Oesophageal candidiasis in elderly patients: risk factors, prevention and management

This article reviews risk factors, prevention and management of oesophageal candidiasis (OC) in the elderly. Putative risk factors for OC in the elderly include old age itself, malignant disease, antibacterial and corticosteroid use, chronic obstructive pulmonary disease, acid suppression treatment, oesophageal dysmotility and other local factors, diabetes mellitus and HIV/AIDS. We have found evidence for a risk association between OC in the elderly and malignant disease (both haematological and non-haematological), antibacterial therapy and corticosteroid (including inhaled corticosteroids) use. We also found evidence of an association between OC in the elderly and oesophageal dysmotility or HIV/AIDS, but little direct evidence of an association between diabetes or old age per se. The literature on OC in the elderly is not large. The published series evaluating OC in this age group are small in size, often do not contain controls and mostly contain only limited information about the age of the patients. Prevention of OC is mainly the avoidance of exposure to the risk factors wherever possible. Specific measures such as highly active antiretroviral therapy in AIDS, prophylactic fluconazole when receiving chemotherapy for malignancy, using spacing devices, mouth rinsing soon after inhalation of corticosteroids and avoiding the use of cortiocosteroids just before bedtime are useful. OC is often responsive to a 2- to 3-week course of oral fluconazole, but resistance may be encountered in AIDS or in the presence of uncorrected anatomical factors in the oesophagus. Itraconazole solution, voriconazole or caspofungin may be used in refractory cases. Use of amphotericin B is restricted because of its narrow therapeutic index.