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

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

• 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

• Candidiasis

References

Authors

Ross Donaldson, Brandon Lee, Claire, Neil Young