Unclear focus - functional decline
Frailty syndromes are common presentations to hospital and may involve falls, immobility, delirium and incontinence. The causes of functional decline in patients with frailty are numerous and can include drug adverse effects, metabolic or organ dysfunction, cerebral vascular events and infection.
Many patients with frailty presenting to the hospital are not suffering from an infection and can safely be observed after performing a septic screen without commencing antibiotics. Patients with clear evidence of sepsis should have prompt commencement of antibiotics Sepsis Identification and Management
Functional decline - unclear focus:
- Where infection is suspected but there is no clear focus and differentials could include intra-abdominal, respiratory or urinary tract infection.
- Perform septic screen (blood and urine cultures, CXR).
Review need for continued antibiotics at day 1-3. Consider stopping if cultures negative, clinically improving and no clear diagnosis made (e.g. by imaging).
Preferred
amoxicillin 500mg po tds AND nitrofurantoin 50mg po qds (caution: do not use if eGFR is under 45 ml/min/1.73m2)
Adverse effects have been reported with nitrofurantoin see Nitrofurantoin MHRA drug safety updates
OR
amoxicillin 500mg po tds AND trimethoprim 200mg po bd (Use trimethoprim if eGFR less than 45ml/min/1.73m2)
Alternative
amoxicillin 1g iv tds AND gentamicin 5mg/kg iv (Gentamicin is for maximum of 3 days). Take a gentamicin level at 6-14 hours after first dose to calculate dosing interval, usually 24 hourly, 36 hourly or 48 hourly. See gentamicin monograph for dosing (including renal dosing) and monitoring
OR
doxycycline 100mg po bd (iv only if NBM) AND gentamicin 5mg/kg iv (Gentamicin is for a maximum of 3 days). Take a gentamicin level at 6-14 hours after first dose to calculate dosing interval, usually 24 hourly, 36 hourly or 48 hourly. See gentamicin monograph for dosing (including renal dosing) and monitoring
OR
co-trimoxazole 960mg po bd (iv only if NBM)
Frailty syndromes
- Clinical Frailty Scale see HERE
- See British Geriatric Society Frailty: what's it all about?
- See NHS Rightcare: Frailty Toolkit