Function and Infection Prevention ? Prof. Gatan Gavazzi GREPI - PowerPoint PPT Presentation

Function and Infection Prevention ? Prof. Gaëtan Gavazzi GREPI EA7408 University of Grenoble-Alpes Clinc of Geriatric Medicine University hospital of Grenoble-Alpes

CONFLICT OF INTEREST DISCLOSURE I have no potential conflict of interest to report - - - - …

If Ageing is Universal, Intrinseque, Progressive and somehow Deleterious Ageing is Genetic Environment Epigenetic HETEROGENEOUS (comorbidites) 80% OF >80 Y POP. AT HOME WITHOUT ADL DISABILITY Concept de Fragilité

Micro-organisms More abondant / mammals Same species / Genetic and Environment HETEROGENEITE Epigenetic factors > than 10 29 species ???

Host-pathogen interaction and its evolution / Colon Microbiota ? Epigenetic, Bio-Age ? Impact of antibiotic?

The classical view of functional ….the decline in ageing population Herpes zoster consortium Gavazzi G Aging Clin Exp Res 2016

The older persons One trigger = several complications Numerous unexpected complications Iatrogenic events, Health care Associated Infection Falls Malnutrition Immobilisation / pressure sores Delirium /behavioural disorders Complications of Chronic Diseases ( known or unknown ) Disability  in hospital length of stay and  cost

Outline infection and functional status relationship ? Infection as a risk factor for funcional decline/ functional status as a risk factor for infection or severity Prevention of Infection to prevent disability ? Prevention of disability to prevent infection ?

Influenza and functional decline Gozalo JAGS 2013 William H. Barker Arch Intern Med 1998 Grenoble 2013 : flu outbreak: 29 cases Out of 220 admissions, 20 were nosocomial Functional decline in chez 66,6% patients (loss of > 1 ADLpoint), Median Functional decline : from 4.5 to 3.2 Drevet S 2017 (in preparation)

Impact of infection on Functional status CAP/ NHAP and functional decline CAP NHAP n 99 79 781 1070 Functional decline 23% 29% 28.8 % 31.1% Date of Evaluation (d) 15 180 30-90 180 Risk Factors PSI no Multiples Torres Sharma Binder Bula JAGS 2003 Infec Dis clin Pract J Gerontol 2003 JAGS 2005 2006

Motor dysfunction

Zoster and functional decline ? ZBPI interference score on ADL burden Mc Elhaney Eur Ger Med 2016 * Schmader K JAGS 2010

Impact of herpes zoster pain on health-related quality of life Zoster : does it Harm ? and functioning : risk of loss of autonomy Greater pain burden, associated with poorer physical functioning, increased emotional distress, and decreased role and social functioning 1 out of 4/5 individual Physical impact > 50% >60 years Chronic fatigue will experiment Anorexia Zoster over his life Weight loss, Physical inactivity Insomnia Functional impact Interfere with basic and Psychological HZ-related pain instrumental activities of impact The magnitude of suffering is daily living: Depression directly related to pain intensity - Dressing, bathing, Anxiety & duration eating, mobility, Difficulty concentrating - Ttravelling, cooking, housework, shopping > 80 y Social impact 10-20% With Decreased social gatherings Post Herpectic Change in social role Neuralgia Schmader CID (2001).

CMV Infection With inflammation response and Frailty phenotype ? Adjusted for age, history of smoking, BMI 25 kg/m2, diabetes mellitus, CHF, Caucasian race, and high school education; race and education used as markers for socioeconomic status (SES) Schmaltz HN JAGS 2005

outline infection and functional status relation ship ? Infection as a risk factor for funcional decline/ Functional status as a risk factor for infection or severity Prevention of Infection to prevent disability ? Prevention of disability to prevent infection ?

Facteurs de risque de pneumonie Functional status As a risk factor for Pneumonia ? 18 Jackson ML et al. J Am Geriatr Soc. 2009;57(5):882-8.

Jackson JAGS 2009 Diasability as a risk factor according age

Functional Status and infection FS as a risk factor Loeb M Arch Intern Med 1999 (prospective study, 85 y, 254 à 79 patients 3y ) Respiratory tract infection in « Nursing home » -  Functional status =  incidence x 2.6(1.8-3.8) Bula JAGS 2005 prospective study , Infections in « Nursing home » 3 level of ADL, 85 y, 1070 patients 6 month follow up

Functional Status and infection FS as a risk factor Case-control , Surgical site Infections due to MRSA 2 levels of ADL, 73 y, 253 patients

MDR Colonisations risk factors ESBL Escherichia coli Bacteriemia Marchaim D AAC 2011

Functional Status and infection FS as a risk factor Nosocomial infection level of ADL, 85 y, 214 patients  Functional status =  prevalence NI Non adjusted Adjusted OR (CI 95 %) p OR (CI 95 %) p Urinary tract indwelling 5,8 (2,5-13,9) <0,01 4,4 (1,6-12,3) <0,01 ADL<3 at admission 6,5 (2,4-17,3) <0,01 4,4 (1,8-11,1) <0,01 New functional decline 2,3 (1,1-4,7) 0,02 - - Pressure sore 3,3 (1,4-7,7) <0,01 - - Pneumonia 3,3 (1,6-7,2) <0,01 - - Life threatening diagnosis 3,1 (1,3-7,1) <0,01 2,7 (1,1-6,6) 0,03 Independant from recent surgery, ATBic consumption, catheter… Maziere S, Gavazzi G, JNHA 2013

Functional status is a prognosis factor for death associated Nosocomial bacteremia Nosocomial bacteremia level of ADL, 85 y, 62 patients  Functional status =  30d-Mortality Gavazzi G Aging Clin Exper Res 2004,

Endocarditis in older? Incidence Peak > 70 ans 194/million/an Mortality >65 ans 16 à 45 % Clinic : Atypical Presentation Microbiology S aureus et Streptococcus sp Anatomic more prothesis TAVI…. Selton-Suty Clin Infect Dis 2012,, Forestier E Clin interv Aging 2015

Endocarditis in older? Elderl-IE multicentre study (Cardio / infectio / Geriatrician) , France ( GinGer) n= 120, 83±5 ans, 53% male Charlson 1,8±1,7, CIRS-G 15±8, 7 pills /d IAS 24(22%) Germs : Strepto D et Enteroc65(55%) S. aureus 32 (27%) Selton, Roubaud, Forestier en preparation

Prognosis • A 3 month-mortality rate of 28.4% Motif� pas� de� chir� � EG� alt é r é � 12� Grabataire� 7� D é mence� 2� Factors associated with survival Comorbidit é s� 7� ADL at day 0 Etat� cardiaque� 5� MMSE à J0 Refus� famille � 2� � Complication� pdt� hospit� � Escarre� 15� (12.9)� Chute� 12� (10.5)� Contention � 9� (8.1)� �

Functional Trajectory ADL et IADL (n=57) Loss in ADL Part of recovery Loss in IADL No recovery Long term impact Selton, Roubaud, Forestier en preparation

outline infection and functional status relation ship ? Infection as a risk factor for funcional decline/ Functional status as a risk factor for infection or severity Prevention of Infection to prevent disability ? Prevention of disability to prevent infection ?

Age-related efficacy response to 1st live- attenuated VZV vaccine --- 18 incidence incidence Real decrease efficacy to reduce shingles incidence after 80 years old Still a large efficay regarding, PHN and impact on activity Levin MJ , Current op Immunol 2012, *Schmader K JAGS 2010

Outline infection and functional status relation ship ? Infection as a risk factor for funcional decline/ Functional status as a risk factor for infection or severity Prevention of Infection to prevent disability ? Prevention of disability to prevent infection ? No study

Take Home Messages Functional status act as strong risk factor / prognosis in many infections Flu /Pneumonia / bacteremia act as triggers for Functional decline Some strategies (vaccine) may decrease functional decline (few studies) But NO study to test if prevention of functional decline may prevent infection

Thank you for your attention Still a long way …… Massif de Belledone, France “The good physician treats the disease; the great physician treats the patient who has the disease.” William Osler Invitation to : EUGMS Study Interest Group on Infection and vaccine ggavazzi@chu-grenoble.fr