Candidemia in the elderly: What does it change?

Abstract

BackgroundCandidemia is a life-threatening fungal infection and it can affect patients of all ages. Characterization of candidemia in the elderly is lacking.MethodsWe performed a retrospective study of adults (≥ 18 years) with candidemia diagnosed in our center in 2010–2015. Demographics, comorbidities, clinical and microbiologic characteristics, antifungal treatment and outcome were compared between older (≤65 years) and younger (>65 years) patients.ResultsAmong 302 patients with candidemia identified during the study period, 188 (62%) belonged to the elderly group. Comorbidities were significantly more frequent in older patients and included chronic pulmonary diseases, cardiovascular diseases, diabetes mellitus, and chronic renal failure (p ranging from <0.0001 to 0.017). A significantly higher proportion of older patients had septic shock (p = 0.040) at the time of candidemia. Candida albicans accounted for 53% of isolates and there were no significant differences between patients’ age and Candida species. Thirty-day mortality was significantly higher in older (45%) than in younger (28%) patients (p = 0.003). Factors associated with a significant higher proportion of death in the elderly included older age (i.e.: old-old), being hospitalized in ICU rather than in other wards, suffering from chronic pulmonary diseases, the presence of septic shock, multiple organ failure, dialysis and being infected with C. glabrata (p ranging from <0.0001 to 0.034). On multivariate analysis septic shock (HR 1.744 [CI95% 1.049–2.898], p = 0.032) and multiple organ failure (HR 2.242 [CI95% 1.070–4.698], p = 0.032) were independently associated with a higher risk of death. The probability of 30-days survival of older patients was significantly reduced when compared to that of younger patients (p = 0.005) who did not receive any treatment. In the elderly, there was a trend toward higher MICs for fluconazole/C. albicans, fluconazole/C. glabrata, amphotericin B/C. albicans, and caspofungin/C. glabrata.ConclusionsIn our study, we found that elderly patients with Candida bloodstream infections are characterized by a high mortality rate. In particular, the lack of any antifungal therapy as well as the occurrence of septic shock increased significantly the overall mortality. Additionally, we found that there was a trend of higher MIC for specific drug/Candida combination.

Strategies to Improve Medication Adherence in Older Persons: Consensus Statement from the Senior Italia Federanziani Advisory Board

“…Amphotericin B is not metabolised, and thus changes in drug metabolism or pharmacokinetic drug-drug interactions do not play a significant role [49]. The effectiveness of amphotericin B could be reduced in elderly as a recent study found a trend towards higher minimum inhibitory concentration (MIC) values for C. albicans in elderly than in younger patients treated for Candida infections, potentially due to the fact that older patients have been exposed more often to antibiotic and antifungal treatments, resulting in the selection of less susceptible strains [1]. Isolates were, however, still susceptible according to the EUCAST (European Committee on Antimicrobial Susceptibility Testing) clinical breakpoints (http://www.eucas t.org/clini cal_break point s/).…”

“…Invasive Candida infections are associated with high morbidity and mortality [2]. The most important Candida species causing invasive disease are C. albicans, C. glabrata, C. krusei, C. parapsilosis and C. tropicalis [1]. Rapid initiation of appropriate antifungal therapy with adequate exposure is needed to achieve optimal treatment outcomes [2,3].…”

Invasive Candidiasis: Epidemiology and Risk Factors

“…Studies with diverse population have shown that elderly patients have higher mortality [130]. In these patients, a combination of comorbidity, poor clinical situation, and more pathogenic species might contribute to their mortality [131]. A pooled analysis from patients included in randomized clinical trials comparing micafungin and amphotericin B showed differences among geographic regions, severity of disease (measured with Apache score for patients critically ill), and catheter removal [132].…”

Candida Endocarditis: A Review of the Pathogenesis, Morphology, Risk Factors, and Management of an Emerging and Serious Condition

“…We also discuss the complications of postoperative recovery compared to medical treatment alone in this literature review. Candida endocarditis is an emerging disease and a growing health concern globally, especially among the elderly population and immunosuppressed [23]. Additionally, patients needing long-term hospital care with indwelling devices and catheters often suffer from unwanted life-threatening nosocomial infections [10].…”