Elderly Patients
As they age, elderly patients become more susceptible to infection and diagnostic uncertainty. This can lead to increased levels of antibiotic exposure.
Greater use of antibiotics limits their effectiveness and can result in antibiotic resistance, especially among patients older than 65.
Antibiotic stewardship in elderly population
The challenge of managing infection in elderly patients
Compared to younger adults, diagnostic uncertainty is much more pronounced when assessing elderly patients as infections in older patients often present atypically.1
This is associated with:
Increased length of stay
Higher hospital mortality
Increased hospital costs
Avoid antibiotic overuse in elderly patients
PCT-aided stewardship can help reduce unnecessary use of antibiotics
Decrease diagnostic uncertainty and improve antibiotic decision making by aid of PCT.
Procalcitonin (PCT) has been demonstrated in a range of interventional, randomized, controlled trials to:
- facilitate effective and safe antibiotic stewardship (ABS)
- reduce antibiotic exposure without compromising patients' outcomes5,6,7,8
Higher susceptibility to infection with increasing age and diagnostic uncertainty contribute to higher antibiotic exposure in elderly patients.2 High antibiotic use is also reflected in the rise of antibiotic resistance observed in elderly patients compared to patients younger than 65 years.3,4
The impact of PCT-aided antibiotic stewardship (ABS) on antibiotic exposure and mortality was similar in elderly patients as compared to younger adults independent of clinical diagnosis and place of treatment.5
30-day mortality
- No adverse impact: OR 0.90 (95% CI 0.81-1.00) for PCT approach vs. standard of care, respectively.
- No significant difference between age-specific subgroups.
The highest reduction of antibiotic exposure by a PCT-aided approach was achieved for
patients with pneumonia (-3.71 days)
or other LRTI (-2.32 days)
patients with low-severity disease/
low outcome risk (SOFA 0-6) (-2.43 days)
patients treated on the ward (or in
primary care) (-3.02 days)
Sepsis is especially dangerous for elderly patients
Sepsis is a life-threatening medical emergency that affects people of all ages. However, older adults, particularly those who have health issues, are disproportionally affected. Early detection and treatment are essential for survival. PCT testing adds key information to the clinical assessment on the presence, course, and severity of sepsis, allowing clinicians to improve antibiotic decision making.
People over 65 are 13 times more likely to be hospitalized with sepsis10-13 than adults younger than 65, and the mortality rates for elderly patients with severe sepsis and septic shock are around 50 –60%.9-12 These high death rates occur because the elderly often experience co-morbidities, frequent and extended hospitalizations, weakened immune systems, functional limitations, and general effects of aging like thinning skin, frailty, and a sedentary lifestyle.9
People over 65 are 13x more likely to be hospitalized with sepsis10-13
The mortality rates for elderly patients with sepsis and septic shock are around 50-60%.
Making a timely and accurate diagnosis is essential
Diagnosis of infection is often difficult and delayed.13 For example, the first symptom of a UTI, a leading cause of infection, is typically confusion and disorientation, making it hard for the patient to describe his or her symptoms. In addition, the presentation of symptoms can be ambiguous or atypical. Moreover, elderly patients may not exhibit fever or other clinical signs of infection or inflammation seen in younger patients, even though seniors are at higher mortality risk.
Additionally, the bladder is often colonized in many elderly people leading to false positive results of the urinalysis that show colonization and not infection. This leads to an over prescription of antibiotics in this patient population.14
The decline in immune function often observed in elderly patients15-17 can result in atypical and frequently subtle (e.g., mild fever or even apyrexia) clinical presentations of bacteremia,15,16,18-20 further increasing the risk of under diagnosis and subsequent delays in the treatment of sepsis.
Given these challenges to diagnosis, and the vulnerability of the geriatric population to infection, having a diagnostic test with high specificity and predictive value is essential. Procalcitonin (PCT) can meet this need. With PCT testing, physicians gain timely information specific to systemic bacterial infection, including its presence, course, and severity.21
PCT is sensitive and specific
One meta-analysis of four studies (760 patients, aged 65 years and older) evaluated the accuracy of procalcitonin in diagnosing systemic bacterial infections in elderly patients.19 It was found that procalcitonin is both specific and sensitive in the diagnosis of severe bacterial infection in elderly patients. As shown in randomized controlled trials, very elderly patients can benefit from the use of PCT as a means of lowering antibiotic exposure. While kidney function in many older patients may be impaired, which can affect biomarker kinetics, there is no evidence that it impacts the usefulness of PCT as a diagnostic tool. As always, test results should be interpreted in the context of clinical findings.
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Learn more about implementing optimized procalcitonin testing in your hospital.
- Becket et al., Clin Microbiol Infect 2015; 21(1): 3–9, https://doi.org/10.1016/j.cmi.2014.08.018.
- Chui et al., Drug Safety 2020; 43: 595–606, https://doi.org/10.1007/s40264-020-00920-9.
- Giarratano et al., Clin Interv Aging 2018; 13: 657–667, https://doi.org/10.2147/cia.s133640.
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- Pallin DJ, Ronan C, Montazeri K, Wai K, Gold A, Parmar S, et al. Urinalysis in acute care of adults: Pitfalls in testing and interpreting results. Open Forum Infect Dis. 2014 Mar 1 (Vol. 1, No. 1). Oxford University Press.
- Ackermann RJ, Monroe PW. Bacteremic urinary tract infection in older people. J Am Geriatr Soc. 1996 Aug;44(8):927-33.
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- Lee SH, Chan RC, Wu JY, et al. Diagnostic value of procalcitonin for bacterial infection in elderly patients - A systemic review and meta-analysis. Int J Clin Pract. 2013;67:1350-1357.
- Fernández-Sabé N, Carratalà J, Rosón B, Dorca J, Verdaguer R, Manresa F, et al. Community-acquired pneumonia in very elderly patients: Causative organisms, clinical characteristics, and outcomes. Medicine. 2003 May 1;82(3):159-69.
- Karzai W, Oberhoffer M, Meier-Hellmann A, Reinhart K. Procalcitonin—A new indicator of the systemic response to severe infections. Infection. 1997 Nov 1;25(6):329-34.
- Gómez-Cerquera JM, Daroca-Pérez R, Baeza-Trinidad R, Casañas-Martinez M, Mosquera-Lozano JD, Ramalle-Gómara E. Validity of procalcitonin for the diagnosis of bacterial infection in elderly patients. Enferm Infecc Microbiol Clin. 2015 Oct;33(8):521-4.
- Fuentes E, Fuentes M, Alarcon M, Palomo I. Immune System Dysfunction in the Elderly. An Acad Bras Cienc. 2017;89(1):285-299.
- Guertler C, Wirz B, Christ-Crain M, Zimmerli W, Mueller B, Schuetz P. Inflammatory responses predict long-term mortality risk in community-acquired pneumonia. Eur Respir J. 2011;37(6):1439-1446.
- Schuetz P, Christ-Crain M, Muller B. Biomarkers to improve diagnostic and prognostic accuracy in systemic infections. Current opinion in critical care. 2007;13(5):578-585.
