Candidemia

A recently discussed case was of a patient with sepsis secondary to fungemia with Candida parapsilosis. Candida in the blood should never be assumed to be contaminant, though this can sometimes be a result of a contaminated line. As with all cases of sepsis, Candidemia has been increasing in the US and Canada.

Candidemia can be invasive or non-invasive, the presence of end organ involvement (endophthalmitis, endocarditis, renal and CNS involvement) defines invasive disease. Diagnosis should be based on positivie blood cultures. Skin biopsies if lesions are present can also be used to identify systemic disease. Recently, assay for beta-D-glucan, a component of the cell wall of Candida has been shown to be useful in diagnosis candidemia. This test is not specific to Candida and will be positive in other invasive fungal infections. This test has been shown to have reasonable sensitivity and specificity for fungal infections. Risk factors identified by several case-control studies in hospitalized and ICU patients included the following:



1. Hickman lines
2. ESRD on dialysis
3. Broad spectrum antibiotics use
4. Gastric acid suppression
5. ICU admission
6. Total parenteral nutrition (present in our patient)
7. Immunsuppression


Candida albicans is the most common species identified in candidemia, however additional strains are being recognized with increasing frequency. C. glabrata, C. parapsilosis, C. krusei and C. tropicalis are amongst the most common species seen. C. glabrata can be resistant to azole therapy, while all C. krusei is resistant to this class of medications. A less common species C. lusitaniae can develop resistance to amphotericin, which should be recocgnized by treating physicians.

Empiric treatment of fungemia should consider multiple factors: history of recent azole antifungals, nuetropenia, severity of illness, local epidemiology, invasive disease and history of resistant organisims in the individual. If the patient was well and had few risk factors, initial treatment with fluconazole IV is reasonable. otherwise, neutropenic/septic patients should receive an echinocandin (caspofungin/micafungin) until speciation occurs. Amphotericin has significant toxicity and tends to be used less. Duration of therapy is based on consensus guidelines, and the IDSA has said 2 weeks following negative blood cultures is a reasonable duration in patient without invasive disease (abscess/endocarditis).

See the link below for candidal guidelines:

IDSA guidlines for candidemia