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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Construct a prudent empiric antifungal regimen for a patient with candidemia.

  • Determine situations to use echinocandins for invasive Candida infections.

  • Discuss how the identification of non-albicans Candida species can influence antifungal selection.

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PATIENT PRESENTATION

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Chief Complaint

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“I am burning up and feel like I have the flu.”

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HPI

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August Hops is a 50-year-old man who has been experiencing fever and chills and has not been feeling well over the past 4 days. He was admitted to our hospital yesterday. He was at home receiving home therapy with daptomycin 700 mg IV once daily (day 12 of a 14-day course) via PICC line for MRSA bacteremia, which he developed after having an appendectomy at an outside community hospital about a month ago. During that hospitalization, he also received a course of piperacillin–tazobactam for his appendicitis. His postoperative stay was complicated by a surgical site infection and MRSA bacteremia. He had his catheter removed at that time and was started on vancomycin, until he developed a rash and possible neutropenia. He was then switched to (and eventually sent home on) daptomycin. Prior to being discharged from the outside hospital, Mr Hops also received 7 days of fluconazole 200 mg PO daily for a urine sample from a Foley catheter that grew 100,000 colonies/mL of C. glabrata. He never grew Candida from any other site.

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A set of blood cultures was drawn on this admission to our hospital and is showing no growth at 24 hours. His surgical site does not look infected. His PICC line was removed, and blood and urine cultures were drawn. Piperacillin–tazobactam was added to the daptomycin empirically on admission.

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PMH

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  • GERD

  • Hyperlipidemia

  • HTN

  • Chronic knee pain (bilateral)

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PSH

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  • S/P hernia repair

  • S/P appendectomy 1 month ago

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FH

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Father died of CHF, mother still alive with no major medical problems

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SH

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He is the brewmaster at the local brewery. Married, has four adult children. Denies smoking or excessive ethanol use.

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Home Meds

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  • Omeprazole 40 mg PO once daily

  • Simvastatin 40 mg PO once daily

  • Metoprolol XL 50 mg PO once daily

  • Ibuprofen 600 mg PO TID PRN

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All

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Vancomycin—reaction: neutropenia and rash.

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Physical Examination

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Gen
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Patient is a 50-year-old Caucasian man who is resting somewhat comfortably in bed. Weight: 125 kg; height: 5′11″.

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VS
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BP 130/85 mm Hg, P 70 bpm, RR 20, T 38.5°C, O2 sat 97

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Skin
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