Elderly Age, Underlying Malignancy and Diabetes (DM) Are Not Significant Risk Factors for Candidemia with Candida glabrata (CG)

Background: The 2016 update of the clinical practice guideline for the management of candidasis recommends an echinocandin as initial therapy for treatment of candidemia in neutropenic and non-neutropenic patients. Fluconazole is acceptable as initial therpay only in patient who are hemodynamically stable, without prior azole exposure, and are not at increased risk for CG infections. Elderly patients or those with underlying malignancy or DM are defined as groups at high risk for CG infections. These risk factors include a wide range of patients, may lead to increased echinocandin use, and have not been consistently proven in prior studies. We sought to evaluate if elderly age (≥ 65 years), underlying malignancy and DM are risk factors for candidemia with CG at our institution.

Methods: Adult patients with at least one positive blood culture for Candida species between 1/1/2013-12/31/2015 were included. Only the first episode of candidemia was included for patients with recurrent candidemia. Risk factors were analyzed using regression analysis.

Results: A total of 147 patients were reviewed. CG: 47; non-CG: 100 (C. albicans: 52; C. parapsilosis: 25; C. dubliniensis: 6; C. tropicalis: 5; C. krusei: 5; other: 7). Demographics and outcomes are summarized in table 1. Risk factors and their association with CG candidemia are shown in table 2. Elderly age and DM met a priori p < 0.2 for inclusion in multivariate (MV) analysis, neither was found to be an independent predictor for CG candidemia in MV analysis (elderly age: p = 0.26; DM: p = 0.08).

Table 1. Patient Demographics and Outcomes

	CG	Non-CG	p-Value
Male (%)	45	46	0.79
Age (Years)	60.1 ± 14.1	56.9 ± 16.0	0.24
All-Cause Inpatient Mortality (%)	21	44	0.01
Length of Stay (Days)	16 (4-98)	19.5 (2-122)	0.21

Table 2. Univariate Analysis of Risk Factors Associated with CG candidemia

	OR (95% CI)	p-Value
Elderly Age	1.7 (0.8-3.5)	0.14
Underlying Malignancy	1.4 (0.7-3.0)	0.32
DM	2.3 (1.0-5.1)	0.04

Conclusion: Contrary to recommendations from the candidiasis guideline, elderly age, underlying malignancy and DM were not significant risk factors for CG candidemia in our patients. Presence of these patient characteristics should not preclude the use of fluconazole as initial therapy.