Page 140 nursing.elitecme.com Complete Your CE Test Online - Click Here Nursing consideration: Older adults often present atypically with infection and sepsis. The nurse must be astute in evaluating changes in the patient and take into consideration changes from the patient’s baseline presentation whenever possible. Involving a family member or caregiver in the evaluation of the elderly may help to achieve a comprehensive evaluation. Bacteremia in the older adult Older patients are more likely to develop bacteremia from gastrointestinal and genitourinary sources than younger patients, with gram-negative bacteria the infectious agent (Mody, 2017). Mortality rates increase with age for nosocomial gram-negative bacteremia (Mody, 2017). Mortality rates for older adults were found to be 37% to 50%, compared to a mortality rate of 5% to 35% in younger adults (Pien et al., 2010). Reasons for the increased risk of mortality for older adults include higher frequency of invasive catheters, depressed immune response, comorbidities, and a higher incidence of end organ damage, such as renal insufficiency or acute respiratory distress syndrome (Mody, 2017). Infective endocarditis in the older adult Infective endocarditis is an infection in the endocardium of the heart that affects older adults 4.6 times more than it affects younger populations (Hoen et al., 2002). In older adults, streptococci and staphylococci are the main causative organisms. Infective endocarditis is also more difficult to diagnose in older patients, leaving them at a higher risk for undetected infection that may lead to sepsis. Pneumonia in the older adult Pneumonia is a cause for concern with the aging population. Adults older than age 65 comprise more than 50% of all cases of reported pneumonia (Fry, Shay, Holman, Curns, & Anderson, 2005; Hoen et al., 2002; Jackson et al., 2004). Streptococcus pneumoniae is the most frequent causative organism in older populations, but gram-negative organisms—such as Haemophilus influenzae, Legionella pneumophila, Moraxella catarrhalis, and Klebsiella spp—are more frequently seen in older adults with chronic obstructive pulmonary disease (COPD) who reside in long-term care facilities than those who reside elsewhere (Mody, 2017). Lack of vaccinations, immobility, immunosuppression, and chronic respiratory illnesses increase the risk of developing pneumonia and subsequent sepsis. Prosthetic device infections Many older adults are likely to have prosthetic devices as they age, including joint replacements, pacemakers, heart valves, and vascular grafts (Mody, 2017). Prosthetic joint replacements offer a particular challenge for treatment, as they are found to have microbial biofilms that reduce the effectiveness of antibiotics and may also have reduced blood flow secondary to scarring from surgery (Mody, 2017). Typically, removal of the prosthesis and reimplantation is recommended, which could be difficult to withstand for the older patient with existing comorbidities (Mody, 2017). Urinary tract infections in the older adult Older adults are particularly prone to the development of urinary tract infections (UTIs). UTIs are the most frequent cause of infection in adults older than age 65, with the incidence in men over age 80 of 5.3% and 10% in women over age 80 (Foxman & Brown, 2003). Gram-negative bacilli—such as Escherichia coli, Enterobacter, Klebsiella, and Proteus—are the most common causative organisms. But there is increased incidence of more resistant organisms also being isolated, such as Pseudomonas aeruginosa and gram-positive organisms, such as Enterococci, Staphylococci, and Streptococcus (Mody, 2017). Elderly patients with catheters are at the greatest risk for sepsis. The use of chronic indwelling catheters in nursing homes leading to cases of asymptomatic UTI is seen in 25% to 54% of women (Juthani-Mehta, 2007). In these cases, there is no benefit to treating with antibiotics, and treatment can lead to the problem of antibiotic- resistant organisms (Mody, 2017). Key points ● ● Older adults are at risk for developing sepsis for many reasons, including immune system changes, nutritional deficiencies, increased risk for HAIs and CAIs, comorbidities, and chronic health issues. ● ● Older adults may present atypically with infection, allowing the infection to go undiagnosed and, therefore, untreated, potentially leading to sepsis. ● ● Older adults are more likely to have prosthetic devices and subsequent infections of devices, infective endocarditis, pneumonia, and urinary tract infections than younger populations. SEPSIS AND PREGNANCY Pregnant women and those in the postpartum or puerperal phase (6 weeks after delivery) can develop sepsis and septic shock. In this population, sepsis can develop quickly in an otherwise healthy- appearing patient and have serious and life-threatening consequences, such as preterm labor and delivery, fetal infection, septic shock, multiple organ dysfunction syndrome multiple organ dysfunction syndrome (MODS), and death (Barton & Sibai, 2012). Incidence Maternal sepsis (sepsis that develops during pregnancy) and postpartum sepsis are more common in developing countries where women do not have access to quality medical care or may live in unsanitary conditions than women in developed countries (Sepsis Alliance, n.d.). While maternal and postpartum sepsis is considered to be rare in the more developed countries, incidence and maternal deaths from sepsis are rising, and attention to this specific population should be considered in the discussion of the adult patient with sepsis. Data from the mid-1990s showed sepsis as the cause of 7.6% of maternal deaths in the United States, and this number continues to rise (Bauer et al., 2013; Sepsis Alliance, n.d.). Sepsis is the leading cause of maternal deaths in the United Kingdom (Bauer et al., 2013). The incidence of medical and surgical emergencies in the pregnant and postpartum patient leading to sepsis is rising and is expected to continue to rise in the future (Barton & Sibai, 2012). The reasons for this rise include an increased maternal age, multiple gestations, and obesity (Barton & Sibai, 2012), along with the following reasons. Increasing maternal age: Pregnancy in women over age 40 is much more common than it was in the past, carrying with it an increase in the incidence of obesity, diabetes, placenta previa, and abruptio placentae (Barton & Sibai, 2012; Montan, 2007). Multiple gestations: Multiple gestations that carry increased maternal risk are on the rise with the availability of reproductive technologies. Multiple gestations require more invasive and diagnostic procedures, such as cervical cerclage, serial amnioreduction, and fetal or placental surgery (Barton & Sibai, 2012; Hoffman & Sciscione, 2004; Plachouras, Sotiriadis, Dalkalitsis, Kontostolis, Xiropotamos, & Paraskevaidis, 2004). Obesity: The incidence of pregnant women who are obese or morbidly obese has risen over the past decade causing an increase in obesity- related complications, such as increased hypertensive disorders, type 2 diabetes, caesarean section, and cardiopulmonary complications (Barton & Sibai, 2012; Gunatilake & Perlow, 2011).