Patient handout

Geriatric infection syndromes overlay — atypical presentation, blunted fever, UTI stewardship in older adults

PRODUCTION

1. Your condition

This handout is for geriatric infection syndromes overlay — atypical presentation, blunted fever, uti stewardship in older adults. Your care team identified this based on: age ≥ 65 with suspected infection (fever / delirium / functional decline / falls / non-specific decline) — geriatric overlay anchor (norman j am geriatr soc 2000 pmid 10968297).

Other reasons your team may use this plan: acute change in cognition / inattention / disorganised thinking / altered level of consciousness in older adult — cam / 4at positive → infection workup (inouye nejm 2006 pmid 16540616; bellelli 4at 2014); acute loss of adls / inability to perform prior activities / new dependence in older adult — infection workup (bellelli age ageing 2014; geriatric acute illness presentation framework); new / recurrent falls in older adult without clear mechanical cause — lower threshold for occult infection workup (uti / pneumonia / cholecystitis / appendicitis).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
ceftriaxone	1-2 g IV q24h (no renal adjustment unless CrCl < 10)	IV	daily	IDSA Hooton 2010 + standard for pyelonephritis in older adult; preserved renal function not required
cefepime	2 g IV q8-12h with renal adjustment per CrCl (1 g q24h if CrCl 11-29; 500 mg q24h if CrCl ≤ 10)	IV	q8-12h	IDSA Hooton 2010 + IDSA/ATS 2016 Kalil for HCA-spectrum; cefepime neurotoxicity in older adult with renal impairment — dose-adjust strictly per CrCl
nitrofurantoin	100 mg PO BID × 5-7 d (uncomplicated cystitis only)	PO	BID	AGS Beers 2023 — AVOID if CrCl < 30 (inadequate urinary concentrations + pulmonary / hepatic toxicity in long-term suppression). Acceptable if CrCl ≥ 30 for short-course uncomplicated cystitis
trimethoprim-sulfamethoxazole	160-800 mg PO BID × 3 d (uncomplicated cystitis)	PO	BID	IDSA Gupta 2011 + AGS Beers 2023 — caution with renal impairment + hyperkalemia + warfarin DDI; use only if susceptible
ciprofloxacin	500 mg PO BID OR 400 mg IV q12h × 7 d	PO/IV	BID	AGS Beers 2023 — AVOID for uncomplicated UTI when alternatives available (delirium / tendinopathy / QTc / aortic dissection risks). DailyMed fluoroquinolone black box. Reserve for culture-directed when no alternative

Plan: Geriatric infection empiric antibiotics — by source × Beers/STOPP review × renal dose-adjustment

3. When to call your provider

Contact your care team if any of the following happen:

Recurrence of infection features → ED + cultures + ID urgent consult
New cognitive / functional decline → geriatric psychiatry + neurology + caregiver support
Caregiver crisis → palliative + social work + alternative placement

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

New delirium (positive CAM / 4AT) + fever ≥ 38 °C OR 1.3 °C above baseline OR new functional decline in older adult — severe; sepsis-screen with full workup; CAM-positive triggers immediate evaluation; do NOT attribute to "old age" (Inouye NEJM 2006 PMID 16540616; Bellelli 4AT 2014 Norman 2000 PMID 10968297)
New ADL loss / acute fall / inability to perform prior activities / new dependence in older adult — severe; infection-as-cause until ruled out (Bellelli Age Ageing 2014; geriatric acute illness presentation framework)
SNF resident WITHOUT catheter: acute dysuria OR fever ≥ 37.9 °C OR 1.5 °C above baseline + ≥ 1 of (new / worsened urgency, frequency, suprapubic pain, gross haematuria, CVA tenderness, urinary incontinence). SNF resident WITH catheter: fever / rigors / new hypotension / acute mental status change / acute haematuria / pelvic discomfort / CVA tenderness. Severe; treat as UTI; otherwise re-evaluate alternative source (Loeb 2001 PMID 11380742)
Older adult with sepsis features (qSOFA ≥ 2 / hypotension on adequate fluids / lactate ≥ 4 / SOFA delta ≥ 2) WITHOUT classical fever ≥ 38 °C — life-threatening; treat as sepsis based on clinical features + lactate + procalcitonin even without fever ≥ 38; routes to id.sepsis.core.v1 with geriatric-host flag (Norman 2000 PMID 10968297; Singer JAMA 2016 PMID 26903336; SSC 2026)(life-threatening)
Older adult with empiric cefepime / vancomycin / aminoglycosides / piperacillin-tazobactam — severe; age-appropriate CrCl via CKD-EPI 2021 + dose-adjustment to prevent neurotoxicity (cefepime), nephrotoxicity (vancomycin / aminoglycosides), and accumulation (Inker NEJM 2021; Rybak IDSA 2020 PMID 32191793)
Dementia + recurrent pneumonia + dysphagia signs (coughing on swallow, food residue, weight loss, repeated chest infections) — severe; swallowing-eval + nutrition + speech-pathology consult + repeat-event-prevention; goals-of-care discussion if advanced dementia (ATS/IDSA Metlay 2019 PMID 31573350)

5. Follow-up

Post-hospital syndrome surveillance (delirium recovery, functional restoration, sarcopenia screening); caregiver education on signs of recurrence; advance care planning + POLST update; vaccination (PCV20, influenza, COVID-19, herpes zoster per ACIP 2024); STOPP/START re-review at 4-6 wk; outpatient geriatrics follow-up; SNF / hospital-at-home coordination if applicable.

6. Sources

Guideline: IDSA Nicolle 2019 Asymptomatic Bacteriuria guideline (PMID 30895288) + AGS Beers Criteria 2023 + STOPP/START v3 2023 (O'Mahony Age Ageing 2023) + Loeb 2001 SNF UTI minimum criteria (PMID 11380742) + Norman 2000 fever in elderly (PMID 10968297) + Inouye 2006 delirium NEJM (PMID 16540616) + Bellelli 4AT 2014 + Rockwood 2005 Clinical Frailty Scale (PMID 16129869) + Fried 2001 frailty phenotype (PMID 11253156) + ATS/IDSA Metlay 2019 CAP (PMID 31573350) + IDSA Stevens 2014 SSTI (PMID 24973422) + Mid-Atlantic Stewardship Network 2022 antibiotic-stewardship-for-the-elderly + NICE NG144 catheter UTI + SSC 2026 sepsis bundle