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Minxi Lao,1,* Kaicong Zhang,1,* Meng Zhang,2,* Qian Wang,1 Jin Li,1 Lei Su,1 Meilin Ding,1 Wen He,1 Yingying Gong1 1Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China; 2Department of Pathology, Shenzhen Second People’s Hospital/The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, People’s Republic of China*These authors contributed equally to this workCorrespondence: Yingying Gong Email gongyy5@mail.sysu.edu.cnIntroduction: Invasive pulmonary aspergillosis (IPA) is a potentially lethal opportunistic infection. Old age is one of the important risk factors of IPA. However, data regarding the clinical characteristics and prognostic factors of elderly patients with IPA are limited, with data regarding co-infection of other bacteria or fungi even scarcer.Methods: We performed a retrospective study of elderly patients (aged≥ 60) with IPA diagnosed in the First Affiliated Hospital of Sun Yat-sen University from January 2000 to December 2019. Data collection included demographic characteristics, premorbid conditions, underlying diseases, clinical manifestations, therapeutic procedures, and pathogenic detection. Associated factors were analyzed by logistic regression analysis.Results: A total of 97 elderly patients (75 males, 22 females) with IPA were included. The all-cause mortality rate was 36.1% (35/97). Body mass index (BMI) (adjusted odds ratio (OR) 1.27, 95% confidence interval (CI) 1.08– 1.50, P=0.01), solid organ malignancy (adjusted OR 5.37, 95% CI 1.35– 21.33, P=0.02), and co-infections (adjusted OR 5.73, 95% CI 1.40– 23.51, P=0.02) were associated with mortality in the elderly patients with IPA. Nearly, 76.3% (74/97) of the patients developed co-infections. Most of the infections (55/74, 74.3%) involved the lung. A total of 77 strains of bacteria were isolated, and Gram-negative bacteria (63/77, 81.3%) were predominant. Patients with co-infections are older (72.3± 7.6 vs 67.4± 7.4, P=0.04), prone to admit to the intensive care unit (ICU) (59.5% vs 26.1%, P=0.01), and present lymphopenia (60.8% vs 26.1%, P=0.004). In multivariate analysis, ICU admission (adjusted OR 4.57, 95% CI 1.53– 13.67, P=0.01), and lymphopenia (adjusted OR 4.82, 95% CI 1.62– 14.38, P=0.01) were significantly associated with co-infection in the elderly patients with IPA.Conclusion: IPA is a fatal disease in the elderly population. Co-infection is closely associated with mortality. Lymphopenia could be an indicator for co-infection in the elderly patients with IPA.Keywords: pulmonary aspergillosis, elderly, co-infection, mortality

Yingying Gong,1,* Chen Li,1,* Cuicui Wang,2,* Jin Li,1 Meilin Ding,1 Dongying Chen,2 Minxi Lao1,2 1Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China; 2Department of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China*These authors contributed equally to this workCorrespondence: Minxi LaoDepartment of Geriatrics, The First Affiliated Hospital of Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, Guangzhou 510080, People’s Republic of ChinaEmail laomx3@mail.sysu.edu.cnDongying ChenDepartment of Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou 510080, People’s Republic of ChinaEmail cdongying@163.comIntroduction: Invasive fungal disease (IFD) is a life-threatening infection. The epidemiology and clinical features of IFD in the elderly population are less discussed. The aim of this study was to explore the epidemiology and mortality-associated factors for IFD in the elderly inpatients.Methods: A retrospective study enrolling 512 elderly inpatients from The First Affiliated Hospital of Sun Yat-sen University during the last two decades was performed.Results: The annual prevalence of IFD was 0.1– 0.5%. Candidiasis was the most common (236/521, 45.3%). An increasing trend was observed in aspergillosis from 11.1% in year 1998 to 28.8% in year 2018. The common infective sites of candidiasis were abdominal cavity (83/236, 35.2%) and bloodstream (55/236, 23.3%). Invasive aspergillosis mainly developed in the sinus (74/149, 49.7%) and lung (65/149, 43.6%). Patients with diabetes mellitus (DM) (59/126, 46.8%), solid organ malignancy (84/114, 73.7%), chronic kidney disease (CKD) (40/62, 64.5%) or receiving operation (109/147, 74.1%) were prone to develop candidiasis, while aspergillosis was usually complicated in patients with chronic obstructive pulmonary disease (COPD) (25/51, 49.0%). The all-cause mortality rate was 25.9% (135/521), and patients aged ≥ 80 years were the riskiest (20/51, 39.2%). Lymphopenia (59.5% vs 17.3%, P< 0.001) was significant in deceased patients with mold infection. Higher proportion of non-survivors with invasive candidiasis received central venous catheterization (CVC) (68.4% vs 40.6%, P< 0.001) or indwelling urinary catheter (68.4% vs 46.3%, P=0.001).Conclusion: IFD is a life-threatening complication especially in the oldest-old. Surveillance on lymphopenia, prompt treatment and reduce invasive procedures could benefit the prognosis.Keywords: invasive fungal disease, elderly, mortality, hypoalbuminemia