Fungemia

Background

• Systemic infection with a Candida species

Microbiology

• Candida albicans (46%)
• Candida glabrata (26%)
• Candida parapsilosis (16%)
• Candida tropicalis (8%)
• Candida krusei (3%)
• Candida auris (rare): growing concern for multidrug resistance
• Numbers based on https://doi.org/10.1086/599039

Risk Factors

• Hospital-onset
  • Multiple or long-term IV lines, central lines, etc.
  • Long-term and broad-spectrum antibiotic use, especially in ICU
  • Immunosuppression
  • Total parenteral nutrition
  • Acute kidney injury, especially requiring dialysis
  • Abdominal surgery
  • Gastrointestinal perforation
• Community-onset1
  • Hospitalization within the past month
  • HIV, malignancy, neutropenia, and diabetes similar to hospital-onset
  • Less immunosuppressive therapy, recent surgery, or central venous catheters than hospital-onset, but still risk factors

Clinical Manifestations

• Positive blood culture for a Candida species
• Fever
• Triad of bowel perforation, increase white cell count, and decreased platelets
• Ocular infections in 16%, which as primarily chorioretinitis, although endophthalmitis is possible
• Fungal endocarditis found in 8%
• In patients with community-onset candidemia and candiduria, many have fungal endocarditis

Prognosis

• Mortality of about 25%1

Investigations

• Blood cultures
• Blood count (increased WBCs, decreased platelets)
• Consider echo to rule out endocarditis

Management

• Never treat as a contaminant!
• Requires ophthalmology consult to rule out endophthalmitis, ideally around 1 week after positive cultures
• Repeat 1 to 2 blood cultures every 24 to 48 hours until negative (1 culture q24h in ESCMID guidelines)
• Antifungal therapy
  • First-line (stable patients): fluconazole if no risk factors for a resistant species
  • Alternative (resistance or septic): micafungin or another echinocandin
  • Alternative (last-line): amphotericin B
• Duration
  • No organ involvement: 14 days from first negative
  • Ocular infection: until resolution of ocular findings, often 4 to 6 weeks
  • Endocarditis: at least 6 weeks; see fungal endocarditis