title: Mycobacterium ulcerans in the Elderly: More Severe Disease and Suboptimal Outcomes.
abstract: BACKGROUND
  The clinical presentation of M. ulcerans disease and the safety and effectiveness of treatment may differ in elderly compared with younger populations related to relative immune defficiencies, co-morbidities and drug interactions. However, elderly populations with M. ulcerans disease have not been comprehensively studied.
  
  
  RESULTS
  A retrospective analysis was performed on an observational cohort of all confirmed M. ulcerans cases managed at Barwon Health from 1/1/1998-31/12/2014. The cohort included 327 patients; 131(40.0%) ≥65 years and 196(60.0%) <65 years of age. Patients ≥65 years had a shorter median duration of symptoms prior to diagnosis (p<0.01), a higher proportion with diabetes (p<0.001) and immune suppression (p<0.001), and were more likely to have lesions that were multiple (OR 4.67, 95% CI 1.78-12.31, p<0.001) and WHO category 3 (OR 4.59, 95% CI 1.98-10.59, p<0.001). Antibiotic complications occurred in 69(24.3%) treatment episodes at an increased incidence in those aged ≥65 years (OR 5.29, 95% CI 2.81-9.98, p<0.001). There were 4(1.2%) deaths, with significantly more in the age-group ≥65 years (4 compared with 0 deaths, p = 0.01). The overall treatment success rate was 92.2%. For the age-group ≥65 years there was a reduced rate of treatment success overall (OR 0.34, 95% CI 0.14-0.80, p = <0.01) and when surgery was used alone (OR 0.21, 95% CI 0.06-0.76, p<0.01). Patients ≥65 years were more likely to have a paradoxical reaction (OR 2.06, 95% CI 1.17-3.62, p = 0.01).
  
  
  CONCLUSIONS
  Elderly patients comprise a significant proportion of M. ulcerans disease patients in Australian populations and present with more severe and advanced disease forms. Currently recommended treatments are associated with increased toxicity and reduced effectiveness in elderly populations. Increased efforts are required to diagnose M. ulcerans earlier in elderly populations, and research is urgently required to develop more effective and less toxic treatments for this age-group.
authors.affiliation: Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.|Department of Medicine and Infectious Diseases, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.|Manson Unit, Médecins Sans Frontières, London, United Kingdom.
authors.forename: Daniel P
authors.initials: DP
authors.lastname: O'Brien
authors.affiliation: Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.
authors.forename: N Deborah
authors.initials: ND
authors.lastname: Friedman
authors.affiliation: Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.
authors.forename: Raquel
authors.initials: R
authors.lastname: Cowan
authors.affiliation: Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.
authors.forename: James
authors.initials: J
authors.lastname: Pollard
authors.affiliation: Department of Plastic Surgery, Barwon Health, Geelong, Victoria, Australia.
authors.forename: Anthony
authors.initials: A
authors.lastname: McDonald
authors.affiliation: Department of Plastic Surgery, Barwon Health, Geelong, Victoria, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Callan
authors.affiliation: Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.
authors.forename: Andrew
authors.initials: A
authors.lastname: Hughes
authors.affiliation: Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.
authors.forename: Eugene
authors.initials: E
authors.lastname: Athan
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001315:Australia / Q000453:epidemiology; D054312:Buruli Ulcer / Q000188:drug therapy / Q000453:epidemiology / Q000473:pathology*; D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019911:Mycobacterium ulcerans / Q000302:isolation & purification; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents