A diagnostic approach to the adult with fever of unknown origin.

The evaluation of the condition of a patient with fever of unknown origin requires a knowledge of those disorders that produce this syndrome, an awareness of the potential significance of subtle findings in the history and physical examination, and an appreciation of the value in this clinical setting of specific diagnostic procedures. In this report, we review these aspects of fever of unknown origin and outline a diagnostic approach to the persistently febrile patient.

Fever in the wake of a stroke.

We performed a prospective study of the frequency and cause of fever, defined as a rectal temperature of greater than or equal to 101 degrees F detected within the first 5 days, in 104 consecutive adults admitted to a community/teaching hospital because of a nontraumatic stroke. Fever was documented in 23 patients. A source for the fever was identified in 19 patients and was attributed to a pulmonary insult, either aspiration chemical pneumonitis or an infectious pneumonia, in 13 of these patients. Patients who experienced lacunar infarcts did not develop fever. Fever occurring in the wake of a stroke should not be attributed to the vascular process, but should direct attention to inflammatory disorders of the lungs.

Fever of unknown origin in the elderly.

An extensive literature survey was performed and hospital records were reviewed in order to identify cases of fever of undetermined origin in patients aged 65 or older. Analysis of the 111 cases discovered demonstrates a characteristic but not unique spectrum of underlying disorders. Potentially curable entities such as abdominal abscess, bacterial endocarditis, tuberculosis and giant-cell arteritis account for more than half of the serious illnesses presenting with prolonged pyrexia in elderly subjects. A diagnostic approach to the management of the persistently febrile geriatric patient is discussed.

Bacterial pneumonia in the elderly: a reappraisal of conventional therapy, with a note on cefamandole.

Community-acquired bacterial pneumonia in the elderly has for years been attributed almost exclusively to Streptococcus pneumoniae. Recent technical advances have provided bacteriologic and epidemiologic data demonstrating that other pathogens are important causes of pulmonary infection in older patients. This report reviews these data and reappraises the conventional therapy of community-acquired bacterial pneumonia in geriatric patients. Some properties of a new antibiotic, cefamandole nafate, are described.

Community-acquired bacteremia in the elderly: analysis of one hundred consecutive episodes.

A retrospective analysis was made of the records of 100 consecutive geriatric patients with community-acquired bacteremia, admitted to a suburban hospital. The most frequently identified tissue sources for these bacteremias were the urinary tract (34 percent), biliary tract (20 percent), and lungs (13 percent). In 11 percent of the patients, the tissue focus was not established. E. coli, Klebsiella species and Streptococcus pneumoniae were the most common organisms isolated, and they contributed to 73 percent of the bacteremias. Of the 100 patients, 26 succumbed to the infection. Clinical manifestations unique to the geriatric patient are described.

Antibiotic use in the elderly. A selective review.

There are unique challenges for the physician who prescribes an antibiotic to an elderly patient. Advanced age is associated with physiological alterations and a reduction in the excretion of numerous compounds. Mental and physical illness in aged patients will impair unsupervised drug compliance. Antibiotic-related adverse events and antibiotic-associated drug interactions pose a threat to life and impede the desired therapeutic outcome.

Antibiotic concerns in the elderly. A clinician's perspective.

Unique antibiotic concerns exist for the management of infections in elderly patients. Issues concerning age-associated physiological alterations, compliance, drug-drug interactions, adverse drug reactions, and guidelines for empiric therapy are reviewed in this article.

Introduction of trimethoprim: a mixed blessing.

Trimethoprim recently has been released by the Food and Drug Administration (FDA) exclusively for the treatment of acute symptomatic uncomplicated bacterial urinary tract infections. The compound compares favorably with alternative standard agents, such as ampicillin and cephalexin, for the therapy of women with acute symptomatic urinary tract infections caused by Escherichia coli. Trimethoprim should not be prescribed for the pregnant woman. Indiscriminate administration of the drug could foster the emergence of strains resistant to trimethoprim and trimethoprim-sulfamethoxazole. Trimethoprim has not been approved by the FDA for the treatment of recurrent, bacterial urinary tract infections.

Community-acquired bacterial pneumonia in the elderly.

Pneumonia remains the leading infectious disease-related cause of death among the elderly. Streptococcus pneumoniae is the most frequent pathogen isolated from aged individuals with community-acquired pneumonia. Other common bacteria that cause this disease include Haemophilus influenzae and Legionella pneumophila. Manifestations of pneumonia in the elderly can be subtle and result in delayed recognition and treatment. Gram stain evaluation and culture of non-contaminated expectorated sputum remain the conventional techniques to guide initial antibiotic selection. While the presence of a new infiltrate on chest X-ray confirms the clinical diagnosis of pneumonia, the radiographic appearance of the infiltrate cannot accurately define the etiologic agent. Specific therapeutic measures include administration of appropriate antibiotics, correction of fluid and electrolyte imbalances, nutritional support and treatment of concomitant disorders. Preventive measures include use of influenza vaccine, amantadine and pneumococcal vaccine.

Antibiotic irrigations. A plea for controlled clinical trials.

Although the medical literature describes the perioperative use of antibiotic irrigations in abdominal, pelvic, orthopedic and vascular surgery, the lack of well-designed and executed, controlled clinical studies often precludes a definitive assessment of the value of this technique. Future randomized, double-blind, controlled clinical trials are required to establish its merit. In this age of cost consciousness, lavages with antibiotic solutions cannot at present be regarded as conventional medical therapy.

Cinoxacin: mechanism of action, spectrum of activity, pharmacokinetics, adverse reactions, and therapeutic indications.

Cinoxacin, a chemotherapeutic agent that inhibits bacterial DNA synthesis, has recently been approved for the treatment of initial and recurrent bacterial urinary tract infections. Although closely related to nalidixic acid, cinoxacin possesses some distinct characteristics: rapid attainment of therapeutic urinary concentrations and greater activity against strains of Enterobacteriaceae that cause urinary tract infections. Biopharmaceutical properties include serum protein binding of approximately 70%, 50-60% excretion of intact drug in the urine of patients with normal renal function, and an elimination half-life of approximately one hour. The elimination half-life is increased in patients with decreased renal function and when probenecid is coadministered. Adverse events occur infrequently and consist of nausea, vomiting, headache, dizziness, and hypersensitivity reactions. The drug compares favorably with standard therapies for the treatment of bacterial cystitis and recurrent urinary tract infections. Initial studies demonstrate that cinoxacin has substantial efficacy as a prophylactic agent for those women who experience recurrent, symptomatic urinary tract infections.

Urinary tract infection.

Urinary tract infections are the most common bacterial infections experienced by elderly patients. These infections are often asymptomatic, although on occasion they produce discomfort for selective older patients (particularly those with obstructive uropathy), and present a risk for bacteremia, septic shock, adult respiratory distress syndrome, and death. The limited available data suggest that there are major differences with regard to pathogenesis, microbiology, clinical features, laboratory abnormalities, and therapy between young and elderly women who develop symptomatic pyelonephritis. There is a need to provide a standard antibiotic prophylaxis program to those elderly patients with specific cardiac conditions who are scheduled to undergo urinary procedures.

Diagnosing a common kidney infection of the elderly inpatient.

Initial antibiotic therapy should be based on Gram's stained urine. For the elderly patient with acute symptomatic bacterial pyelonephritis caused by gram-negative aerobic bacilli, an aminoglycoside is recommended, eg, gentamicin, tobramycin, or amikacin. Pathologic pyuria (greater than 10 WBC/high-power field) supports the clinical impression of acute symptomatic bacterial pyelonephritis. However, many factors can spuriously lower the number of bacteria in the urine: prior diuresis or antimicrobials; obstruction distal to the site of infection; and infection not directly accessible to the collecting system.

Managing the older bronchitis patient.

In this era of cost containment, it is not appropriate to obtain a complete blood cell count, Gram's stain of sputum, sputum culture, or blood cultures for elderly outpatients with an exacerbation of chronic bronchitis. For monitoring antibiotic therapy of infectious exacerbations, clinicians rely on the patient's observations that dyspnea is less severe, and that sputum volume is reduced and appears more mucoid than purulent. These criteria may be rudimentary, but they have withstood the test of time.

Pneumonia: update on diagnosis and treatment.

Pneumonia is the most common infectious disease necessitating hospitalization of elderly patients. A number of misconceptions exist regarding the clinical and radiological features of pneumonia in elderly patients. Early recognition and appropriate therapy can reduce morbidity and enhance survival. This article explores the manifestations of pneumonia in the elderly, as well as the diagnostic approach and contemporary therapy.

Newer antibiotics: their place in geriatric care. Part I.

The third-generation cephalosporins offer considerable appeal for treatment of specific life-threatening infections (nosocomial pneumonia, meningitis, urosepsis) in elderly patients when the disorders are caused by aerobic gram-negative bacilli. Despite the frequent presence of cross-reactive antibodies in the sera of recipients of cephalosporins, clinically evident serious reactions to cephalosporins occur infrequently in patients with known penicillin allergy.

Managing diabetes-related infections in the elderly.

The elevated serum glucose levels of diabetics affect traditional host defenses, predisposing these individuals to infectious processes. The elderly diabetic patient is also faced with senescence of the immune system which can alter host defense mechanisms and increase the risk of infection. Infections in elderly diabetics can be severe and life-threatening, and only through the prompt recognition and treatment of these disorders can morbidity and mortality be avoided. Broad-spectrum antimicrobial agents, in conjunction with surgical intervention, are often necessary to eradicate these infections. Common sites of involvement include the skin, biliary tract, urinary tract, and the soft tissues and bones of the feet.

Reviewing the safe use of antibiotics in the elderly.

As the elderly segment of our population expands, physicians will be prescribing medications more frequently for this age group. Physiologic changes, drug-drug interactions, and untoward adverse reactions are more common in the elderly. In addition, therapeutic decisions regarding antimicrobial agents for infectious disease in the aged are also complicated by the burgeoning number of compounds available to clinicians. A thorough knowledge of various antibiotic interactions, potential toxicities, and pharmacokinetics is necessary to safely and effectively prescribe these agents for elderly patients.

Newer antibiotics: their place in geriatric care. Part II.

The pharmaceutical industry has addressed the problem of combating infections caused by gram-negative aerobic bacilli with the development of newer penicillins and a novel class of antibiotics known as the carbapenems. These compounds represent the culmination of years of research designed to overcome bacterial resistance mediated by inactivating enzymes, called beta-lactamases. These latter enzymes, contained within the gram-negative aerobic bacilli, have the capacity to hydrolyze select penicillins to inactive derivatives. We outline the therapeutic indications and limitations of these newer antibiotics.

Bacterial pneumonia: specific diagnosis and treatment of the elderly.

Community-acquired bacterial pneumonia remains a formidable problem for the elderly. Patients' clinical presentations do not invariably coincide with those "classically" described. Predisposing factors, clinical manifestations, laboratory assessment, and differential diagnosis are discussed. The pivotal role of the technically adequate chest x-ray and the potential limitations of its interpretation are underscored. A comprehensive treatment program is presented, including supportive measures and specific antibiotic strategies. Immunoprophylaxis, its advantages and limitations, is also outlined.