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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 5  |  Page : 892-897
Are elderly end-stage renal disease patients more susceptible for drug resistant organisms in their sputum?


Department of General Medicine, Sri Ramachandra University, Chennai, Tamilnadu, India

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Date of Web Publication31-Aug-2010
 

   Abstract 

End stage renal disease (ESRD) patients are at risk for pneumonia in view of their impaired immune status. Similar empiric antibiotic regimens are used in elderly as well as young ESRD patients with respiratory tract infections. We conducted an observational, cross sectional study between June 2007 and June 2008 in 100 ESRD patients half being > 65 yrs. All patients had positive sputum culture and chest X-ray findings of pneumonia Streptococcus pneumoniae was the commonest in younger while Klebsiella pneumoniae in > 65yrs old patients. Elderly patients had significant resistance to common antibiotics. Ceftrioxone was the most suitable antibiotic in the younger patients while a combination of piperacillin with gentamycin was the best choice in the geriatric age group. In conclusion, organisms cultured from sputum in ESRD patients with pneumo­nia were different in the ESRD patients of more than and less than 65 years of age as well as the drug susceptibility. We should probably redefine the management of pneumonia according to the sensitivities in our local populations to better treat these patients.

How to cite this article:
Subash Shantha GP, Kumar AA, Rajan AG, Subramanian KK, Srinivasan Y, Abraham G. Are elderly end-stage renal disease patients more susceptible for drug resistant organisms in their sputum?. Saudi J Kidney Dis Transpl 2010;21:892-7

How to cite this URL:
Subash Shantha GP, Kumar AA, Rajan AG, Subramanian KK, Srinivasan Y, Abraham G. Are elderly end-stage renal disease patients more susceptible for drug resistant organisms in their sputum?. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Aug 19];21:892-7. Available from: http://www.sjkdt.org/text.asp?2010/21/5/892/68887

   Introduction Top


Why are elderly people more prone for infec­tions? The answer lies in their immunity, ad­versely affected by factors like immune sene­scence, changes in non-adaptive immunity, chronic diseases, medications, malnutrition, and functional impairments. T-lymphocyte produc­tion and proliferation decline with age, resulting in decreased cell-mediated immunity and de­creased antibody production to new antigens. [1],[2],[3] Defective cell mediated immunity, T cell dys­function, improper compliment activation are among the many causes proposed to explain the decline in immunity among ESRD patients. [2],[3] These factors predispose them for various in­fections especially of the respiratory tract.

Pneumonia is approximately 10-fold more fre­quent in elderly and the leading infectious cause of death in especially very old (aged > 80 years). [3] It is a common practice to start empirical anti­biotics for patients getting admitted with respi­ratory sepsis with the similar regimens in elderly as well as young patients. Our study is an effort to identify the microbial variation in the sputum between these two groups and to identify the presence of antibiotic resistance among the microorganisms from sputum of these elderly patients as compared to their younger counter­parts.


   Materials and Methods Top


This is an observational cross sectional study, involving 100 patients at a single tertiary care centre in Chennai (South India). All the 100 patients had ESRD and were receiving 3 times weekly maintenance hemodialysis during June 2007 to June 2008. The study population in­volved 50 consecutive patients of age < 65 yrs (young) and 50 consecutive patients of age > 65 yrs (elderly) all admitted for suspected respi­ratory sepsis. All these patients had history sug­gestive of pneumonia (fever, cough with expec­toration) with a well defined non-homogeneous opacity on chest X-ray (which included cases with both unilateral and bilateral involvement). The sputum cultures of all the patients were po­sitive for growth. Pulmonary tuberculosis was ruled out as only patients with three early mor­ning sputum samples negative for acid fast bacillus were included in the study. None of the patients were hospitalized up to 2 months prior to the study. None of the patients had primary lung pathology like chronic obstructive pulmo­nary disease or bronchiectasis etc. All were non diabetics and retroviral infection had been ruled out in all the patients.

Specimen collection

The specimen used was an expectorated sputum sample taken after nebulization with 3% saline. Sample adequacy was defined by the presence of less than 25 epithelial cells per high power field. The sputum was analyzed for the type of organism and the antibiotic sensitivity pattern for 9 commonly used antibiotics was studied:

  1. Ampicillin (Amp),
  2. Ceftriaxone (CT),
  3. Gentamycin (GM),
  4. Crystalline penicillin (CP),
  5. Piperacillin (PP),
  6. Cefaperazone (CR),
  7. Amikacin (AK),
  8. Erythromycin (EM),
  9. Cefazolin (CZ)


The antibiotic susceptibility testing was done by the disk diffusion technique in Muller Hinton agar. [4]


   Statistical Analysis Top


The profile of organisms in these two age groups were initially analyzed, following which, the resistance pattern of these organisms to the 9 common antibiotics were expressed as per­centages and compared between the two groups. Chi-square analysis was applied to compare the antibiotic resistance among the isolated orga­nisms between these two groups. P < 0.05 was taken to be significant. Statistical analysis was performed using SPSS windows version 15.0 software (SPSS Inc., Chicago, Illinois).


   Results Top


The mean age was 47 ± 15.21 years and 73 ± 5.9 years in the young and elderly respectively. The two groups were comparable with respect to sex, smoking and alcohol intake [Table 1]. Mean systolic and diastolic pressures were significantly higher in the elderly as compared to the younger patients [Table 1]. Amongst the 50 patients who were < 65 yrs, the commonest causative organism was found to be Strep. Pneu­moniae, found in as many as 21 (42%) patients [Table 2],[Figure 1], while Klebsiella pneumo­niae was the commonest causative organism found in 18 (36%) elderly patients [Table 2], [Figure 1].The elderly patients showed a signi­ficantly higher incidence of (4-fold) to Pseud­omonas aeruginosa infection than the younger subjects. They also had a 2-fold higher rate of Staph. aureus infection than the younger group [Figure 1], [Table 2].
Table 1 :Patient characteristics.

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Table 2 :Profile of organisms isolated from sputum.

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Figure 1 :Different microbial organisms cultured from sputum of community acquired pneumonia end stage
renal disease patients on maintenance hemodialysis.


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Among the younger patients with Strep pneu­moniae infection, ampicillin, ceftriaxone and piperacillin were most efficacious, with the least resistance rates [Figure 2], Among the elderly patients with Klebsiella infection (commonest in this age group), gentamicin and ceftriaxone were the most efficacious antibiotics [Figure 3]. On comparison geriatric patients had significant resistance against  Streptococcus pneumoniae Scientific Name Search i>= 0.01), Klebsiella pneumoniae Scientific Name Search  (P= 00.03), Staph. aureus (P= 0.021) and Pseudomonas aerogenosa (P= 0.001) as compared to younger patients. However there was no significant difference in antibiotic resistance with respect to Hemophilus influenza, Morrexela cattarallis, and Acinetobac­ter species between the two groups [Table 3],[Table 4] and [Figure 2],[Figure 3],[Figure 4].
Table 3 :Antibiotic resistance pattern (patients < 65 years).

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Table 4 :Antibiotic resistance pattern (patients > 65 years).

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Figure 2 :Antimicrobial resitance pattern for streptococcus pneumoniae cultured from sputum of community acquired pneumonia end stage renal disease patients of l < 65 years age on maintenance hemodialysis.

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Figure 3 :Antimicrobial resitance pattern for Klebsiella pneumoniae cultured from sputum of community acquired pneumonia end stage renal disease patients of > 65 years age on maintenance hemodialysis.

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Figure 4 :Resitance to piperacillin in community acquired pneumonia end stage renal disease patients
of > 65 years of age on maintenance hemodialysis.


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Pseudomonas aeruginosa in the geriatric pa­tients was found to be resistant to all the anti­biotics except partial sensitivity to piperacillin.

Staphylococcus aureus was twice more common in elderly patients showed more susceptibility to piperacillin and cefazolin.  Moraxella More Details cata­rralis was the most resistant among the elderly infections showing sensitivity only to pipera­cillin.


   Discussion Top


In our study, commonest causative organism was Strep. pneumoniae in as many as 42% of the young patients, while Klebsiella pneumo­niae was the commonest causative organism in the elderly patients, found in 35%. Our results are quite different from those of literature from the West which shows Streptococcus pneumo­niae, still the most prevalent organism among the elderly, with a high risk of drug resistance. [11] However this literature was from general adult population and not from ESRD patients. Data on organism profile of respiratory infections in ESRD patients are scanty especially from el­derly ESRD patients.

Only patients with structural lung disease, cor­ticosteroid therapy, broad spectrum antibacte­rial therapy for > 7 days in the past month, mal­nutrition are said to be at risk for Pseudomonal infection. In our study all patients with above mentioned risk factors were excluded from the study. Hence our study patients were not at risk for pseudomonas infection. But still 13 (26%) elderly patients and 3 (6%) young patients had pseudomonas grown in their sputum. This ob­servation helps us learn that ESRD patients with­out known risk factors for pseudomonas can still acquire this infection and that elderly pa­tients are more susceptible.

So far, a number of different guidelines, based on age, severity of pneumonia and presence of comorbidities, have been developed. [5],[6],[7],[8],[9],[10] Following the recent indications of the American Thoracic Society (ATS) guidelines [7] [Table 4], patients admitted with community acquired pneumonia (CAP) in the ward will benefit from an empi­rical combination of 3 rd generation cephalos­porin and a macrolide. Even patients admitted in ICU will be initiated on this combination if they are not at risk for Pseudomonas infection. Only patients with risk factors for Pseudomonal infection will require Piperacillin. Hence accor­ding to this guideline all our study patients if dealt as general patients should be initiated on a 3 rd generation cephalosporin and a only.

Our results agree with this recommendation for the younger ESRD patients only; however our elderly patients need pseudomonal coverage also. According to our sensitivity results the later group will need a combination of amino­glycoside and piperacillin for empiric therapy.

Though penicillins and cephalosporins are widely used in the treatment of lower respira­tory tract infections in the elderly, [12],[13],[14] recently, a correlation between penicillin resistance and higher mortality rates in CAP has been demons­trated. [15],[16] Hence in treating an elderly ESRD patient admitted with CAP, though an empirical therapy is initiated, the culture sensitivity pat­tern should be obtained as soon as possible and accordingly antibiotic should be changed to im­prove outcome in this age group.


   Conclusion Top


In conclusion, antibiotic resistance is common in the elderly ESRD patients and more serious infections happen in this age group. A combi­nation of piperacillin with gentamycin will be a good empirical choice in the old, while ATS guidelines could still be followed in the young.

 
   References Top

1.Crossley Crossley KB, Peterson PK. Infec­tions in the elderly. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and practice of infec­tious diseases. 5th ed. Philadelphia: Churchill Livingstone; 2000;3164-9.  Back to cited text no. 1      
2.Strausbaugh LJ, Joseph CJ. Epidemiology and prevention of infections in residents of long term care facilities. In: Mayhall CG, edr. Hospital epidemiology and infection control. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 1999;1461-82.  Back to cited text no. 2      
3.Gravenstein S, Fillit H, Ershler WB. Clinical immunology of aging. In: Tallis R, Fillit H, Brocklehurst JC, eds. Geriatric medicine and gerontology. 5th ed. Edinburgh: Churchill Livingstone; 1999;109-21.  Back to cited text no. 3      
4.Bauer AW, Kirby WM, Sherris JC, Turck M. Antibiotic susceptibility testing by a standar­dized single-disk method: Am J Clin Pathol 1966;45:493.  Back to cited text no. 4      
5.Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community acquired pneumonia in adults. Clin Infect Dis 2000;31:347-82.  Back to cited text no. 5      
6.European Study on Community-Acquired Pneu­monia (ESO- CAP) Committee. Guidelines for management of adult community-acquired lower respiratory tract infections. Eur Respir J 1998; 11:986-91.  Back to cited text no. 6      
7.Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the management of adults with community-acquired pneumonia: diagnosis, as­sessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001; 163:1730-54  Back to cited text no. 7      
8.Mandell LA, Marrie TJ, Grossman RF, et al. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence based update by the Canadian Infectious Di­seases Society and the Canadian Thoracic So­ciety. The Canadian Community-Acquired Pneu­monia Working Group. Clin Infect Dis 2000;31:383-421.  Back to cited text no. 8      
9.Woodhead M. Community-acquired pneumonia guidelines: an international comparison: a view from Europe. Chest 1998;113(3 Suppl):183-7S.  Back to cited text no. 9      
10.British Thoracic Society. Guidelines for the management of community-acquired pneumo­nia in adults admitted to hospital. Br J Hosp Med 1993;49:346-51.  Back to cited text no. 10      
11.Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the management of adults with community-acquired pneumonia: diagnosis, as­sessment of severity, antimicrobial therapy and prevention. Am J Respir Crit Care Med 2001; 163:1730-54.  Back to cited text no. 11      
12.Feldman C. Pneumonia in the elderly. Clin Chest Med 1999;20:563-73.  Back to cited text no. 12      
13.Rajagopalan S, Yoshikawa TT. Antimicrobial therapy in the elderly. Med Clin North Am 2001;85:133-47.  Back to cited text no. 13      
14.Marshall WF, Blair JE. The cephalosporins. Mayo Clin Proc 1999;74:187-95.  Back to cited text no. 14      
15.Feikin D, Scuchat A, Kolczak M, et al. Mortality from invasive pneumococcal pneu­monia in the era of antibiotic resistance, 1995-­1997. Am J Public Health 2000;90:223-9  Back to cited text no. 15      
16.Dowell SF, Smith T, Leversedge K, et al. Pneu­monia treatment failure associated with highly resistant pneumococci. Clin Infect Dis 1999;29: 462-3.  Back to cited text no. 16      

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Correspondence Address:
Ghanshyam Palamaner Subash Shantha
Plot no: 70, door no: 12, Kattabomman street, Alwarthirunagar, Chennai 600087
India
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