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Antibiotic Resistance and Antimicrobial Use in Elderly Patients

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A special issue of Antibiotics (ISSN 2079-6382). This special issue belongs to the section "Antibiotics Use and Antimicrobial Stewardship".

Deadline for manuscript submissions: closed (29 February 2024) | Viewed by 18309

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Dr. Marcello Covino

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Emergency Medicine, Fondazione Policlinico, Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
Interests: medical and surgical emergencies in older adults; acute diverticulitis; acute pancreatitis; sepsis, infection in emergency; procalcitonin; trauma; head trauma; early warning scores; COVID-19; COVID-19 in the elderly
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Dr. Giuseppe De Matteis

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Internal Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
Interests: general medicine; diabetology; geriatric medicine
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Special Issue Information

Dear Colleagues,

The aging population is a worldwide phenomenon. According to the World Health Organization, in almost all countries in the world, the proportion of people over 60 years is increasing faster than other age groups. In 2050, it is expected that people over 60 will amount to almost 2 billion and will represent more than 20% of the population worldwide. In the European Union, it has been estimated that the population over 65 years, in the next 40 years, will double from about 87 million people today to around 148 million. At the same time, the population of the oldest (aged ≥85) is estimated to reach 7.8% of the total population, from the current value of 2.3%.

Elderly patients often present multiple comorbidities and complex clinical conditions compared to younger patients. Elderly patients with multi-morbidity are consequently very heterogeneous in terms of functional status, prognosis, and risk of adverse events.

Bacterial infectious disease and sepsis are common in the elderly population. Sepsis alone accounts for about ¼ of all in-hospital deaths in elderly people. Moreover, in older adults, more than 40% of patients have a recurrent hospitalization within three months of the initial sepsis, most commonly due to a repeat episode of sepsis or another infection.

Antimicrobial use in the elderly population requires a cautious evaluation of underlying clinical conditions, as well as specific adjustments for multi-therapy, reduced kidney and liver function, and potentially harming specific side effects.

At the same time, the optimization of antimicrobial use should take into account the increasing occurrence of Antimicrobial Multi Resistance, which is well recognized as one of the leading threats to human health in the next future.

Antimicrobial use is complex and dynamic and is influenced by sociocultural contexts as well as changing population and individual characteristics, such as the increasing prevalence of multi-morbidity and frailty.

Interventions developed in general clinical practice may not necessarily work for the elderly patients and the interventions to optimize antimicrobial use need to extend beyond a narrow concept of antimicrobial stewardship, and should be based on a comprehensive and inclusive systems approach, informed by a broad research base on the older populations.

This Special Issue invites articles on antimicrobial use in elderly and very elderly patients including (but not limited to) the following topics:

Specific approaches to antimicrobial therapy in elderly populations;
Antimicrobial use in the multi-therapy and multi-morbid patients;
Recurrent infections, sepsis, and antimicrobial therapy in frail patients;
Antibiotic stewardship in elderly people;
Changes in microbiota and antibiotic therapy in the elderly;
Role of new technologies (bacteriophages/probiotics, machine learning, etc.) to control antimicrobial-resistant organisms in the elderly.

Dr. Marcello Covino
Dr. Giuseppe De Matteis
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Antibiotics is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2900 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

elderly
oldest old
antimicrobial resistance
antibiotic stewardship
probiotics
microbiota
multi-morbidity
multi-therapy
sepsis

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Antibiotic Resistance and Antimicrobial Use in Elderly Patients, 2nd Edition in Antibiotics

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21 pages, 2285 KiB

Open AccessArticle

Knowledge, Attitudes, and Practices of Rural Communities Regarding Antimicrobial Resistance and Climate Change in Adadle District, Somali Region, Ethiopia: A Mixed-Methods Study

by Abdifatah Muktar Muhummed, Ashenafi Alemu, Yahya Osman Maidane, Rea Tschopp, Jan Hattendorf, Pascale Vonaesch, Jakob Zinsstag and Guéladio Cissé

Antibiotics 2024, 13(4), 292; https://doi.org/10.3390/antibiotics13040292 - 22 Mar 2024

Viewed by 1956

Abstract

There is an urgent need for interventions in addressing the rapid and disproportionate impact of antimicrobial resistance (AMR) and climate change (CC) on low- and middle-income countries. Within this context, it is important to understand indigenous knowledge in rural communities, which are highly affected. This study examined knowledge, attitude, and practices (KAP) regarding AMR and CC in the Adadle district, Somali region, Ethiopia, utilizing mixed methods, including 362 surveys and 12 focus group discussions among rural communities. Findings showed that 39% and 63% of participants were familiar with AMR and CC, respectively. Of those surveyed, 57% attributed AMR to inappropriate antimicrobial use in animals and humans, while CC was often associated with Allah/God. Multivariable analysis indicated that males exhibited superior knowledge and a positive attitude towards AMR and CC. Additionally, individuals aged 26–35 and 36–45 years showed heightened awareness of AMR and CC, respectively. Moreover, participants who were government employees, pastoralists, and business owners showed better knowledge on CC compared to family caretaker. Religious education and households with more than six members were linked to lower AMR knowledge. This study underlines a greater awareness of CC than AMR and highlights gender-based disparities, recommending integrated educational AMR programs targeting different demographics through a One Health lens, actively involving females, and incorporating local beliefs and practices. Full article

(This article belongs to the Special Issue Antibiotic Resistance and Antimicrobial Use in Elderly Patients)

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10 pages, 694 KiB

Open AccessArticle

Risk Factors and Outcomes of Community-Acquired Carbapenem-Resistant Klebsiella pneumoniae Infection in Elderly Patients

by Yen-Chou Chen, I-Ting Tsai, Chung-Hsu Lai, Kuo-Hsuan Lin and Yin-Chou Hsu

Antibiotics 2024, 13(3), 282; https://doi.org/10.3390/antibiotics13030282 - 20 Mar 2024

Viewed by 1864

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The increasing prevalence of carbapenem-resistant Klebsiella pneumoniae (CRKP) infections is a global concern. Elderly patients have a diminished immune response and functional reserve, and are thus more vulnerable to bacterial infection. This study aimed to investigate the risk factors and outcomes in elderly patients with community-acquired CRKP infections. We performed a retrospective cohort study in a tertiary medical center between 1 January 2021, and 31 December 2021. All elderly patients who visited the emergency department during this period with culture-positive K. pneumoniae were enrolled, and their baseline demographics, laboratory profiles, management strategies, and outcomes were recorded and analyzed. We identified 528 elderly patients with K. pneumonia infection, and the proportion of patients with CRKP infection was 10.2% (54/528). Recent intensive care unit (ICU) admission and prior carbapenem use are independent risk factors for CRKP infection in elderly patients. Compared to patients with carbapenem-sensitive K. pneumoniae infection, those with CRKP infection had a significantly higher risk of adverse outcomes, including ICU care, respiratory failure, septic shock, and 90-day mortality. CRKP infection was also identified as an independent risk factor for 90-day mortality. Clinicians should be aware of the increasing prevalence of CRKP infections in elderly patients and judiciously choose appropriate antibiotics for these patients. Full article

(This article belongs to the Special Issue Antibiotic Resistance and Antimicrobial Use in Elderly Patients)

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14 pages, 1492 KiB

Open AccessArticle

Reduced Prognostic Role of Serum PCT Measurement in Very Frail Older Adults Admitted to the Emergency Department

by Andrea Russo, Sara Salini, Giordana Gava, Giuseppe Merra, Andrea Piccioni, Giuseppe De Matteis, Gianluca Tullo, Angela Novelli, Martina Petrucci, Antonio Gasbarrini, Francesco Landi, Francesco Franceschi and Marcello Covino

Antibiotics 2023, 12(6), 1036; https://doi.org/10.3390/antibiotics12061036 - 10 Jun 2023

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Abstract

Background: This study aims to evaluate the prognostic role of serum PCT in older patients with suspect sepsis or infective diagnosis in the Emergency Department (ED) with a particular focus on the clinical consequences and characteristics due to frailty status. Methods: This is a observational retrospective study conducted in the ED of a teaching hospital. We identified all consecutive patients aged ≥ 80 years admitted to the ED and subsequently hospitalized for clinical suspicion of infection. Inclusion criteria were: age ≥ 80 years and clinical suspicion of infection; availability of a PCT determination obtained < 24 h since ED access; and Clinical Frailty Scale (CFS) determination. Study endpoints were the diagnostic accuracy of PCT for all-cause in-hospital death, infective diagnosis at discharge, and bloodstream infection. Diagnostic accuracy was calculated via ROC analysis and compared in the patients with severe frailty, measured by CFS > 6, and patients with low or moderate frailty (CFS 1–6). A multivariate analysis was performed to calculate the adjusted odds of raised PCT values for the study endpoints. Results: In total, 1459 adults ≥ 80 years with a clinical suspicion of infection were included in the study cohort. The median age of the sample was 85 years (82–89), with 718 (49.2%) males. The multivariate models revealed that, after adjusting for significant covariates, the PCT values at ED admission were significantly associated with higher odds of infective diagnosis only in the fit/moderately frail group (Odds Ratio [95% CI] 1.04 [1.01–1.08], p 0.009) and not in very frail patients (Odds Ratio [95% CI] 1.02 [0.99–1.06], p 0.130). Similarly, PCT values were significantly associated with higher odds of in-hospital death in the fit/moderately frail group (Odds Ratio [95% CI] 1.01 [1.00–1.02], p 0.047), but not in the very frail ones (Odds Ratio [95% CI] 1.00 [0.98–1.02], p 0.948). Conversely, the PCT values were confirmed to be a good independent predictor of bloodstream infection in both the fit/moderately frail group (Odds Ratio [95% CI] 1.06 [1.04–1.08], p < 0.001) and the very frail group (Odds Ratio [95% CI] 1.05 [1.03–1.07], p < 0.001). Conclusions: The PCT values at ED admission do not predict infective diagnosis, nor are associated with higher odds of in-hospital death. Still, in frail older adults, the PCT values in ED could be a useful predictor of bloodstream infection. Full article

(This article belongs to the Special Issue Antibiotic Resistance and Antimicrobial Use in Elderly Patients)

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15 pages, 980 KiB

Open AccessArticle

Identifying Predictors Associated with Risk of Death or Admission to Intensive Care Unit in Internal Medicine Patients with Sepsis: A Comparison of Statistical Models and Machine Learning Algorithms

by Antonio Mirijello, Andrea Fontana, Antonio Pio Greco, Alberto Tosoni, Angelo D’Agruma, Maria Labonia, Massimiliano Copetti, Pamela Piscitelli, Salvatore De Cosmo and on behalf of the Internal Medicine Sepsis Study Group

Antibiotics 2023, 12(5), 925; https://doi.org/10.3390/antibiotics12050925 - 18 May 2023

Cited by 5 | Viewed by 2077

Abstract

Background: Sepsis is a time-dependent disease: the early recognition of patients at risk for poor outcome is mandatory. Aim: To identify prognostic predictors of the risk of death or admission to intensive care units in a consecutive sample of septic patients, comparing different statistical models and machine learning algorithms. Methods: Retrospective study including 148 patients discharged from an Italian internal medicine unit with a diagnosis of sepsis/septic shock and microbiological identification. Results: Of the total, 37 (25.0%) patients reached the composite outcome. The sequential organ failure assessment (SOFA) score at admission (odds ratio (OR): 1.83; 95% confidence interval (CI): 1.41–2.39; p < 0.001), delta SOFA (OR: 1.64; 95% CI: 1.28–2.10; p < 0.001), and the alert, verbal, pain, unresponsive (AVPU) status (OR: 5.96; 95% CI: 2.13–16.67; p < 0.001) were identified through the multivariable logistic model as independent predictors of the composite outcome. The area under the receiver operating characteristic curve (AUC) was 0.894; 95% CI: 0.840–0.948. In addition, different statistical models and machine learning algorithms identified further predictive variables: delta quick-SOFA, delta-procalcitonin, mortality in emergency department sepsis, mean arterial pressure, and the Glasgow Coma Scale. The cross-validated multivariable logistic model with the least absolute shrinkage and selection operator (LASSO) penalty identified 5 predictors; and recursive partitioning and regression tree (RPART) identified 4 predictors with higher AUC (0.915 and 0.917, respectively); the random forest (RF) approach, including all evaluated variables, obtained the highest AUC (0.978). All models’ results were well calibrated. Conclusions: Although structurally different, each model identified similar predictive covariates. The classical multivariable logistic regression model was the most parsimonious and calibrated one, while RPART was the easiest to interpret clinically. Finally, LASSO and RF were the costliest in terms of number of variables identified. Full article

(This article belongs to the Special Issue Antibiotic Resistance and Antimicrobial Use in Elderly Patients)

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10 pages, 1364 KiB

Open AccessArticle

Perioperative Antibiotics in Appendicitis—Do We Need to Adjust Therapy for the Elderly? A Matched Pair Analysis

by Jens Strohäker, Martin Brüschke, Nora Leser, Alfred Königsrainer, Ruth Ladurner and Robert Bachmann

Antibiotics 2022, 11(11), 1525; https://doi.org/10.3390/antibiotics11111525 - 1 Nov 2022

Cited by 1 | Viewed by 1683

Abstract

(1) Background: Perioperative Antibiotics for acute complicated appendicitis are a standard of care. While there are plenty of trials for pediatric patients, data for elderly patients are scarce. The goal of our study was to evaluate whether elderly patients carry more resistant bacteria and thus have less favorable outcomes after an appendectomy that may warrant intensified perioperative antibiotic treatment (2) We present a retrospective single-center matched pair (139 patients each) analysis of perioperative and microbiological outcomes of an elderly appendicitis cohort (i.e., older than 60 years) compared with a younger adult cohort (i.e., ≤60 years). Both groups were matched one for one according to gender, duration of symptoms, c-reactive protein at presentation and whether they presented with uncomplicated or complicated appendicitis. (3) Results: After matching, complicated appendicitis was present in 76.3% of both groups. Elderly patients more frequently received preoperative diagnostic CT (p < 0.001) than the young. Both operative strategy (laparoscopic appendectomy in 92.1% each) and duration of surgery (57 vs. 56 min) were equal in both groups. Postoperative antibiotics were prescribed in ~57% for a median of 3 days in both groups and antibiotic selection was similar. The incidence of surgical site infections was higher in the young (12.2% vs. 7.9%) yet not significant. There was no difference in culture positivity or bacterial spectrum and the elderly cohort did not present with increased resistant bacterial isolates. (4) Conclusions: While overall resistant bacterial strains were rare, perioperative outcomes between the young and the elderly did not differ and did neither warrant longer nor intensified antibiotic treatment. Full article

(This article belongs to the Special Issue Antibiotic Resistance and Antimicrobial Use in Elderly Patients)

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11 pages, 574 KiB

Open AccessArticle

Prior Antibiotic Use Increases Risk of Urinary Tract Infections Caused by Resistant Escherichia coli among Elderly in Primary Care: A Case-Control Study

by Maria L. V. Jensen, Volkert Siersma, Lillian M. Søes, Dagny Nicolaisdottir, Lars Bjerrum and Barbara J. Holzknecht

Antibiotics 2022, 11(10), 1382; https://doi.org/10.3390/antibiotics11101382 - 9 Oct 2022

Cited by 4 | Viewed by 2993 | Correction

Abstract

We investigated whether prior use of antibiotics affects the risk of mecillinam/trimethoprim/nitrofurantoin/multi-resistant Escherichia coli urinary tract infection (UTI) among elderly patients in general practice. Data on urine culture came from urine samples performed in general practice and sent to hospitals in the Capital Region of Denmark, and prescription data came from a nationwide prescription database. The study population consisted of patients with UTI episodes (n = 41,027) caused by E. coli that received a concurrent antibiotic prescription against UTI from 2012 to 2017. We used a case-control design. Cases were UTI episodes caused by mecillinam, trimethoprim, nitrofurantoin or multi-resistant E. coli and controls were UTI episodes caused by E. coli not displaying the respective resistance pattern. We analyzed whether exposure to antibiotics in a period of 8–90 days prior to the UTI episode affected the risk of antibiotic resistant uropathogenic E coli. The analyses were adjusted for age, sex, hospital admission and nursing home status. The odds of resistance to all of the four antibiotics increased significantly after exposure to antibiotics within 90 days prior to the UTI episode. In general, mecillinam showed the lowest increase in the odds for selection of resistance. The results indicate that mecillinam is a favorable antibiotic choice in terms of selection of resistance. Full article

(This article belongs to the Special Issue Antibiotic Resistance and Antimicrobial Use in Elderly Patients)

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16 pages, 2457 KiB

Open AccessArticle

Antibiotic Prescription in the Community-Dwelling Elderly Population in Lombardy, Italy: A Sub-Analysis of the EDU.RE.DRUG Study

by Federica Galimberti, Manuela Casula, Elena Olmastroni, Alberico L Catapano, Elena Tragni and on behalf of EDU.RE.DRUG Group

Antibiotics 2022, 11(10), 1369; https://doi.org/10.3390/antibiotics11101369 - 7 Oct 2022

Cited by 5 | Viewed by 1999

Abstract

Inappropriate consumption and over-prescription of antibiotics have been extensively reported. Our aim was to specifically evaluate the antibiotic prescribing patterns and appropriateness among the elderly (≥65 years) from the Lombardy region (Italy) in primary care. Antibiotic consumption (as DID: DDD/1000 inhabitants × day) and prevalence rates in 2018 were assessed, and the prescribing quality was evaluated using ESAC-based indicators and WHO-AWaRe criteria. A multivariate logistic regression analysis was performed to evaluate the association between the probability of receiving an antibiotic prescription and patients’ and physicians’ characteristics. A total of 237,004 antibiotic users were included (mean age ± SD 75.98 ± 7.63; males 42.7%). Antibacterial consumption was equal to 17.2 DID, with values increasing with age in both males and females. The study found that the proportion of patients with at least one antibiotic prescription in 2018 was around 39.1%, with different age-related trends between males and females. Consumption (as DID) of cephalosporines (65–74 years: 1.65; 75–84 years: 2.06; ≥85 years: 2.86) and quinolones (3.88, 4.61, 4.96, respectively) increased with growing age, while consumption of penicillins (6.21, 6.08, 6.04, respectively) and macrolides, lincosamides, and streptogramins (3.25, 2.91, 2.64, respectively) decreased. In 2018, antibiotics considered to have higher toxicity concerns or resistance potential, as reported by WHO-AWaRe tool, were consumed more intensively than those to be used as first choices, independent of age and sex. The probability of receiving an antibiotic prescription was greater in females, in subjects with polypharmacy, in treatment with respiratory drugs, anti-inflammatory agents or glucocorticoids, and with previous hospitalization; but increasing age was less associated with exposition to antibiotics. Full article

(This article belongs to the Special Issue Antibiotic Resistance and Antimicrobial Use in Elderly Patients)

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Open AccessCorrection

Correction: Jensen et al. Prior Antibiotic Use Increases Risk of Urinary Tract Infections Caused by Resistant Escherichia coli among Elderly in Primary Care: A Case-Control Study. Antibiotics 2022, 11, 1382

by Maria L. V. Jensen, Volkert Siersma, Lillian M. Søes, Dagny Nicolaisdottir, Lars Bjerrum and Barbara J. Holzknecht

Antibiotics 2023, 12(2), 386; https://doi.org/10.3390/antibiotics12020386 - 14 Feb 2023

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Abstract

In the original publication [...] Full article

(This article belongs to the Special Issue Antibiotic Resistance and Antimicrobial Use in Elderly Patients)

6 pages, 398 KiB

Open AccessBrief Report

Feasibility of Algorithm-Based Clinical Decision Support for Suspected Urinary Tract Infections in Nursing Home Residents

by Garrett P. New, Arif Nazir, Penny Logan and Christine E. Kistler

Antibiotics 2022, 11(10), 1276; https://doi.org/10.3390/antibiotics11101276 - 20 Sep 2022

Cited by 2 | Viewed by 2021

Abstract

Urinary tract infections (UTIs) are commonly suspected in nursing home (NH) residents, commonly resulting in antimicrobial prescriptions, even when symptoms are non-specific. To improve the diagnosis and management of suspected UTIs in NH residents, we conducted a pilot test of a paper-based clinical algorithm across NHs in the southern U.S. with ten advanced practice providers (APPs). The paper-based algorithm was modified based on the clinical care needs of our APPs and included antimicrobial treatment recommendations. The APPs found the UTI antimicrobial stewardship and clinical decision support acceptable. The educational sessions and algorithm improved baseline confidence toward UTI diagnosing and treatment. The APPs thought the algorithm was useful and did not negatively impact workload. Feedback from the pilot study will be used to improve the next iteration of the algorithm as we assess its impact on prescribing outcomes. Full article

(This article belongs to the Special Issue Antibiotic Resistance and Antimicrobial Use in Elderly Patients)

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