Principles of antibiotic prescribing in the elderly

Clinicians providing care to elderly patients must appreciate the subtle clinical manifestations that herald the onset of life-threatening infectious disease. Aged patients with an infection may have neither fever nor leucocytosis, making diagnosis challenging. Often, the early features of infectious disease are nonspecific and may resemble inflammatory or neoplastic processes, or there may be insufficient time to await definitive laboratory confirmation, and empirical antimicrobial treatment must be initiated. Aging involves inevitable deleterious alterations in biological processes and, in many elderly patients, this is most strongly characterised by diminished renal functional capacity. This has a major influence on antimicrobial prescribing in the elderly, because therapeutic efficacy must be achieved while minimising the risk of drug-related toxicity. Before prescribing an antibiotic to an aged patient with an infection, the clinician must be cognisant of the patient's drug allergy history and the other drugs that the patient is taking. Ignorance of potential drug-drug interactions can result in ineffective treatment or enhanced toxicity. The therapy of elderly patients with infections is being expanded. To reduce costs and enhance the efficiency of care, systems have been developed to provide antimicrobial care in the home and in long term care facilities. Home healthcare has burgeoned, and drugs that are well tolerated, have a broad spectrum of activity and are simple to administer (e.g. ceftriaxone and fluoroquinolones) appear to be eminently suitable for this therapeutic role. Physicians must also be informed of the factors responsible for the emergence of resistant bacteria that are contributing to infections in institutional and community settings. Clinicians should strive to curb inappropriate antibiotic use to stem the tide of infections that are caused by multidrug-resistant bacteria.