Candidiasis

OVERVIEW

  • diagnosis and treatment of candidiasis is a contentious issue
  • invasive candidiasis is difficult to diagnose
  • Over 150 species of Candida (a yeast), few are pathogens
  • Pathogens include: C. albicans, C. tropicalis, C. glabrata, C. krusei, C. parapsilosis, C. dubliniensis, and C. lusitaniae.

Invasive if found in:

(1) blood culture
(2) found in a sterile site
(3) cultured from two non-contiguous sites
(4) identified species is a non-commensal
(5) cultured from tissue or burn wound biopsy

RISK FACTORS

  • colonisation by a Candida species
  • broad spectrum antibiotic cover
  • CVL
  • Hickman lines
  • haemodialysis
  • recent abdominal surgery
  • GI tract perforation
  • TPN

HISTORY

  • unexplained fever (though fever is an unreliable sign of fungal infections)
  • sepsis syndrome
  • deterioration in the presence of immunocompromise
  • Candida cultured from: vascular catheter, colonisation of bladder, respiratory tract, wounds, intraperitoneal cavity

EXAMINATION

  • candida – oral, genital, retina, skin creases
  • line sites
  • endoscopy

COMPLICATIONS

  • liver abscess
  • splenic abscess
  • endocarditis
  • retinopathy
  • osteomyelitis
  • systemic microabscesses

INVESTIGATIONS

  • BAL
  • blood culture positive for candida (treat)
  • cultured from a sterile site (ie. aspiration of an abscess (hepatic)) -> treat
  • serological testing has a low specificity

MANAGEMENT

  • Resuscitation
  • Treat the cause (source control) – remove lines, foreign bodies, drain abscesses
  • Improve immunocompetence – reduce steroids and other immunosuppressants, improve nutrition
  • Reduce colonisation load – oral anti-fungal, bladder washout

Broad spectrum anti-fungal (IV):

  • caspofungin – 70mg LD -> 50mg Q24 hrly – GI upset, myalgia, increased LFTs (first line for invasive candidiasis)
  • amphotericin B – 0.5-1mg/kg Q24 hrly – nephro and hepatotoxic, blood dyscrasias
  • fluconazole – 10mg/kg IV daily (for proven albicans; only drug that achieves high urine concentrations)
  • voriconazole – 6mg/kg Q12hrly for 24 hrs (LD) -> 4mg/kg Q12hrly – transient visual disturbance, GI upset, fever, rash
  • itraconazole – 200mg Q12 hrly for 4 doses -> 200mg Q24 hrly

PROPHYLAXIS

Prophylaxis with Fluconazole

Arguments For

  • reduces invasive fungal infections
  • reduces total mortality across a broad range of clinical settings in non-neutropenic critically ill patients on systematic review
  • achieves good concentrations in the urine

Arguments Against

  • resistance formation
  • drug interaction with fluconazole
  • hepatotoxicity
  • certain Candida species are resistant to fluconazole (e.g. glabrata, krusei) as are other fungi (e.g. Aspergillus)

References and Links

  • Andes DR, et al; Mycoses Study Group. Impact of treatment strategy on outcomes in patients with candidemia and other forms of invasive candidiasis: a patient-level quantitative review of randomized trials. Clin Infect Dis. 2012 Apr;54(8):1110-22. PMID: 22412055.
  • Bassetti M, Mikulska M, Viscoli C. Bench-to-bedside review: therapeutic management of invasive candidiasis in the intensive care unit. Crit Care. 2010;14(6):244. PMC3220045.
  • Mora-Duarte J, Betts R, Rotstein C, Colombo AL, Thompson-Moya L, Smietana J, Lupinacci R, Sable C, Kartsonis N, Perfect J; Caspofungin Invasive Candidiasis Study Group. Comparison of caspofungin and amphotericin B for invasive candidiasis. N Engl J Med. 2002 Dec 19;347(25):2020-9. PMID: 12490683. [Free Fulltext]
  • Reboli AC, et al; Anidulafungin Study Group. Anidulafungin versus fluconazole for invasive candidiasis. N Engl J Med. 2007 Jun 14;356(24):2472-82. PMID: 17568028.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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