CHALLENGES WITH DIAGNOSING AND

MANAGING SEPSIS IN OLDER PEOPLE

Kalin M Clifford, Eliza A, Krystal K, Kristen Maxvill
Expret Review of Anti Infective Therapy 2016 vol 14, no 2, 231-241
INTRODUCTION OLDER ADULT > 65 Y.O
Delayed initiation
Increased risk
of sepsis bundle
contracting Decline Immune
because abnormal
infectious System
infectious disease
pathogen
presentation
60 % patients diagnosed with sepsis are older than 65
years old

Purpose of this journal is to identify age related changes

that increase the risk of sepsis and cause difficulty with
diagnose
To provide recommendation for treating sepsis in older
adults age > 65 years
 Initiate
antibiotics
Fluid
resuscitatio
n

Vasopresor
s

NO RECOMMENDATION FOR OLDER

ADULTS
Surviving Sepsis
Campaign (SSC) 2012
guidelines
 GERIATRIC SPECIFIC FACTORS
Immunosenescence
 Increase the vulnerability of older
Decrease T cell counts
adult to contract an infection

Decreased thymal mass

decreased output nave T cells,
decrease in interleukin-2 (IL-2)
activation, secretion, proliferation
that effects to activate lymphocyte Immunosenescence
delayed activation of
lymphocytes immune system
cannot eradicate invading pathogen
 CHRONIC LOW GRADE PRO
INFLAMATORY STATE
Increased concentration of IL-6, Tumor necrosis
factor alpha (TNF-alpha) and CRP

Response to infection decrease

 DIAGNOSTIC CHALLENGES

Unique sysptom of
infection in older
patient :
Lethargy
Most common :
altered mental state Tachypnea Often under
does not indicate Loss appetite diagnosed
a nervous system atypical, non specific
Dehydration
infection as in symptom
younger adult Weaknes
Dizziness
Fall
incontinence
 BIOMARKER THAT HELPS :
Erytrocyte sedimen rate CRP, Lactate and
procalcitonin
 SEPSIS
Ex : difficulty assessing
Is syndrome of temp criteria of SIRS :
Typical sign of sepsis and
inflammatory response to older adults in fact that the
SIRS criteria are not
infection, is typicaly bodys temperature are
commonly seen in geriatric
diagnosed using (SIRS) often be 0.6 0.8 lower in
patients
criteria older adults than in
younger adults

decrease temp response

to infection as a result
decreased cytokine malnutrition also lead to
production, decreased decreased temperature
sensitivity of response
hypothalamus to cytokines
and poor thermoregulation
 More be advantegious to assess
Shaking chills, an elevated
change in temperature from
temperature was a good predictor of
individual patients baseline rather
bacteremia in patients over the age
than absolute temperature value in
80
older adults
 COMORBID CONDITION
Congestive Heart Failure
Chronic Kidney Disease
Iron overload inhibits cellular immune effector function
Diabetes Mellitus
Neuropathy and poor vasculature leads to delayed phagocytosis
corresponding with decreased clearance of yeast and bacteria by
neutrophile
Chronic Liver Failure
Impairment of complement factor formation and proliferation of
cellular imunity
Chronic Obstructive Lung Disease
Malignancies
 Lactate development
Serum lactate level are anaerobic metabolism
considered for diagnosis which is caused by
of sepsis hypoperfusion of end
organs

Anemia, severe
Lactate level increase dehydration
increase mortality risk increased level of
lactate due to lack of
red blood cells and fluid
 PHARMACODYNAMIC /
PHARMACOKINETIC CHALLENGES
Absorbtion, distribution, metabolism and
elimination of drugs in older adult
 ABSORBTION
Decline in older adult

Atrophy of the gastric parietal cells increases gastric

pH, alter the absorption that dependent on gastric
acidity
Delayed emptying time leads to decrease rate of
absorbtion

Decreased drug peak concentration

Decreased intestinal surface area

Decreased abdominal blood flow

 DISTRIBUTION

Muscle mass Total body water Decreased serum

deacrease, body fat decrease albumin leading to
increases increased
concentration free
fraction of drugs,
which are normaly
highlt protein bound
 METABOLISM AND ELIMINATION

Decline in hepatic blood flow and impairment in

hepatic enzymes lead to decreased 1st pass effects
and increased half live
Decrease of renal function lead to decreased
clearance medication
 CONSIDERATION OF SEPSIS
TREATMENT IN OLDER ADULTS
 FLUID RESUSCITATION AND
HEMODYNAMIC SUPPORT
Fluid resuscitation one of mainstays of sepsis
management
Initial resuscitation should be achieved within 6h using
using a protocol based process improved mortality
outcomes
Patients should initialy received a 30ml/kg IV fluid
challenge + additional fluid boluses until patient no longer
demonstrates hemodynamic improvement
Dynamic test such as passive leg raise and pulse preassure
variation may more accurately predict fluid response when
compared to CVP
 VASOACTIVE AGENTS
Recommended to improve and preserve sepsis induced end
organ perfusion
MAP is the driving preassure for peripheral blood flow and as
the therapeutic target for all patient with sepsis induce end
organ hipoperfusion
Vasopresor target MAP > 65mmHG, higher goal may benefit
in patient with hypertension or atherosclerosis
One study demonstrate that a target MAP of 80-85 mmHg
improve renal function when compared to standard target in
patient with history arterial hypertension
 VASOACTIVE AGENTS
Vasopressors
Inotropes
Vasodilators

SSC Guidelines support NorEpinefrin as preferred

vasopressor, particulary when hypovolemic is not
resolved with IV Fluid administration
 NOREPINEPHRINE VS DOPAMINE
Several studies in patients with septic shock, DA
demonstrates a higher short term mortality,
tachycardia and new diagnosis of arhytmia

Only recommended as an alternative vasopressor

agent to NE in selected patient with low rish of
tachyarhytmia or relative bradycardia
 Epinephrine is recommended as alternative vasopressor
added to and potentially substitute to NE

Vasopresin is adjunct to catecholamines in patient with

severe septic syock based on relative vasopresin deficiency
hypotesis during 24-48H as shock continues restore
vascular tone and blood preasure

Higher dose >0.05 unit/min are associated with cardiac arest

 Maintain high CO in sepsis associated with a
better outcome ( one of Early Goal Directed
Therapy)
 ANTIBIOTIC AND SOURCE
CONTROL
SSC 2012 guidelines strongly recommend an appropriate
broad spectrum antibiotic regimen be administered in 1h of
recognition of severe sepsis or shock

Timely recognition of sepsis is challenging in older patient due

of atypical symptom

Inapropriate empiric therapy is independent predictor of

mortality particularly in older adult

Selecting agents should be based on site of infection,

comorbidities, antibiotic exposure in past 30 days, and nursing
home recidence
 Older adults more likely to have gram negative
pathogens when compared to young group
Multi drug resistant organism such as MRSA,
Vancomycin resistant enterococci, ESBL organism are
more likely in residents of long term facility

Based on site of infection broad spectrum AB

should be started initially and de-escalate as
appropriate
AB should always be started at full initial doses and
then adjusted based on renal function
 Once a regimen has been selected important to
monitor potential advers drug reaction
Advers drug reaction occur 2 3 times more often in
this population
Aminoglicoside incidence of ototoxicity in older
adult
Fluoroquinolones risk to have longer QT intervals
 SOURCE CONTROL
Rapid identification of infection and source control
intervention within 12 H

Most common infection sites in older adult lung,

urinary tract, abdomen

Source control procedures include removal of

catheters, drainage of abscesses, debridement of
necrotic tissue, and removal om empyema
 SUPPORTIVE CARE
Ventilated patient protocol based sedation with daily interruption
and spontaneous breathing trials

All patient should receive venous thromboembolism prophylaxis with

low molecular weight or unfractionated heparin unles contraindicated
and stress ulcer prophylaxis with PPI or AH2 receptor blocker

Receive protocol based glucose management targeting blood glucose

< 180 and avoidance of hypoglycemia

Enteral nutrition should be initiated in first 48 H care for

inadequate nutritional status prior to admission
 END OF LIFE CARE
Setting goals of care and end of life planning are important for septic,
older adults

Goals of care and prognosis

should be discussed with patients and a families
Incorporated into treatment and end of life care planning
Discussed as soon as feasible but no later than 72 H after ICU
admission

Focus on two concept ethical decision making and shared decision

making
Autonomy(self determination)
Beneficience (do good)
Non maleficience ( do no harm)
 CONCLUSION
Sepsis is time dependent syndrome late diagnosis
can lead to increased mortality risk if not diagnosed
and treated appropriately
Older adult contract sepsis have greater mortality
risk due delay in time to diagnosis
Need additional research in this special population as
well as recognition of specific guidelines within future
update to indntify and diagnose sepsis in older adult
who present with atypical symptoms
Thank You