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Managing Candidemia in the ICU

August 19, 2019


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.

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