterium tubercu-
losis and varicella zoster virus is also more common [13–15].
Common co-morbidities found in the aging population also
contribute to an increased risk of infection, such as pulmonary
diseases increasing the risk of pneumonia, and the frequent
presence of foreign material, such as joint prostheses, pace-
makers or artificial cardiac valves, enhancing risk of prosthetic
device infection [16].
Elderly patients in institutions, such as nursing homes or
geriatric hospitals, pose a particular challenge. Not only does
this group of patients tend to have more pronounced impair-
ment of defences against infection, and a large number of co-
morbidities, but common activities (e.g. common meals) com-
bined with suboptimal hygiene (e.g. due to a high proportion of
patients with dementia) promote rapid dissemination of respi-
ratory and gastrointestinal viruses (e.g. influenza virus and
norovirus) and multidrug-resistant organisms (MDROs)
[16,17]. Several studies have shown that age remains an
important risk factor of carriage of MDROs, independent of
other determinants [18]. Furthermore, geriatric hospitals may
have a higher prevalence of nosocomial infections compared
with acute-care settings, even after adjustment for case-mix
[19]. The outcome from infection is often worse in elderly
populations. For example, mortality related to Staphylococcus
aureus bacteraemia has been extensively studied, and shows a
significant increase in mortality in the later decades of life
[20,21]. Prognosis for severe infections, particularly in geriatric
patients more than 80 years of age, is clearly linked to functional
status [22].
Unusual presentation of infectious diseases in
the elderly
Common infections such as urinary tract infections, lower
respiratory tract infections and skin and soft tissue infections,
are frequent in the elderly [16]. Unfortunately, however, the
diagnosis of infection in the elderly is not always straightforward
and obvious. Symptoms and signs of infection in the elderly may
not include the typical features such as fever and chills that
clinicians usually rely on to make a clinical diagnosis of infection
Clinical Microbiology and Infection © 2014 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved, CMI, 21, 3–9
CMI
[23,24]. This is because of altered physiological responses to
the infecting pathogen in this patient group, and age-related
changes in temperature regulation [25]. Older subjects have a
lower body temperature than that of younger people and their
tolerance of thermal extremes is more limited. Instead, symp-
toms may mimic normal signs of aging or a concomitant disease,
or symptoms may be non-specific such as when elderly patients
with pneumonia present solely with confusion. Conversely,
patients may have fever without apparent infections compli-
cating the decision to administer antibiotics to elderly patients
[24]. In addition, accurate history taking is often complicated by
cognitive impairment, the physical examination is often
hampered by lack of cooperation and the positive predictive
value of many diagnostic tests is lower than in the other pop-
ulations (e.g. chest X-rays or urinary cultures).
Acute confusion or disturbance of consciousness is one of
the common atypical (relative to non-elderly) primary mani-
festations of infection in geriatric patients [9]. In an analysis of
73 consecutive acute admissions of patients older than 70 with
impaired consciousness, the proportion where a presumed
infection was the triggering cause was 34.3% [9]. Other non-
specific manifestations of infection in the elderly can include
acute deterioration of mobility, and subtle disturbances of cir-
culatory regulation (hypotension and lactic acidosis without
overt toxaemia or tachycardia) [9]. Altered cognitive states
such as dementia or acute confusion often hamper the ability of
the clinician to obtain important details regarding relevant
symptoms or risk factors for infection, further complicating the
process of accurate clinical diagnosis in this patient group [26].
Laboratory markers of infection may not show responses found
typically in younger patients. Inflammatory markers are often
initially not elevated or are minimally abnormal in the infected
geriatric patient, further contributing to delays in diagnosis and
therapy [27,28].
The presentation of urinary tract infections in the elderly
may be atypical. Positive urinary cultures without active infec-
tion are very common in the elderly, reducing the positive
predictive value of bacteriuria for diagnosing urinary tract in-
fections and, in the absence of better performing diagnostic
tests, making it difficult—if not impossible in certain cases—to
differentiate between asymptomatic bacteriuria and active uri-
nary tract infection [8,9].
The frequency of bacteraemia increases in elderly patients,
and is one of the leading causes of morbidity and mortality in
the geriatric population [29]. Fever, chills and shakes are less
likely to be present; however, fever remains common in bac-
teraemic geriatric patients [30,31]. End-organ effects are re-
ported to be more common in the elderly bacteraemic patients,
with manifestations such as renal failure and respiratory
compromise [31]. There does not appear to be a difference in
CMI
the specificity or sensitivity of positive blood cultures with age,
if the cultures are collected appropriately [32]. However, given
the potential for non-specific presentations of infections in the
elderly, the key challenge is collecting cultures in the appro-
priate patient group [8]. In general there should be a low
threshold for obtaining blood cultures in older patients, even in
the absence of fever, in selected patients with changes in the
functional status (e.g. new confusion) [8]. Unusual microor-
ganisms may be more prevalent in the very aged population, as
demonstrated in a retrospective, multicentre cohort study that
revealed age >90 years as an independent risk factor for Pseu-
domonas aeruginosa bacteraemia on hospital admission [33]. As
described above, the outcome from bacteraemia is usually
worse for elderly patients with higher rates of mortality.
Lower respiratory tract infections and pneumonia are lead-
ing causes of morbidity and mortality in older patients, resulting
in almost half of all infectious disease-related hospitalizations
and deaths [34–36]. The diagnosis of pneumonia may not be
obvious in the elderly. This is especially true for nosocomial
pneumonia. Classical presentations of pneumonia are often
absent in the elderly with less chest pain, fever, chills, cough or
expectoration [8,9]. The standard investigation for pneumonia
diagnosis, chest radiography, is difficult to interpret because of
non-specific radiological findings in elderly patients and sub-
optimal quality of radiographs [37]. In practical terms this
means that it is hard, if not impossible, to exclude pneumonia
based on a chest radiograph, which contributes to significant
diagnostic uncertainty and can result in incorrect or unnec-
essary therapy. Additionally there is often difficulty obtaining
adequate sputum samples for culture and consequently no
pathogen is identified in most older patients with pneumonia
[24,38–40].
With increasing age prosthetic valve endocarditis, which is
often more difficult to treat, becomes more common [41,42].
Elderly patients are less likely to present with peripheral stig-
mata of endocarditis, such as splenomegaly and Osler’s nodes
[8]. While the spectrum of offending pathogens remains similar,
the need for transoesophageal echocardiogram to confirm the
diagnosis of endocarditis may be increased in elderly patients
[41]. Decisions regarding the appropriate investigation and
management of elderly patients with possible bacterial endo-
carditis are frequently difficult, not only because of the
perceived invasive nature of the testing that is required, but
because of the prolonged duration of therapy necessary to cure
the infection.
Overall, this uncertainty puts physicians treating the elderly
in a difficult situation when having to decide whether to start
antibiotics. On the one hand, several factors favour a ‘low
threshold’ to antibiotic therapy: infections are frequent in this
population, have a higher morbidity and mortality than in
Clinical Microbiology and Infection © 2014 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved, CMI, 21, 3–9
Beckett et al. The geriatric ID consultant 5
younger adults and may present atypically. On the other hand,
several factors would favour a ‘high threshold’ to start antibiotic
therapy: numerous other factors may contribute to alterations
in the physical status and fever in this population and diagnostic
tests are rarely useful to exclude infections. This population is
also particularly vulnerable to the deleterious effect of unnec-
essary antibiotic use. The timely and accurate assessment of
infections in the elderly patient group therefore requires
expertise in this area, with an understanding of the altered
manifestations of infection in this patient group [8]. On the
other hand, it is just as important that the ID consultant sup-
ports the treating geriatricians in decisions not to treat a patient
with antibiotics, when an infection is not certain and ‘watchful
waiting’ may be justified.
Management of infectious diseases in
geriatrics is a challenge
The management of infectious diseases in geriatric patients in
relation to their multiple co-morbidities, poly-pharmaco-
therapy, impending disabilities and functional impairments is a
unique challenge [9]. In addition, decisions about appropriate
duration of therapy, such as the need for curative therapy
versus long-term suppression, require the expertise of physi-
cians with knowledge and expertise in this area. With regard to
many day-to-day decisions about the management of infectious
diseases in the elderly, we essentially move to an ‘evidence-free’
area that is largely based on expert opinion. While the evidence
base for most infectious disease recommendations is already
weak, this is certainly even worse for the elderly, who are often
underrepresented in clinical trials of new therapeutic or pre-
ventive interventions [43].
All too often clinicians are confronted with a geriatric patient
with fever, elevated inflammatory markers or merely confusion,
with an abnormal urine status and a questionable infiltrate on a
chest X ray. More often than not, these non-specific findings
lead the physician to commence antibiotic therapy often with
broad-spectrum drugs. It is in these instances that the geriatric
ID consultant can provide valuable input.
Antibiotic therapy in the elderly
Early administration of appropriate antimicrobials has been
postulated as a key strategy in the survival of patients with very
severe infections requiring intensive care unit admission
[44,45]. However, it is unclear how far these data can be
extrapolated to other patient groups. Rapid, indiscriminate
6 Clinical Microbiology and Infection, Volume 21 Number 1, January 2015 CMI

TABLE 1. Selected challenges and the role of infectious patient’s microbiome [58]. The most striking example is
diseases consultants in managing infectious diseases in C. difficile infection, which is rare in the absence of previous
geriatrics antibiotic exposure impairing the ‘colonization resistance’
Role of ID consultant in meeting provided by the healthy gut microbiota. It is estimated that in
Challenge challenge the USA alone 250 000 illnesses and 14 000 deaths each year
Atypical presentations of infectious Balance risk of not treating an infectious are due to C. difficile infection [59]. These facts highlight the
diseases disease with risk associated with
unnecessary antibiotic use on the importance of judicious antibiotic use in geriatric patients. Here
individual and the ecological level the ID consultant with expertise in decision-making in situa-
High risk of nursing home/geriatric ward Ensure appropriate vaccination of
outbreaks of viral infections residents (e.g. influenza) tions of diagnostic uncertainty and protocol generation make an
Design strategies to prevent spread
within nursing homes important contribution. The authors would argue that in the
Respond to and manage outbreaks of
infection rapidly geriatric setting the role of the ID physician as the steward of
Colonization and infection with Implement appropriate infection control
antibiotic-resistant bacterial pathogens strategies to: not only antibiotics, but also the patients’ microbiome, is even
in geriatric wards and nursing homes
more important than in other specialties.
Screen for drug resistant
pathogens
Prevent spread within the
nursing home
Prevent spread to acute-care Value of the infectious diseases consultant
hospitals
Develop local empiric treatment
guidelines for nursing home patients
presenting with severe infections
Altered antibiotic metabolism and drug Careful consideration of drug therapies.
In the previous sections we have already alluded to the role of
interactions Liaison with clinical pharmacist. the ID consultant in geriatrics. Table 1 summarizes key chal-
lenges in geriatric infectious diseases and the role of the ID
consultant in addressing these. While based on the arguments
outlined above the value of the ID consultant may seem
administration of broad-spectrum antibiotic therapy favours obvious, there is a paucity of data regarding the value of ID
antibiotic resistance [46]. There are significant risks and consultation in general. A major limitation of the existing
possible adverse consequences of inappropriate antibiotic studies is that they are almost exclusively conducted by ID
therapy in the elderly, including risks of drug interactions, side specialists, who clearly have an interest in demonstrating their
effects related to age or disease-related changes in metabolisms, own usefulness and this may impact the credibility of these
and risks associated with MDROs and Clostridium difficile. findings for other physicians. Recent studies have examined the
involvement of ID consultants in some inpatient specialty areas,
Drug-resistant bacterial infections and the including orthopaedic surgery, critical care and oncology
[60–63]. These studies suggest, not surprisingly, that involve-
elderly
ment of ID consultants often results in modification of the
antibiotic treatment regimen and may also decrease overall
Outbreaks of infection with MDROs are frequently reported antibiotic use, costs and complications [60].
from long-term care facilities, and high rates of colonization The ID consultant also has an important understanding of
with resistant pathogens are also reported, even among current local antimicrobial resistance patterns, a factor that is
community-dwelling elderly [47–51]. A low functional status is critical in making correct empiric treatment decisions in geri-
a common risk factor both for both extended-spectrum atric patients where there is a high risk of resistance. In addi-
β-lactamase-producing Enterobacteriaceae and for methicillin- tion, ID consultants may be useful in the evaluation of unclear
resistant S. aureus colonization, and it highlights the need to febrile syndromes [64]. Some studies also report that ID
reinforce infection control measures and promote the judicious consultation and adherence to its recommendations results in
use of antibiotics [17,18,52]. Of special concern is the recent improved outcomes in inpatient and outpatient settings. This is
worldwide emergence of carbapenem-resistant Enter- best documented for S. aureus bacteraemia, where ID consul-
obacteriaceae. Long-term care and geriatric institutions seem to tation has been shown to decrease mortality, give better
be especially concerned by carbapenem-resistant Enter- adherence to standard of care, decrease rate of relapse, and
obacteriaceae outbreaks and may serve as a reservoir for spread improve diagnosis of metastatic foci of infection or endocarditis
to the acute-care setting [53]. Antibiotic exposure increases the [65–71]. A recent US study looking at claims data from over
risk of both acquiring and transmitting most MDROs, but the 270 000 hospitalized patients with one or more of 11 types of
mechanisms are complex [54–57]. An increasingly recognized infections (e.g. bacteraemia, C. difficile infection, endocarditis
deleterious effect of antibiotic exposure is its effect on the etc.), determined that after risk adjustment, ID input was
Clinical Microbiology and Infection © 2014 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved, CMI, 21, 3–9
CMI
associated with better outcomes and lower cost of care. These
benefits were greatest when ID specialist involvement started
within the first 2 days of hospital admission [72].
In our experience the ID consultant has other important
roles, especially when interacting with inexperienced physicians
and junior house officers, to address practical issues such as the
role of vascular access devices or urinary catheters as a focus of
infection, the need for device removal, and the role of surgery
in deep-seated infection. Geriatric units may not have significant
input from hospital infection-control physicians. Given the high
rates of drug-resistant pathogens and the risk of nosocomial
outbreaks in these populations, ‘infection-control physician’ is
another vital role that ID consultants can perform in the geri-
atric setting.
Conclusion
As outlined above, the prevention, diagnosis and management
of infectious diseases in geriatric patients poses significant and
evolving challenges. While clinical studies have not yet been
undertaken to measure the impact of ID consultants in geriat-
rics, ID consultants who work closely with geriatric units are
well placed to optimize the diagnosis and management of in-
fections within the unit, and to respond to evolving challenges
in the prevention of infection, especially in a role as an infection
control advisor and antibiotic steward.
Transparency Declaration
The authors declare that they have no conflicts of interest.
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