Esther-Lee Marcus

Ethical Issues Relating to the Use of Antimicrobial Therapy in Older Adults

This article aims to review the literature relating to the ethics of antibiotic prescription decisions in older adults and to offer some suggestions as to how one might approach these difficult problems. According to many studies, most patients and their family members wish to receive antibiotics even when they are terminally ill or suffering from advanced dementia. Health care professionals are also frequently reluctant to deny the use of antibiotics in such situations. We suggest that the difficult decisions regarding whether one should withhold treatment can be based on consideration of the ethical principles of autonomy, beneficence, nonmaleficence, and justice. From the public health point of view, one should also take into account the need to avoid the emergence of antimicrobial resistance, keeping in mind the balance between the benefit to the specific patient and the cost to future patients. Infectious diseases consultants should actively participate in these ethical dilemmas.

Contradictions in end-of-life decisions for self and other, expressed by relatives of chronically ventilated patients

OBJECTIVES In certain populations, social, legal, and religious factors may influence end-of-life decisions in ventilator-dependent patients. This study aims to evaluate attitudes of first-degree relatives of chronically ventilated patients in Israel, toward end-of-life decisions regarding their loved ones, themselves, and unrelated others. MATERIALS AND METHODS The study was conducted in a chronic ventilation unit. First-degree family members of chronically ventilated patients were interviewed about their end-of-life attitudes for patients with end-stage diseases. Distinctions were made between attitudes in the case of their ventilated relatives, themselves, and unrelated others; between conscious and unconscious patients; and between a variety of interventions. RESULTS Thirty-one family members of 25 patients were interviewed. Median length of ventilation at the time of the interview was 13.4 months. Most interviewees wanted further interventions for their ventilated relatives, yet, for themselves, only 21% and 18% supported chronic ventilation and resuscitation, respectively, and 48% would want to be disconnected from the ventilator. Interventions were more likely to be endorsed for others (vs self), for the conscious self (vs unconscious self), and for artificial feeding (vs chronic ventilation and resuscitation). Interviewees were reluctant to disconnect patients from a ventilator. CONCLUSIONS Family members often want escalation of treatment for their ventilated relatives; however, most would not wish to be chronically ventilated or resuscitated under similar circumstances. Advance directives may reconcile peoples wishes at the end of their own lives with their reticence to make decisions regarding others.

Golden Years and Silver Screens: Cinematic Representations of Old Age

Several memorable portrayals notwithstanding, most depictions of old age and aging in motion pictures are narrowly stereotypical, doing little justice to the complex and variable phenomena of old age. The following overview discusses the various reasons (cultural, political, economic, etc.) for the glaring paucity of believable, committed, and altogether worthwhile cinematic realizations of old age. The discussion distinguishes between representations of old age in the movies as a communication and social issue and the portrayal of the experience of old age via the cinematic medium and provides support for the latter as a means of enriching both humanistic gerontology and the study of cinema.

Potentially Inappropriate Medications in Older Adults: Why the Revised Criteria Matter.

The 2 most widely used explicit criteria regarding inappropriate medication use in older adults are the American Geriatrics Society’s Beers Criteria and the Screening Tool of Older People’s Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START). Both documents were updated recently. They are important educational tools that highlight medications for which risks of use may often exceed benefits in older adults and situations in which potentially appropriate medications should be considered for use. The application of these tools has the potential to significantly affect patient care. Thus, it is important for clinicians to be familiar with both documents.

Antimicrobial Resistance Patterns Among Urine Isolates from Patients in a Geriatric Hospital and from Older Patients in a General Hospital in Jerusalem

INTRODUCTION AND RATIONALE Urinary tract infection is the most common cause of nosocomial infections in patients hospitalized in chronic care facilities. The changing spectrum of microorganisms involved in urinary tract infections and the emerging resistance require continuous monitoring to provide crucial information to guide empirical therapy and encourage prudent use of antibiotics. The aim of this survey was to assess the antimicrobial resistance profile of urine isolates from patients hospitalized in a geriatric hospital and from elderly patients hospitalized in an acute care hospital in order to guide empirical therapy of urinary tract infections. METHODS The survey was performed in two hospitals in Jerusalem: a university-affiliated geriatric hospital- Herzog -and an acute secondary- and tertiary-care university hospital- Hadassah. We performed a retrospective analysis of antimicrobial resistance of all positive urine cultures obtained from patients in the geriatric division of Herzog Hospital and from patients aged 65 years and older hospitalized in the Internal Medicine departments in Hadassah Hospital during a 1-year period. RESULTS The most common bacteria isolated from urine specimens in Herzog Hospital were, in order of frequency, Escherichia coli, Proteus mirabilis, and Pseudomonas aeruginosa. We demonstrated a high rate of antimicrobial resistance of those bacteria in both hospitals. The pattern we observed necessitates recommending ceftazidime as the most appropriate empirical therapy for urinary tract infection in Herzog Hospital. In Hadassah Hospital we recommend cefuroxime for those patients in good general condition and ceftazidime for those who present with clinical sepsis. Antimicrobial resistance patterns should be assessed periodically and recommendations modified accordingly. Infection control guidelines should be implemented in order to try to decrease the rate of antimicrobial resistance. Further research is requested to assess the efficacy of such interventions in long-term care facilities.

Reduction of health care–associated infection indicators by copper oxide–impregnated textiles: Crossover, double-blind controlled study in chronic ventilator-dependent patients

HighlightsWe investigated the effect of copper oxide–impregnated textiles in reducing nosocomial infection‐related indicators.The study subjects were mechanically ventilated patients in long‐term care wards.The design was a crossover, double‐blind controlled study.Using these biocidal textiles resulted in reduction in antibiotic utilization and fever days.Biocidal textiles may be a supplementary measure aimed at reducing the rate of health care–associated infections. Graphical abstract Figure. No Caption available. Background: Copper oxide has potent wide‐spectrum biocidal properties. The purpose of this study is to determine if replacing hospital textiles with copper oxide–impregnated textiles reduces the following health care–associated infection (HAI) indicators: antibiotic treatment initiation events (ATIEs), fever days, and antibiotic usage in hospitalized chronic ventilator‐dependent patients. Methods: A 7‐month, crossover, double‐blind controlled trial including all patients in 2 ventilator‐dependent wards in a long‐term care hospital. For 3 months (period 1), one ward received copper oxide–impregnated textiles and the other received untreated textiles. After a 1‐month washout period of using regular textiles, for 3 months (period 2) the ward that received the treated textiles received the control textiles and vice versa. The personnel were blinded to which were treated or control textiles. There were no differences in infection control measures during the study. Results: There were reductions of 29.3% (P = .002), 55.5% (P < .0001), 23.0% (P < .0001), and 27.5% (P < .0001) in the ATIEs, fever days (>37.6°C), days of antibiotic treatment, and antibiotic defined daily dose per 1,000 hospitalization days, respectively, when using the copper oxide–impregnated textiles. Conclusions: Use of copper oxide–impregnated biocidal textiles in a long‐term care ward of ventilator‐dependent patients was associated with a significant reduction of HAI indicators and antibiotic utilization. Using copper oxide–impregnated biocidal textiles may be an important measure aimed at reducing HAIs in long‐term care medical settings.

Diagnosis and conservative management of late tracheotomy complications in chronic ventilator-dependent patients

Complications associated with long‐term tracheotomy are obstruction of the distal end of the tube by granulation tissue and tracheomalacia. These complications have traditionally been surgically treated.

Tracheal Obstruction Due to Heterotopic Ossification in a Tracheostomy Scar

L ong-term tracheostomy has been associated with various complications, including obstruction of the distal end of the tube by granulation tissue in the trachea, stenosis of the stoma, dilatation of the stoma, tracheomalacia, tracheal stenosis, tracheoinnominate artery fistula, and tracheoesophageal fistula. We report a rare and, to our knowledge, previously undescribed life-threatening complication resulting from tracheal obstruction due to heterotopic ossification in a tracheostomy scar in a mechanically ventilated patient. The ossification prevented intubation or the insertion of a larger tracheostomy tube. Unlike heterotopic ossification in abdominal scars, which is benign, ossification in a tracheostomy scar may be lifethreatening during a routine change of a tracheostomy tube. With the increasing number of tracheostomies performed in long-term ventilated patients, physicians may encounter this complication and should be aware of its presentation, management, and possible prevention.

Agranulocytosis Associated with Initiation of Famotidine Therapy

OBJECTIVE: To report a case of agranulocytosis associated with initiation of famotidine. CASE SUMMARY: An 87-year-old white man was admitted to the internal medicine department of an acute care hospital because of fever and agranulocytosis (granulocyte count 0). Eight days prior to admission, famotidine therapy had been initiated. Famotidine was discontinued and granulocyte—macrophage colony stimulating factor was administered, with concomitant recovery of the granulocyte count and subsequent development of a leukemoid reaction. DISCUSSION: According to the Naranjo probability scale, famotidine was the probable cause of agranulocytosis. This is a rare adverse effect of this medication; only a few other cases have been reported. CONCLUSIONS: Although agranulocytosis is a rare adverse effect of famotidine, the pharmacist and physician should be aware of this potentially fatal event. If any patient treated with famotidine develops fever, the clinician should consider, among other things, performing a white blood cell count.

Experience of famine and bone health in post-menopausal women

We read with great interest the article by Kin et al. In their study of 1826 Hong Kong women aged 65 years or older, those who experienced famine during World War II had a significantly higher rate of developing osteoporosis than those who had not experienced famine. Recently we reported similar findings among Jewish women aged 60 years or older, residing in Israel. We examined two groups of women: 73 Holocaust survivors (mean age 72.2 6.3 years) and a control group of 60 European-born Jews who were not in the Holocaust (mean age 71.6 7.1 years). Among the Holocaust survivors 54.8% had osteoporosis, 39.7% osteopenia, and 5.5% normal bone mineral density (BMD); whereas among controls 25% had osteoporosis, 55.0% osteopenia, and 20% normal BMD (P1⁄4 0.0001). Interestingly, the effect of severe malnutrition on the skeleton was mainly found in those who were less than 17 years old during World War II. In this age group, among Holocaust survivors 58.0% had osteoporosis, 34.0% osteopenia, and 8.0% normal BMD; whereas among controls in the same age group, 20.0% had osteoporosis, 57.8% osteopenia, and 22.2% normal BMD (P1⁄4 0.0003). In those who were 17 years old or older during World War II, there was not a statistically significant difference in the prevalence of osteoporosis between Holocaust survivors and controls; among the Holocaust survivors 47.8% had osteoporosis, 52.2% osteopenia, and none had a normal BMD; whereas among controls 40% had osteoporosis, 46.7% osteopenia, and 13.3% normal BMD (P1⁄4 0.28). Kin et al. stratified their sample into three age groups: 65-69, 70-74, and 575 years. It would be interesting to know if the effect of famine on the skeleton was found in all age groups or was limited to the younger age groups.