老年患者侵袭性念珠菌病特点和治疗研究

Invasive candidiasis in the elderly:a single-center,retrospective cohort study

目的探讨老年患者侵袭性念珠菌病(IC)的临床及真菌学特点、治疗现状与预后。方法回顾性收集2010年1月至2019年12月10年间依据真菌培养确诊为IC的老年住院患者(≥65岁)的临床资料,对其感染菌株进行鉴定及耐药性实验,分析老年IC患者的临床、真菌学、治疗与预后特点,并与非老年人患者进行比较。结果共纳入99例老年患者,中位年龄78(70~83)岁,男女比为2.1∶1.0,占成年患者62.7%(99/158例)。与非老年人患者相比,老年患者中长期住院、重症监护室(ICU)、合并心力衰竭、呼吸衰竭、肾功能衰竭、伴发细菌感染、多点定植、接受机械通气及有氟康唑暴露史的患者更为多见(均P<0.05)。老年患者中血流相关感染最常见(71/99,71.7%),感染菌种以白念珠菌为主(47/99,47.5%),氟康唑与伏立康唑耐药发生率最高(分别为17/117,14.5%;15/117,12.8%)。老年人感染部位、感染菌种分布、对各抗真菌药物的耐药性均与非老年组差异无统计学意义(P>0.05)。共86例(86.9%)老年患者接受了系统性抗真菌治疗,氟康唑为最常用药(35/86,40.7%)。老年IC患者30 d全因病死率为32.6%(29/89),高于非老年组(P=0.022)。多因素Logistic回归分析结果显示高龄(OR=1.12;95%CI:1.06~1.20;P<0.001)、肾衰(OR=4.81;95%CI:1.65~14.03;P=0.004)、高念珠菌评分(OR=1.81;95%CI:1.06~3.11;P=0.031)可增加死亡风险。结论老年人为IC主要发病人群,且病死率随年龄增加不断升高,对于老年IC患者的治疗应积极且谨慎。

Objective To investigate the clinical and mycological characteristics,treatment and prognosis of invasive candidiasis(IC)in the elderly.Methods This retrospective study included aged patients(≥65 years)admitted to the Peking University First Hospital between January,2010 and December,2019,who were diagnosed with IC based on positive culture results.The infecting strains were re-identified and their antifungal drug resistance was tested.The clinical and mycological characteristics,treatment and prognosis information of the elderly patients were collected and compared with those of non-elderly adults.Results A total of 99 aged patients were included,with a median age of 78(70-83)years and a male-to-female ratio of 2.1∶1.0.The elderly accounted for 62.7%(99/158)of the adult IC patients.Compared with their younger counterparts,elderly patients were more likely to need medium-to long-term hospitalization and intensive care unit(ICU)stay,and to show concurrent heart failure,respiratory failure or renal failure,to require mechanical ventilation,and to show deep-seated bacterial infections and multifocal Candida colonization,especially for those with previous fluconazole exposure(P<0.05).Bloodstream was the most common Candida transmission route(71/99,71.7%)and Candida albicans was the most prevalent species(47/99,47.5%).Antifungal resistance was highest for fluconazole(17/117,14.5%)and voriconazole(15/117,12.8%).No significant difference was found between elderly patients and non-elderly patients in terms of infected sites,Candida species,and antifungal resistance(P>0.05).A total of 86 patients(86.9%)received systemic antifungal treatment and fluconazole was the most commonly used drug(35/86,40.7%).The thirty-day all-cause mortality in aged IC patients was 32.6%(29/89),significantly higher than in younger patients(P=0.022).Logistic regression analysis revealed that advanced age(OR=1.12,95%CI:1.06-1.20,P<0.001),renal failure(OR=4.81;95%CI:1.65-14.03;P=0.004),and a high Candida score(OR=1.81,95%CI:1.06-3.11,P=0.031)significantly increased the risk of death.Conclusions Elderly patients were the main affected population of IC,and the mortality of IC steadily increases with age.Treatment for aged IC patients should be proactive and cautious.