Effect of the implementation of clinical guidelines on management of candidemia in elderly patients

Introduction: Mortality from candidemia is higher in elderly population than in younger patients, which may be related to suboptimal management. The aim of the present study is to evaluate adherence to the recommendations for the clinical management of candidemia in a population over 75 years before and after implementing specific training. Patients and Methods: We recorded retrospectively data from candidemia episodes in elderly patients during two periods of time: 2010– 2015 years (before training) and 2017– 2022 years (after training), as well as adherence to the recommendations of the clinical practice guidelines, mortality and consultation to infectious disease specialists. Results: Forty-five episodes of candidemia were recorded in the first period and 29 episodes in the second period. A better compliance to the recommendations of the clinical practice guidelines was observed in the second period: echocardiogram performance


| INTRODUC TI ON
Candidemia is an invasive fungal infection relevant both for its frequency and mortality. Candida species are the sixth most commonly isolated microorganism in blood cultures. 1 Attributable mortality is between 30 and 60% according to different studies. 2 Adequate clinical management can significantly improve the prognosis of this infection. 3,4 It should be noted that in recent years there has been a notable demographic change in developed countries characterised by the progressive aging of the population. So much so, that it has been proposed to modify the age that defines this population, increasing the age limit from 65 to 75 years. 5 It has been proven that candidemia in elderly patients presents a higher mortality than in younger patients, 6,7 which has been related to a possible suboptimal clinical management. 8 Fortunately, different clinical guidelines for the management of candidemia and various scales have been developed in recent years that make it possible to assess the degree of adherence to their recommendations. Notable among them are those developed by scientific societies such as ECMM (European Confederation of Medical Mycology) or GEMICOMED (Medical Mycology Study Group). 9,10 The aim of this study was to compare adherence to the recommendations on the clinical management of candidemia in the elderly and its prognosis before and after cross-sectional training on the content of the aforementioned guidelines. Likewise, it was intended to evaluate if the evaluation by an infectious disease consultant (IDC) supposes an additional positive factor in the adequate management of this infection.

| PATIENTS AND ME THODS
We conducted a retrospective cohort study in a single tertiary centre in Madrid (Spain). All patients older than 75 years with positive blood cultures for Candida spp. during two different time periods were included: the first period was from January 2010 to September 2015; and the second was from January 2018 to December 2022.
In cases in which the same patient had more than one episode of candidemia, only the first was considered.
The intervention consisted of implementing the diffusion of the measures recommended by GEMICOMED for candidemia 9 by con- The study was approved by the local research ethics committee, which waived the need to obtain informed consent as it was a retrospective study. The most commonly identified Candida species during both periods was C. albicans (50% of the total isolates), followed by C. glabrata (21.6%) and C. parapsilosis (18.9% greater adherence to the recommendations was also found among patients followed up by IDC, although the differences with those who did not have such follow-up were not statistically significant ( Table 3).

| DISCUSS ION
The present study demonstrates that the diffusion of recommendations on the proper management of candidemia in elderly patients improves the quality of care received by these patients.

We have followed the European Confederation of Medical
Mycology (ECMM) Quality (EQUAL) Standard that was developed as a score that quantifies the degree of adherence to the recommen- Previous studies have shown that follow-up of candidemia by an IDC improves compliance with the recommendations of clinical guidelines, and even its prognosis. 17,18 In other infectious pathologies, such as endocarditis (in which candidemia may be involved), experts and consensus documents agree on the need for support and follow-up through IDC. 19 In the present study, it was observed that in both periods the patients with IDE follow-up had better management than those in whom there was no follow-up, although this did not significantly impact mortality. This is an expected result since IDEs treat more cases of this pathology and accumulate greater knowledge and experience in its management. 20   The overall mortality of elderly patients with candidemia is high and higher than that of young patients. 7,22 Previous studies estimate the mortality of candidemia in the elderly between 30% and 50%, which coincides with the data collected in our series. 6,7,14,23 Unfortunately, our work has not been able to demonstrate that the improvement in the management of candidemia has a direct impact on the mortality of elderly patients. Although statistical significance has not been reached, a trend towards lower early and late mortality is observed in the second follow-up period, which is consistent with data previously published in other series, in which bundles of care for the management of candidemia has been shown to improve the prognosis of patients. [24][25][26] The lack of statistical significance can probably be explained by the small sample size of the second period. It must also be clarified that we have not found the reason that justifies younger age and less comorbidity during the second period. It is possible that the COVID-19 pandemic has influenced this fact. 13,27 Likewise, it should be noted that the death can also be re-

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.