Managing Candidemia in the ICU

CA was admitted to the ICU with sepsis due to (E. coli in blood) pyelonephritis. After 8

days of appropriate antibiotics she is still febrile without another identified infection.

She is colonized with yeast -- in her sputum, a wound swab, and she has thrush. She has

multiple IV lines - right internal jugular, right arm peripheral and a left radial arterial

line. She has a foley catheter. After sending blood, urine, and sputum for culture, CA was

started on empiric fluconazole for possible candidemia -- or yeast in her blood.

Candida species are the third leading cause of bloodstream infection

in many ICUs with an associated mortality of up to 50%.

The major risk factor for candidemia is exposure to broad-spectrum antibiotics usually in the

presence of a central venous catheter. Other risk factors include total parenteral nutrition,

immunosuppression, dialysis, diabetes, and uncontrolled intra-abdominal infection -- all

very common in critically ill patients.

Candidemia is suspected in patients with appropriate risk factors, fever, and other non-specific

signs and symptoms of infection.

Hemodynamic instability may

also be present.

Scoring tools to identify the patient who would benefit from empiric antifungal therapy

have been proposed but none are sensitive and specific enough to reliably predict the

at risk patient. Empiric antifungal therapy has not demonstrated a consistent benefit

in clinical outcomes, including mortality.

Therefore candidemia is diagnosed by positive blood cultures; and Candida in the blood should

always be treated.

Guidelines recommend -- remove and change any IV lines as soon as possible and start therapy

with an echinocandin. If Candida albicans is the predominant

species at your institution and fluconazole resistance is uncommon, fluconazole is a reasonable

choice for azole naive patients. If an enchinocandin is started - switch to fluconazole if appropriate

once the Candida species is confirmed.

For CA, wait for blood cultures to come back — before starting fluconazole.

Oral or via feeding tube administration of fluconazole is an option for patients who

are stable and tolerating feeds.

Repeat blood cultures must be sent, as duration of treatment is usually 14 days from the first

negative blood culture. Longer courses are needed if there are multiple sites of infection

-- such as the eye and ophthalmology consults should be considered, especially in patients

with prolonged candidemia.

Key messages -- identify candidemia risk factors; always treat candida in the blood, use fluconazole

if you can, treat most patients for 14 days from negative cultures.