Increased mortality in young candidemia patients associated with presence of a Candida albicans general-purpose genotype.

The yeast Candida albicans causes life-threatening candidemia. A general-purpose genotype (GPG; corresponds to clade 1) causes more infections than other C. albicans genotypes. To investigate if GPG strains also cause higher mortality, we developed a duplex PCR assay which was 98% accurate in identifying GPG strains in an international collection of strains typed with probe Ca3. We applied the assay to 635 European C. albicans candidemia isolates. Of these, 18% conformed to the GPG genotype, 4% were of a borderline genotype, and 78% were of a non-GPG genotype, broadly consistent with genotype distributions in earlier studies. The prevalence of GPG strains was increased in females and in younger patients, exceeding 40% in infants aged ≤1 year. Logistic regression confirmed sex and age as significant determinants of GPG prevalence. Across the entire patient cohort, there was no difference in mortality for patients infected with GPG strains or other strains (36% versus 37%). However, mortality in patients aged ≤48 years was 33% for infection with GPG strains but only 15% for infection with other strains (z test; P < 0.01). Mortality rates associated with GPG and non-GPG strains were comparable in older patients (39% versus 46%). A logistic regression analysis confirmed the age-dependent impact of genotype on mortality. Thus, GPG strains may be more virulent than other strains in younger patients. Because candidemia is usually caused by endogenous strains, our PCR assay could potentially be used as a risk assessment tool for identifying younger patients most at risk of death from candidemia.

Low anthropometric indices in elderly females with fractured neck of femur.

Anthropometric measurements were made in 3 groups of elderly females (1) with fractured neck of femur, (2) those admitted to acute medical and geriatric wards, and (3) healthy women in the community. Mid-arm circumference was different in the three groups with mean values of 22.8 +/- 0.21 cm, 25.9 +/- 0.41 cm and 28.6 +/- 0.27 cm respectively; (p < 0.001 for all comparisons). Triceps skinfold thickness was 24.7 +/- 0.70 mm in the healthy elderly but only 13.0 +/- 0.59 mm in the fracture group (p < 0.001). Fractured femur patients are therefore thinner than both healthy controls and unselected elderly female medical in-patients. These differences are most apparent in anthropometric indices dependent on body fat and this may be significant in terms of the aetiology of fractured femur.

Factors affecting walking speed of elderly people.

Associations between walking speed and other variables have been investigated in a group of 67 women and 58 men aged between 65 and 90 years and living independently. In men, walking speed was related positively to calf strength, step-score (a measure of customary physical activity), hours spent in active leisure, height and weight, and negatively to age and the presence of health problems. In women, the relations were the same, with the exception of weight, and reported leg pain was negatively associated with walking speed. Multiple regression analysis showed that in men 44% of the variance in walking speed was accounted for by height, calf strength and the presence of health problems, and that in women 42% of the variance was accounted for by height, calf strength, step-score and the presence of leg pain limiting mobility. The significance of these findings to maintenance and improvement of walking speed in the elderly is discussed.

Bacterial resistance to trimethoprim in geriatric medical wards.

Urinary tract infections (UTI) caused by organisms resistant to trimethoprim (TMP), as well as their faecal carriage were studied in two geriatric wards. TMP-resistant UTI was common (26 and 50% of admission and ward-acquired infections, respectively) and was associated with male sex, recurrent and transferred admissions and length of stay. There was a strong relationship between faecal carriage and isolation of TMP-resistant organisms from urine. Antimicrobial exposure was the major determinant of TMP-resistant faecal carriage.

Falls by elderly people at home: prevalence and associated factors.

Of 1042 individuals aged 65 years and over who were successfully interviewed in a community survey of health and physical activity, 35% (n = 356) reported one or more falls in the preceding year. Although the overall ratio of female fallers to male fallers was 2.7:1, this ratio approached unity with advancing age. Mobility was significantly impaired in those reporting falls. Asked to provide a reason for their falls, 53% reported tripping, 8% dizziness and 6% reported blackouts. A further 19% were unable to give a reason. There was no association between falls and the use of diuretics, antihypertensives or tranquilizers, but a significant association between falls and the use of hypnotics and antidepressants was found. Discriminant analysis of selected medical and anthropometric variables indicated that handgrip strength in the dominant hand and reported symptoms of arthritis, giddiness and foot difficulties were most influential in predicting reports of recent falls.

Muscle strength in the triceps surae and objectively measured customary walking activity in men and women over 65 years of age.

1. Objective measurements of the maximal voluntary strength of triceps surae and the amount and speed of customary walking have been made in 56 men and 66 women aged over 65 years, who were living independently. 2. Strength was measured using a dynamometer based upon a hydraulic system (Bourdon tube). Walking was assessed, for amount using a mechanical accelerometer (pedometer) over a week, and for speed using a self-paced test for normal walking over 100 m on the level. The reliability and validity of these methods has been described. 3. The men were significantly stronger (1128 +/- 206 vs 873 +/- 177 N) even after adjustment for body weight; their amount of walking was similar to that of women, but they walked significantly faster (4.8 +/- 0.6 vs 4.2 +/- 0.6 km/h). Men were significantly more active in leisure pursuits (as assessed by questionnaire). 4. Significant associations between strength and chosen normal walking speed were found for both sexes (r = 0.41, P less than 0.001 for men and r = 0.36, P less than 0.01 for women). The amount of walking (daily stepscore as a mean from 7 consecutive days recorded) was significantly but less strongly correlated with strength (r = 0.30, P less than 0.05) in the men only. 5. Multiple regression analysis showed that in men neither age nor amount of walking had any further effect in addition to speed, but in women age had an additional effect (multiple R = 0.48). 6. An association has been demonstrated which raises the possibility of reversing loss of muscle strength through increased daily activity.

The effect of an antibiotic policy on bacterial resistance in patients in geriatric medical wards.

In an effort to reduce levels of trimethoprim resistance amongst urinary isolates and faecal organisms two antibiotic policies (policy 1, erythromycin, nitrofurantoin substituted for trimethoprim and ampicillin; policy 2, Augmentin (ampicillin + clavulinic acid) substituted for trimethoprim and ampicillin) were used for 50 weeks on two geriatric acute/rehabilitation wards. The policies were evaluated by comparison with the pre-policy period and between policies. The policies were applied successfully and both were associated with a fall in the proportion of trimethoprim-resistant faecal coliforms and urinary isolates. Policy 1 appeared to affect plasmid-mediated resistance to a greater extent than policy 2. There were no differences in outcome for patients during policy periods. Control of antibiotic usage by formal policies is a viable means of controlling bacterial resistance in geriatric wards. The mode of action of such policies requires further elucidation.

The effects of age on muscle strength and anthropometric indices within a group of elderly men and women.

Within a group of 184 subjects (100 females) aged 65-90 years living independently, age was found to have a significant negative correlation with strength of triceps surae in the calf and biceps brachii in the arm. Muscle area in the limbs also declined significantly with age in males. Weight and strength per cross-sectional area in the calves declined significantly with age in females. Superficial fat did not change with age; height declined, perhaps due to kyphosis. The strength of the calf compared to body weight also declined significantly with age in both sexes. Multiple regression analysis has been used to describe the effects of sex, age and weight on muscle variables.

Muscle strength and anthropometric indices in elderly men and women.

Muscle strength, overlying skinfold thickness and calculated muscle area for the triceps surae muscle of the calf and the biceps brachii of the upper arm are described in 184 subjects (100 female, 84 male) aged between 65 and 90 years. The group comprised mobile volunteers, living independently, from a large group-practice. Health screening was minimal. Relationships between anthropometric and strength variables are explored and compared with other studies. This was apparently a well-nourished group. Muscle strengths and areas were low compared to younger subjects. Strength in relationship to area was variable, lower than in the younger subjects and also lower in the females than the males. Strength of the calf compared to body weight fell below unity in some cases.

A review of urinary tract infection in the elderly.

Bacteriuria is much more common in the elderly than in younger individuals for a variety of reasons. Women have a greater prevalence than men, but the trend to increased prevalence with age in over 65 year olds is greater in men. The acquisition rate for bacteriuria in the elderly is extremely high but information about the sequelae of bacteriuria is scanty. However there is good evidence that bacteriuria is associated with increased mortality. In clinical practice, subjects found to be bacteriuric tend to be treated and there are a variety of problems in this, not only with regard to efficacy but also in suitability of antimicrobials by virtue of resistance patterns and side effects. A small comparative study shows that norfloxacin may be a suitable drug for use in the elderly, but further studies are required to confirm this in larger numbers of unselected patients. A transient but significant rise in serum creatinine was observed in subjects on cotrimoxazole.

An outbreak of infection caused by trimethoprim-resistant coliform bacilli in a geriatric unit.

An outbreak of infections, particularly of the urinary tract, caused by coliform bacilli resistant to trimethoprim, and originating in a geriatric unit, is described. The investigation of the outbreak and the analysis of factors predisposing to asymptomatic carriage of trimethoprim-resistant coliform bacilli enabled successful control measures to be initiated. The significance of geriatric units as sources of hospital infection is discussed. The importance of cooperation between geriatricians, infection control nurses and microbiologists is emphasized.

Hospital outbreak of trimethoprim resistance in pathogenic coliform bacteria.

In an investigation of outbreak of infection caused by coliform bacilli with plasmid-mediated trimethoprim (TMP) resistance many patients were found to be asymptomatic carriers of TMP-resistant coliform bacilli. Analysis of factors predisposing to rectal carriage of these organisms showed that the most important was previous treatment with co-trimoxazole, a sulphonamide, or ampicillin. The outbreak was controlled by a policy restricting the antibiotics given. Geriatric units are an important source of hospital infection. When an outbreak occurs the logical sequence of steps to be taken is to monitor cases, identify the outbreaks, analyse the causative factors, plan corrective action jointly with laboratory staff, and monitor the outcome.

Changing work pattern in a geriatric unit and the effect of a day hospital.

Examination of data collected during domiciliary visits is a useful research technique. It has been used to examine the changing work pattern of a Geriatric Unit over 25 years. The importance of domiciliary visiting in the efficient use of medical facilities is emphasized.