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Invasive candidiasis

Background

Overview

Definition
Invasive candidiasis refers to bloodstream infection (candidemia) caused by Candida species that can lead to deep-seated infections including intra-abdominal abscess, peritonitis, and osteomyelitis.
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Pathophysiology
Invasive candidiasis is most frequently caused by C. albicans. Candidemia pathways include long-term use of antibiotics, gastrointestinal and cutaneous perforation (chemotherapy, gastric surgery, venous catheters), and immunosuppressive medication.
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Epidemiology
The incidence of invasive candidiasis in the US is estimated at 8 per 100,000 population per year, with peak rates at the extremes of age. Half of all invasive candidiasis cases occur in the ICU setting.
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Disease course
Clinical manifestations include unexplained fever nonresponsive to antibacterial treatment. Complications of candidemia can lead to ocular involvement (choroiditis, retinitis, endophthalmitis, and blindness), abdominal cavity (abdominal abscess, pancreatitis, peritonitis), bone (osteomyelitis, spondylodiscitis), brain (brain abscess, meningoencephalitis), heart (endocarditis), kidneys (candiduria, pyelonephritis, pyonephrosis, renal abscess), liver and spleen (chronic disseminated candidiasis, focal abscess), and lung (focal abscess). The disease decreases the QoL.
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Prognosis and risk of recurrence
Invasive candidiasis in the ICU setting is associated with a high mortality rate of 35-80%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of invasive candidiasis are prepared by our editorial team based on guidelines from the European Society of Intensive Care Medicine (ESICM/ESCMID 2019) and the Infectious Diseases Society of America (IDSA 2016). ...
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Diagnostic investigations

Fungal culture: as per IDSA 2016 guidelines, obtain serial blood cultures (every day or every other day) in patients under treatment for candidemia, in order to establish the time point at which candidemia has been cleared.
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  • Antifungal susceptibility testing

  • Ophthalmological examination

Medical management

Antifungal therapy, echinocandins: as per IDSA 2016 guidelines, administer any of the following echinocandins as initial therapy in patients with invasive candidiasis:
Situation
Guidance
Caspofungin
Loading dose 70 mg, then 50 mg daily
Micafungin
100 mg daily
Anidulafungin
Loading dose 200 mg, then 100 mg daily
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  • Antifungal therapy (triazoles)

  • Antifungal therapy (amphotericin)

  • Step-down therapy

  • Duration of therapy

Therapeutic procedures

Catheter removal: as per IDSA 2016 guidelines, remove central venous catheters as early as possible in patients with candidemia, when the source is presumed to be the central venous catheter and the catheter can be removed safely.
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  • Granulocyte transfusion

  • Abdominal drainage/debridement

Specific circumstances

Neonatal patients, prophylaxis in NICU: as per IDSA 2016 guidelines, administer IV or PO fluconazole prophylaxis, 3-6 mg/kg twice weekly for 6 weeks, in neonates with birth weights < 1,000 g in nurseries with high rates (> 10%) of invasive candidiasis.
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  • Neonatal patients (invasive candidiasis and candidemia)

  • Neonatal patients (CNS candidiasis)

  • Critically ill patients

  • Patients with neutropenia

  • Patients with esophageal candidiasis

  • Patients with chronic disseminated candidiasis

  • Patients with intra-abdominal candidiasis

  • Patients with respiratory tract candidiasis

  • Patients with cardiovascular system infection

  • Patients with CNS candidiasis

  • Patients with osteoarticular candidiasis

  • Patients with endophthalmitis

Preventative measures

Primary prevention in ICU patients
As per IDSA 2016 guidelines:
Consider administering prophylactic fluconazole (12 mg/kg loading dose, then 6 mg/kg daily), in high-risk adult patients admitted to the ICU with a high rate of invasive candidiasis.
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Consider performing daily chlorhexidine bathing in patients admitted to the ICU, to decrease the incidence of bloodstream infections including candidemia.
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