Expert: Michalene Peticca - 7/23/2008

Question
My 85 y/o grandmother suffers from pretty severe alzheimer's, currently she is non-ambulatory.  She has been ambulatory in recent past (1-2 months ago) which was acutally shocking because she had gone through a long phase where she was not.  She did suffer a few falls during this period but CT is clear for signs of injury.  She developed a UTI and was put on cipro on 07-05, this caused her to develop c. diff and she was put on Flaygl on 07-12.  She was then admitted for severe dehydration, diarrhea and UTI on 07-19.  On admit she had a temp of 103 and her WBCs were 23.  Apparntly the c. diff was resistant to the Flaygl and she was placed on Vanco.  She has now been on the Vanco for three days, her temps are low to none however her WBC has elevated and is at 32.5.  The RN reports she eats the best at breakfast and that is only about 30-40% and then will not eat much more than 2-3 bites at other meals.  My first instinct was sepsis however the RN told me her blood cx was no growth at 3 days.  However, I don't think that can tell us much due to the fact that it was drawn after she had been on 14 days of antibiotics.  I also noted that her urine was fairly dark and the RN advised she has an average 275 output per 8 hours.  I wonder if my insticts are correct and she could be septic, and also, I read that c. diff has a pretty high rate of reoccurance.  Is this something we should worry about, especially since it was resistant to the Flaygl this time.  My sister called to inform me her boyfriend who is a RN has assured her that Grandma will be just fine and back in her home soon, I am not convinced of that.  Even without temps, she is still suffering from the UTI, c.diff and dehydration. My father is her DPOA but he really does not understand medical issues or terminology.  Her physician was not available today while I was there (I live in a different area) and I could only get some answers from the RN.  I would really like an honest opinion of her current condition. I work in tissue donation and read medical charts every day so I feel as though I most likely know the course to expect, but since I was unable to visit with her physician for some direct answers I was just wondering if these types of infections will cause her more problems d/t her age, med history, and non-ambulatory state, or if it will just take a bit longer but the Vanco should knock it out.  And the risk of reoccurance, she is a resident in a skilled nursing facility, does this perhaps increase those risks or is there simply a small chance that we make it that far?

Answer
Hi Sarah,
Thank you for writing.  Yes, i can hear your medical background in your descriptions and questions.

First, let us address the UTI issue.  Unfortunately, many non-ambulatory nursing home residents suffer from UTIs.  One way to help lower the frequency of these occuring is strongly suggest to staff to place your grandmother on a 2 hr. toileting schedule and a strict fluid intact/output charting (you should discuss this later part with the facility dietician)  

Also, unfortunately, many elderly develop c-diff and have this bad cycle of temps., UTI, c-diff.  so much so that at this point, many geriatricians are questioning the validity of using antibiotics on the elderly at all.  Much like children...it only weakens their immune system more as they go on.   You would know if she still has c-diff if there is a very acidic type smell with her bowel movements.  Believe me..you'll know the smell.

Sepsis is possible....but you would see MUCH more lethargy, sweating, shaking, etc.   I certainly would continue to try and talk with the physician about this if you feel it could possibly be sepsis; however, the Vanco would most likely still be the med. of choice...so, i agree with the others....still give it another few days.   It takes an older person MUCH longer to "snap back" from a UTI than all of us.   

Keep up the great work of staying involved and caring about your grandmother!

Best Regards,
Michalene Peticca, MA