08. Candidemia

Overview

Bacteremia secondary to Candida species. Candida is the 4th most common bloodstream infection in the ICU setting and is NEVER a contaminant in the blood. Candidemia has an overall mortality of approximately 30%.

Risk Factors

  • Immunocompromised patients: neutropenia, prolonged corticosteroids, chemotherapy, solid organ transplant recipients
  • Critical illness, especially prolonged ICU stay
  • Recent abdominal surgery
  • Use of broad-spectrum antibiotics
  • Presence of central vascular catheter
  • TPN use
  • Hemodialysis
  • Candidal colonization

Evaluation

  • Candida albicans is the most common cause of candidemia, but there are increasing rates of non-albicans isolates, especially C. glabrata, C. tropicalis, C. parasilosis and C. krusei.
  • Characteristic findings are often subtle (endocarditis, chorioretinitis, skin) or non-specific (persistent fever, new onset sepsis or septic shock in a critically ill patient in the ICU, etc.).
  • Blood culture sensitivity is 50%-70% (may take several days to turn positive).
  • Positive germ tube test is highly specific for C. albicans.
  • Positive skin biopsy or retinal exam (described below) is diagnostic.

Management

  • Echinocandins are recommended for initial therapy given the high prevalence of non-albicans candida: caspofungin (loading dose 70mg, then 50mg daily); micafungin (100mg daily); anidulafungin (loading dose 200mg, then 100mg daily).
  • Can transition to fluconazole in clinically stable patients with susceptible isolates. Voriconazole is also a possible step-down oral option for fluconazole-resistant isolates (if susceptible).
  • For candidemia without evidence of metastatic complications, treatment duration should be 2 weeks after documented clearance of candidemia and resolution of symptoms (start from the date of the first negative blood culture).
  • Central venous catheters should be removed if possible.
  • Repeat blood cultures in 48 hours to document clearance of candidemia. Patients with persistent candidemia on therapy should be evaluated for endovascular infections. Echocardiography is not otherwise performed routinely.
  • All patients should undergo dilated ophthalmologic exam within one week.
  • See also the IDSA guidelines for management of candidemia (https://doi.org/10.1093/cid/civ933)
  • There is emerging data that ID consultation reduces mortality in patients with candidemia, so consider ID consult in all cases.

Key Points

  • Candidemia is never a contaminant.
  • Remove central lines if presumed source, and repeat cultures to document clearance of candidemia.
  • Echinocandins are preferred initial therapy.
  • Consult ophthalmology for a dilated ophthalmologic exam.

Clancy, C, Nguyen, MH, Finding the “Missing 50%” of Invasive Candidiasis: How Nonculture Diagnostics Will Improve Understanding of Disease Spectrum and Transform Patient Care. Clin Infect Dis. (2013) 56 (9): 1284-1292

Weinstein, R. Fridkin, S. The Changing Face of Fungal Infections in Health Care Settings. Clin Infect Dis. (2005) 41 (10)

Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1‐e50. doi:10.1093/cid/civ9334.

Kullberg BJ, Arendrup MC. Invasive Candidiasis. N Engl J Med. 2015;373(15):1445‐1456. doi:10.1056/NEJMra1315399

Mejia-Chew C, O'Halloran JA, Olsen MA, et al. Effect of infectious disease consultation on mortality and treatment of patients with candida bloodstream infections: a retrospective, cohort study. Lancet Infect Dis. 2019;19(12):1336-1344. doi:10.1016/S1473-3099(19)30405-0