Geriatric Babesia: IDSA Treatment Guidance and Longer Therapy
Babesia can be more severe in older adults
Some elderly and immunocompromised patients may require longer treatment
Coinfections and delayed diagnosis can worsen outcomes
Babesia infections among older adults are rising and may require longer treatment in some cases.[1][2]
Overall, the number of individuals contracting Babesia increased from 4 per 100,000 to 9 per 100,000 in the United States between 2006 and 2017.[1] The annual number of Babesia cases among individuals older than 85 years was 4 per 100,000. In comparison, the number of Lyme disease cases among the elderly was 15.98 per 100,000.[1]
Most Babesia cases occurred in Lyme-endemic states including Massachusetts, Rhode Island, Connecticut, New York, and New Jersey.[2] Other states reporting cases included Florida, Pennsylvania, California, Maryland, and Virginia.
Babesia Diagnosis in Older Adults
The most common institutional diagnostic test for Babesia involved peripheral blood smear evaluation.[1]
The intracellular parasite within red blood cells may clear after several days, making diagnosis more difficult later in the illness.
Physician offices more commonly relied on antibody and PCR testing.[1]
The 2020 IDSA babesiosis guidelines also emphasized peripheral blood smear and PCR testing when evaluating suspected Babesia infection.[6]
Coinfections Can Increase Severity
Babesia coinfections may complicate illness and prolong recovery.
Krause and colleagues reported that patients coinfected with Lyme disease experienced more symptoms and more persistent illness than patients with Babesia alone.[3]
Learn more about Lyme disease coinfections.
Immunocompromised individuals infected with Babesia microti may also develop persistent or relapsing illness.[4]
For elderly patients, Babesia can become life threatening, particularly in individuals who are immunocompromised, asplenic, or medically fragile.[4]
Case Report: Babesia and Ehrlichia in an 85-Year-Old Man
Javed and colleagues described the case of an 85-year-old man who died from concurrent babesiosis and ehrlichiosis.[5]
He was previously healthy except for hypertension and did not recall a tick bite or rash.
The patient was hospitalized with weakness and jaundice. He had mild anemia, severe thrombocytopenia, elevated bilirubin, and declining kidney function.
Babesia was identified based on bone marrow biopsy findings showing intraerythrocytic tetrads typical of babesiosis. Retrospective review of admission bloodwork showed parasitemia involving 8% of red blood cells.[5]
Postmortem testing later revealed ehrlichiosis as well.
He was never treated with doxycycline, the antibiotic most commonly prescribed for Ehrlichia infection.
Babesia Treatment in Elderly Patients
Krause and colleagues reported that atovaquone (Mepron) combined with azithromycin (Zithromax) was as effective as clindamycin plus quinine while causing fewer side effects.[3]
Medicare beneficiaries were significantly more likely to receive atovaquone plus azithromycin than clindamycin plus quinine.[1]
However, some elderly and immunocompromised patients required substantially longer treatment courses.[4]
According to Krause and colleagues, highly immunocompromised patients often required at least six weeks of therapy, including two weeks after blood smears no longer detected parasites.[4]
Some patients can relapse despite prolonged therapy, particularly highly immunocompromised individuals.[4][6]
IDSA 2020 Babesiosis Guideline
The 2020 Infectious Diseases Society of America (IDSA) guidelines highlighted advanced age as an important risk factor for severe babesiosis.[6]
The guidelines noted that severe disease was associated with:
- Advanced age
- Asplenia or hyposplenism
- Cancer
- Congestive heart failure
- HIV infection
- Immunosuppressive medications
The IDSA guidelines recommended monitoring parasitemia with peripheral blood smears in immunocompromised patients, even after symptoms improve.[6]
PCR testing was recommended when blood smears became negative but symptoms persisted.[6]
The guidelines also discussed exchange transfusion for severe babesiosis with high parasitemia or organ dysfunction.[6]
Why Babesia May Be Missed in Older Adults
Babesia symptoms in older adults may initially appear nonspecific.
Weakness, fatigue, confusion, jaundice, anemia, or appetite loss may be attributed to aging or unrelated illness.
Many patients do not recall a tick bite or rash.
Delayed diagnosis may increase the risk of severe disease, prolonged illness, or coinfection-related complications.
Learn more about delayed Lyme disease diagnosis.
Frequently Asked Questions
What is the recommended treatment for Babesia?
The IDSA guidelines commonly recommend atovaquone plus azithromycin for mild-to-moderate babesiosis, while severe disease may require additional therapies and monitoring.
Can elderly patients require longer Babesia treatment?
Yes. Some elderly or immunocompromised patients may require longer treatment courses, particularly when symptoms persist or relapse occurs.
Can Babesia become life threatening?
Yes. Severe babesiosis may lead to anemia, respiratory failure, kidney injury, liver dysfunction, or organ failure, especially in vulnerable individuals.
How is Babesia diagnosed?
Diagnosis may involve peripheral blood smear evaluation, antibody testing, and PCR testing.
Can Babesia occur with Lyme disease?
Yes. Babesia and Lyme disease may occur together after the same tick bite, potentially increasing illness severity.
Clinical Takeaway
Babesia infections in elderly patients may be more severe, more difficult to diagnose, and more likely to require prolonged treatment.
Coinfections, delayed recognition, immunocompromise, and organ dysfunction may substantially complicate recovery.
Older adults with suspected Babesia require careful monitoring for severe disease, persistent parasitemia, and coinfections that may alter treatment decisions and outcomes.
Related Articles
These related articles explore Babesia severity, coinfections, delayed diagnosis, and complications in elderly patients.
Tick bite causes 3 diseases in elderly woman
Lyme disease mimics autoimmune disorder in elderly woman
Confusion in elderly woman with anaplasmosis and Babesia infection
Lyme disease coinfections
Delayed Lyme disease diagnosis
References
- Menis M, Whitaker BI, Wernecke M, et al. Babesiosis Occurrence among the U.S. Medicare Beneficiaries Ages 65 and Older, During 2006-2017: Overall, and by State and County of Residence. Open Forum Infect Dis. 2020.
- Menis M, Forshee RA, Kumar S, et al. Babesiosis Occurrence among the Elderly in the United States, as Recorded in Large Medicare Databases during 2006-2013. PLoS One. 2015;10(10).
- Krause PJ, Telford SR 3rd, Spielman A, et al. Concurrent Lyme disease and babesiosis: Evidence for increased severity and duration of illness. JAMA. 1996;275(21):1657-1660.
- Krause PJ, Gewurz BE, Hill D, et al. Persistent and relapsing babesiosis in immunocompromised patients. Clin Infect Dis. 2008;46(3):370-376.
- Javed MZ, Srivastava M, Zhang S, Kandathil M. Concurrent babesiosis and ehrlichiosis in an elderly host. Mayo Clin Proc. 2001;76(5):563-565.
- Krause PJ, Auwaerter PG, Bannuru RR, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA): 2020 Guideline on Diagnosis and Management of Babesiosis. Clin Infect Dis. 2020.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
12/20/2023
Dr Cameron ,
First thank you for all you do for patients.
I’m 60 yr, female, diagnosed with Lyme and co-infection Babiosis in summer of 2007. I lived in MN at time of diagnosis. 2 yrs prior I was diagnosed as having Fibromyalgia. 2006 jaw pain was bad dental work didn’t decrease pain so I allowed Drs to pull all my upper and lower teeth. The pain has only increased over the years. Ill fitting dentures, 7 sets since 2006. Added lower implant/bone (2)early 2023. My bones are disappearing.
When diagnosed in 2007 I was given Doxycycline. 2 months. I was still sick and getting sicker but was told the antibiotics took care of the Lyme and Babesia. Since I’ve been on so many different medications for suicidal ideation, I rejected many over the years. They just didn’t work in my system. Now on Concerta 54 ER, 2-20 mg Ritalin IR, Duloxetine 120mg, Diazepam 5mg for my severe anxiety. These from psychiatrist. Then there is Losartan 50-100mg for Blood Pressure, Furisimide 20mg for swelling in lower legs.
Ipatropium .06% nasal spray for the clear liquid that runs out my nose, Flonase for allergies environmental. Oxycodone HCI 15 mg IR 1 every 6 hours for the constant diffuse pain I’ve had since 2005. My medical issues are abhorrent. I have so many on my list and more that aren’t even listed. These are issues that were recognized by Radiologists from CT scans and MRI’s. Brain has a pituitary cyst, pineal gland has been seen as calcified, one report said I have scattered perivascular CFS spaces throughout the basal ganglia , faint medical left parietal lobe which may reflect a incidental developmental venous anomaly. Cystic structure within pituitary gland 7.0×9.7×7.2 cm. This was October 25 2014. November 2015 size 7.0×6.3mm
I had surgery 2021 cleanup and fused L-4L-5, in the notes of the Radiologist was seen ovarian cyst 2.4 cm. Spoke to Dr about that he said every one has them. Now that cyst is 4.0 cm. Will watch it. I have facial numbness both sides all the time for over a year now. It started as a small patch under left eye approximately 3 years ago. I’ve had 3 sprains this year knees and ankle, steroid injections shoulders, hip, back and neck. Nerve burns in neck and low back several times also.
Arthritis of some kind that at present is really flared in about all my knuckles both hands and feet. I bend over and sweat pores our my head around the temple area. Night sweats always. I get fevers that cause my skin on lips to dry and peel off sometimes several times a day. Consentration leaves me stranded and wondering what I was doing or where I’m going. Can’t remember so I see something else that needs taken care of on I go. I’ve forgotten most of my children’s young lives. I’ve forgotten all I learned as a massage therapist bones, muscle, nerves ect. My oxygen level is running around 91-98. My skin is mottled most of my body. There is so much more thyroid, kidney, urine output etc I don’t know why Drs
Won’t treat me. I’ve gave them books and many of the articles you have written. To no avail.
Merry Christmas Dr Cameron
March 2017 size of Pituitary cyst 6x4x6mm