candidemia

Fungus Among Us: Navigating Candidemia and Antifungal Strategies

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Intro

45 YOF presents to ED with hypotension, fever and altered mental status. Seen by PCP one week ago for suspected pneumonia, completed Z-Pak and Medrol Dosepak. Patient is on TPN at home for severe short bowel syndrome following multiple resections. PMH includes Chrohn's disease and diabetes.Patient was started on empiric antibiotics of vancomycin and cefepime and admitted to the ICU. Suddenly, the hospital goes into emergency lockdown. Solving this medical mystery will unlock the key. The case is now yours, and the fate of Cone Health is up to you...

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Risk factors

Locked

Locked

Locked

First we must assess the patient's risk:

Which is not a risk factor for candidemia?

short term corticosteroid use

diabetes

parenteral nutrition

Risk Factors

• Critical illness, long-term ICU stay
• Abdominal surgery, especially with anastomic leakage or repeat laparotomies
• Acute necrotizing pancreatitis
• Hematologic malignant disease
• Solid-organ transplant
• Solid-organ tumors
• Neonates (low birth weight, preterm)
• Use of broad-spectrum antibiotics
• Presence of CVC, TPN
• Hemodialysis
• Glucocorticoid use or chemotherapy for cancer
• Candida colonization, particularly if multifocal (colonization index >0.5)

Diagnosis

Completed

Locked

Locked

Now that we have identified this patient's risk factors, we can proceed to diagnostic testing

What is the sensitivity of blood culture for candidiasis?

2-7%

21-71%

80-90%

True or False: Beta-D glucan is specific for candida species

True

Wronganswer

False

Which is not an alternative test for diagnosing candidiasis?

Candida mannan antigen

PCR

galactomannan

Diagnostic Tests for Invasive Candidiasis

ALERT!

Blood cultures were obtained. Microbiology lab calls you to discuss that gram stain is showing yeast.

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Treatment

Completed

Completed

Locked

What antifungal agent has broad spectrum activity against candida species and is recommended for initial therapy in nonneutropenic patients?

fluconazole

voriconazole

echinocandin

Treatment of Candidemia in Nonneutropenic Patients

Which echinocandin does not require a loading dose?

anidulafungin

caspofungin

micafungin

Dosing of Echinocandins for Candidemia

• Anidulafungin: 200 mg loading dose, then 100 mg IV daily

• Caspofungin: 70 mg loading dose, then 50 mg IV daily

• Micafungin: 100 mg IV daily

Which species of candida is the leading cause of candidemia in the United States?

candida glabrata

candida auris

candida albicans

CDC Trends in Candida Species Distribution

Patient was started on empiric antifugnal therapy with micafungin and stopped IV antibiotics. Repeat cultures were obtained.

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For susceptible isolates, when would it be appropriate to transition to oral fluconazole?

gastrointestinal dysfunction

clinical instability

negative repeat cultures, 5-7 days after starting antifungal therapy

IDSA - Oral Transition Criteria

In abscence of metastatic complications, how long do we treat for candidemia from negative blood cultures?

2 months

7 days

2 weeks

IDSA - Treatment Duration

metastatic foci of infection - eye (endophthalmitis), heart (endocarditis), kidney (pyelonephritis), joints, etc.

ALERT!

Blood cultures have finalized as candida albicans susceptible to fluconazole. Repeat cultures obtained 2 days after starting micafungin on 9/10 are no growth final.

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Patient is clinically improving with negative repeat cultures. Is this patient appropriate for transition to fluconazole?

yes

no

if high dose used

Patient is not candidate for oral fluconazole given intestinal failure on TPN. No suspicion for deep-seated infection after extensive workup. Patient's PICC line was replaced and OPAT orders are being requested. Patient was scheduled for dilated ophthalmological examination in one week. You have now unlocked the code which you will need to sign OPAT orders.

Remember the code

216

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Completed

Completed

Completed

OPAT

What is the patient's stop date for micafungin?

9/28/23

9/22/23

9/24/23

9/24

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