Multiple factors as well as changes in the immune system with age are responsible for the increased susceptibility to infection in the elderly. 23 In addition, older persons will have atypical disease presentations of sepsis. Focal symptoms or signs of infection may be lacking. Instead, patients may present with isolated fever or nonspecific symptoms of anorexia, weakness, fatigue, and functional decline as the only evidence of infection. Hypothermia may be evident instead of fever. The most common sites of infection include the lungs, urinary tract, abdomen, and skin.

Bacteremia and occult bacterial infection are common in the febrile elderly. Mellors and coworkers identified the following multivariate predictors of bacteremia and occult bacterial infection in febrile adults without localizing symptoms or signs: (1) age older than 50, (2) diabetes, (3) white blood cell count (WBC) more than 15,000, (4) neutrophil band count more than 1500, and (5) erythrocyte sedimentation rate more than 30 mm/h.24 Patients with one or two of these factors had a seven- to eightfold relative risk for bacteremia or focal bacterial infection. Other studies in the febrile elderly have also found that leukocytosis and "left shift" on the WBC differential was also associated with a two- to threefold greater likelihood of bacterial infection. 25

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