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candidemia

Disseminated (blood-borne) candidiasis. Etiology: (risk factors): 1) immunocompromised hosts a) neutropenia b) glucocorticoids 2) indwelling catheters a) intravascular catheter - Swan-Ganz catheters - Hickman catheter b) foley catheter 3) antibiotics a) prolonged use of antibiotics (> 28 days) b) multiple antibiotics (3-5 days) 4) Candida at other sites 5) ventilator for more than 7 days 6) renal failure (hemodialysis) Epidemiology: - incidence 0.7/1000 patient days - Candida albicans 54%, Candida glabrata 17% Clinical manifestations: 1) fever 2) malaise 3) pharyngitis 4) muscle tenderness 5) erythematous papular rash 6) oral thrush 7) retinal infection Laboratory: 1) abscesses contain mycelia resembling yeast 2) serology 3) blood culture is the gold standard for diagnosis - repeat blood cultures until negative [3] 4) T2 MRI assay of whole blood if culture-negative [3] Special laboratory: - ophthalmoscopy for Candida endophthalmitis - white exudates may be seen on retina [3] Complications: - 30-40% mortality [3] Management: 1) all Candida isolates from blood should be considered pathogenic 2) failure of treatment may be a result of colonization of intravascular catheters - remove intravascular catheters & indwelling ports [3,8] - if associated abscess, incision & drainage of abscess - removal of central venous catheter may not be of benefit (old) [5] 3) antifungal agents a) echinocandin for critically ill patients 1] caspofungin 2] anidulafungin 3] micafungin [3,4,6] b) liposomal amphotericin B - as effective as echinocandins but is nephrotoxic [3] c) fluconazole - formerly drug of choice, but resistance a problem [3] - only appropriate if fluconazole susceptibility documented - overall resistance 5.3% [4] - Candida albicans 0% - Candida glabrata 15% - Candida krusei 71% - may be useful for Candida prophylaxis in neutropenic cancer patients but limited effectiveness against other fungal infections [3] d) voriconazole e) continue antifungal treatment for 2 weeks after blood cultures become negative [3] 4) ophthalmology referral (risk of retinal infection) 5) CNS or eye infection: treatmemt with azole or liposomal amphotericin B [3] 6) mortality 62% of ICU patients with candidemia [4]

Related

Candida candiduria

General

candidiasis fungemia (systemic fungal infection, fungal septicemia)

References

  1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  2. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 871
  3. Medical Knowledge Self Assessment Program (MKSAP) 11,16,17,18. American College of Physicians, Philadelphia 1998,2012,2015,2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Bougnoux M-E et al, Candidemia and candiduria in critically ill patients admittted to intensive care units in France: Incidence, molecular diversity, management and outcome. Intensive care Med 2008, 34:292 PMID: 17909746
  5. Nucci M et al. Early removal of central venous catheter in patients with candidemia does not improve outcome: Analysis of 842 patients from 2 randomized clinical trials. Clin Infect Dis 2010 Aug 1; 51:295. PMID: 20578829 - Brass EP and Edwards JE Jr. Should the guidelines for management of central venous catheters in patients with candidemia be changed now? Clin Infect Dis 2010 Aug 1; 51:304. PMID: 20578828
  6. Pappas PG, Kauffman CA, Andes D, Benjamin DK et al Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Mar 1;48(5):503-35. PMID: 19191635
  7. Kullberg BJ, Arendrup MC Invasive Candidiasis N Engl J Med 2015; 373:1445-1456. October 8, 2015 PMID: 26444731 http://www.nejm.org/doi/full/10.1056/NEJMra1315399
  8. NEJM Knowledge+