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.