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To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2009.02666.x Byline: Cecilia Big (*), Preeti N. Malani (*[dagger][double dagger]s.) Keywords: S. aureus; aging; bloodstream infections Abstract: OBJECTIVES: To assess clinical outcomes and identify risk factors for mortality in older adults with Staphylococcus aureus bloodstream infection (SAB). DESIGN: Retrospective review. SETTING: University of Michigan Health System, Ann Arbor. PARTICIPANTS: All patients aged 80 and older with SAB between January 2004 and July 2008. MEASUREMENTS: Clinical data, including comorbid conditions, SAB source, echocardiography results, Charlson Comorbidity Index, mortality (in-hospital and 6-month), and need for rehospitalization or chronic care after discharge. RESULTS: Seventy-six patients aged 80 and older (mean 85.5 [+ or -] 4.2) with SAB were identified. Infection sources included 14 (18.4%) vascular catheter associated, 16 (21.1%) wound related, seven (9.2%) endocarditis, five (6.6%) intravascular, and 19 (25%) with unknown source; 46 (60.5%) patients had methicillin-resistant strains. Twenty-two (28.9%) patients underwent surgery or device placement within 30 days of developing SAB; 10 of these 22 had SAB associated with surgical site infection (SSI). Twenty two (28.9%) patients died in the hospital or were discharged to hospice care; at least 43 (56.6%) patients died within 6 months of presentation, and eight were lost to follow-up. Unknown source of bacteremia (odds ratio=5.2, P=.008) was independently associated with in-hospital death. Echocardiography was not pursued in 45% of patients. Of surviving patients, 40 (74.1%) required skilled care after discharge; eight (20%) required rehospitalization. CONCLUSION: SAB was associated with high mortality rates in patients aged 80 and older. The observed association between SAB and SSI may direct preventive strategies such as perioperative decolonization or antimicrobial prophylaxis. Interventions to optimize clinical care practices in elderly patients with SAB are essential given the associated morbidity and mortality. Author Affiliation: (*)Infectious Diseases ([dagger])Geriatric Medicine, Department of Internal Medicine ([double dagger])Ann Arbor Veterans Affairs Healthcare System (s.)Geriatric Research, Education and Clinical Center, University of Michigan Health System, Ann Arbor, Michigan. Article note: Address correspondence to Preeti N. Malani, VA Ann Arbor Healthcare System, 2215 Fuller Road, 111-I, 8th floor, Ann Arbor, MI 48105. E-mail: pmalani@umich.edu

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2009.02182.x Byline: Eric D. Cober (*), Preeti N. Malani (*[dagger][double dagger]s.) Keywords: Clostridium difficile; aging; metronidazole; vancomycin Abstract: OBJECTIVES: Clostridium difficile infection (CDI) represents a cause of substantial morbidity, particularly for older adults. Although older age is a risk factor for CDI, few studies have specifically focused on clinical outcomes in older adults, particularly the 'oldest' old. DESIGN: Retrospective review. SETTING: University of Michigan Health System. PARTICIPANTS: All patients aged 80 and older with a positive cytotoxin assay for C. difficile and a clinical course consistent with CDI during 2006. MEASUREMENTS: Clinical data were recorded, including comorbid conditions and treatment regimens, as well as outcomes, including treatment failure, infection relapse, and 90-day mortality. RESULTS: Seventy patients aged 80 and older (mean 84.0[+ or -]4.1) with CDI were identified. Metronidazole was given as initial therapy in 65 (92.8%); 18 of these 65 (27.7%) experienced treatment failure, requiring subsequent use of oral vancomycin. Serious adverse events included three episodes of toxic megacolon, two requiring colectomy. One death was directly attributable to CDI. All-cause mortality was 8.6% at 30 days and 17.1% at 90 days. Higher white blood cell (WBC) counts were independently associated with treatment failure (P=.02) and coronary artery disease with 90-day mortality (P=.02). CONCLUSION: In older adults with CDI, treatment failure on metronidazole occurred frequently and was associated with higher WBC count. Larger prospective studies are needed to determine risk factors for treatment failure and relapse in order to develop better paradigms for CDI treatment in older adults. Initial therapy with vancomycin may be appropriate for elderly patients, especially those with elevated WBC counts. Author Affiliation: (*)Infectious Diseases and ([dagger])Geriatric Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan ([double dagger])Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; and (s.)Geriatric Research Education and Clinical Center, Ann Arbor, Michigan. Article note: Address correspondence to Preeti N. Malani, VA Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105. E-mail: pmalani@umich.edu

To purchase or authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2008.01823.x Byline: Preeti N. Malani (*[dagger][double dagger]s.), Meenakshi M. Rana ([parallel]), Mousumi Banerjee (#), Suzanne F. Bradley (*[dagger][double dagger]s.) Keywords: S. aureus; aging; bloodstream infections Abstract: OBJECTIVES: To assess the association between Staphylococcus aureus (S. aureus) blood stream infections (BSIs) and morbidity and mortality in older adults. DESIGN: Retrospective review. SETTING: Veterans Affairs Ann Arbor Healthcare System. PARTICIPANTS: All patients with S. aureus BSI during 2004/05. MEASUREMENTS: Outcomes included in-hospital and 6-month mortality, as well as need for subacute care. RESULTS: Sixty-eight patients with S. aureus BSI were identified (mean age 63.5[+ or -]13.0). Outcomes of interest included in-hospital mortality (19.1%), 6-month mortality (33.8%), and need for subacute care (65.4%). Univariate analysis identified several predictors of death, including older age, chronic renal insufficiency, catheter-related infection, Charlson weighted index of comorbidity score, and infection with methicillin-resistant S. aureus (MRSA). Multivariable analysis demonstrated that older age (odds ratio (OR)=1.1, P CONCLUSION: Better understanding of the epidemiology of S. aureus BSI in older patients and validation of risk factors for poor functional outcomes and death should be the focus of future prospective studies. Author Affiliation: (*)Department of Internal Medicine, Division of Infectious Diseases ([dagger])Department of Internal Medicine, Division of Geriatric Medicine ([double dagger])Ann Arbor Veterans Affairs Healthcare System, and (s.)Geriatric Research Education and Clinical Center, University of Michigan Health System, Ann Arbor, Michigan; and ([parallel])Department of Internal Medicine, Division of General Internal Medicine (#)Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan. Article note: Address correspondence to Preeti N. Malani, MD, VA Ann Arbor Healthcare System, 2215 Fuller Road, 111-I, 8th floor, Ann Arbor, MI 48105. E-mail: pmalani@umich.edu

To authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2009.02160.x Byline: Preeti N. Malani (*) Author Affiliation: (*)University of Michigan Health System, Ann Arbor, MI, Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, MI