Invasive candidiasis

Background

  • Candida is an important nosocomial infection that requires evaluation to identify a source: central line cathether, intravenous catheter, indwelling foley catheter, recent abdominal surgery with anastamotic leak
  • Associated with candidemia with further hematogenous spread to visceral organs (heart, kidney, liver, spleen, eye, brain, skin, joints etc)

Clinical Features

  • presence of biofilms on catheter
  • fever and chills unresponsive to antibiotics
  • chorioretinitis
  • muscle abscesses
  • skin lesions with satellite pustules

Differential Diagnosis

Evaluation

  • positive blood culture
  • positive culture of blood, tissue, urine from normally sterile sites
  • biopsy of skin lesions for gram staining
  • beta-D-glutan assay can be a diagnostic adjunct to blood cultures and identify systemic fungal infections weeks before positive blood cultures

Management[1]

  • Vascular catheter removal
  • 1st line: IV Echinocandins
    • Caspofungin 70mg IV day 1, 50mg IV Qdaily x 14 days following the last positive blood culture
    • Anidulafungin 200mg IV day 1, 100mg IV Qdaily x 14 days following the last positive blood culture
    • Micafungin 100mg IV Qdaily x 15 days
    • Step down therapy: as early as 5 days, can step down to oral if blood stream is clear and patient can tolerate oral regime
  • 2nd line:
    • Fluconazole 800mg IV loading dose, 400mg (6mg/kg) IV Qdaily for 14 days following first negative blood culture
    • Voriconazole 400mg (6mg/kg) IV Q12 hours x 2 doses (loading dose), 200mg (3mg/kg) IV Q12 x 14 days following first negative blood culture (maintenance dose)
  • Alternative:
    • Amphotericin B is acceptable but carries a higher toxicity and side-effect profile
    • 1mg/kg/day IV x 14 days following first negative blood culture

Disposition

  • Admission

See Also

External Links

References

  1. Kullberg BJ, Arendrup MC Maiken, Invasive Candidiasis. N Engl J Med 2015; 373:1445-1456.