Infection patients in nursing homes
In general, nursing home patients are old, have weakened skin and mucous membrane barriers and a large burden of chronic diseases, implants and other foreign bodies. They use immunosuppressive drugs more frequently than younger patients. An imbalance in the immune system's response to infections also comes with age (6). Taken together, this results in a higher risk of infection, lowered resistance and less reserve capacity for dealing with acute events.
A high prevalence of cognitive impairment and serious somatic diseases in nursing home patients attenuates the reserve capacity of important organs. As a result, we regularly observe that the prominent symptoms in acute events are due to failure of end organs and/or other functions that demand a great deal of the patient. These most frequently take the form of delirium, a tendency to fall, urinary incontinence and dehydration. A substantial share may not have fever, and some patients do not develop, or they have problems in communicating, local symptoms of infection (7). Chronic diseases may also reduce the specificity of the clinical findings commonly associated with acute infectious diseases.
As a rule, the infection diagnosis in nursing homes is based on the clinical picture and a limited selection of cultures and inflammation markers in blood. In our experience, the classical biochemical response commonly associated with acute bacterial infections, a pronounced rise in C-reactive protein (CRP) and leukocytes in peripheral blood, may be lacking in some elderly and frail patients. Nursing home patients also have non-infectious inflammatory conditions and cancer more often than younger people, which can cause interpretation problems when there are high CRP or leukocyte values.
Elderly people can contract infections with a wide spectrum of microorganisms, and it is important to obtain adequate cultures prior to antibiotic therapy. But the incidence of microbial colonisation of the skin, mucous membranes and wounds also increases with age, particularly in the urinary tract (7). This leads to a significant risk of overtreatment with antibiotics.
Elderly people often tolerate antibiotics better than other medications. Nonetheless, they more often experience side effects and complications from antibiotics than younger people (8). In our experience, ciprofloxacin, in particular, can cause very troublesome cognitive side effects, primarily in patients with dementia. Severe renal failure also precludes the use of some groups of antibiotics such as aminoglycosides, and necessitates dose reduction of others.