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Source: Carver PL. Invasive Fungal Infections. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th edition. http://accesspharmacy.com/content.aspx?aID=8005657. Accessed June 24, 2012.

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  • Yeasts that exist primarily as small, unicellular, thin-walled, ovoid cells that reproduce by budding.

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  • Eight species of Candida regarded as clinically important pathogens in human disease: C. albicans, C. tropicalis, C. parapsilosis, C. krusei, C. stellatoidea, C. guilliermondii, C. lusitaniae, and C. glabrata.

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  • Generally acquired via the GI tract, although organisms may also enter bloodstream via indwelling IV catheters.

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  • Incidence of fungal infections caused by Candida species has increased substantially in past three decades.
    • Fourth most common cause of bloodstream infections in ICU patients

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  • Antifungal prophylaxis with fluconazole in
    • Febrile patients with neutropenia unresponsive to antibiotics
    • Patients undergoing hematopoietic stem cell transplantation

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  • Immunosuppressed patients
    • Lymphoreticular or hematologic malignancies
    • Diabetes
    • Immunodeficiency diseases
    • Immunosuppressive therapy with
      • High-dose corticosteroids
      • Immunosuppressants
      • Antineoplastic agents
      • Broad-spectrum antimicrobial agents
  • Risk factors for ICU patients:
    • Central venous catheters
    • Total parenteral nutrition
    • Receipt of multiple antibiotics
    • Extensive surgery and burns
    • Renal failure and hemodialysis
    • Mechanical ventilation
    • Prior fungal colonization

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Signs and Symptoms

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  • Dissemination of C. albicans results in infection in kidney, brain, myocardium, skin, eye, bone, and joints.
  • Several distinct presentations of disseminated C. albicans have been recognized:
    • Acute onset of fever, tachycardia, tachypnea, and occasionally chills or hypotension (similar to bacterial sepsis)
    • Intermittent fevers
    • Progressive deterioration with or without fever
    • Hepatosplenic candidiasis manifested only as fever while patient is neutropenic

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Means of Confirmation and Diagnosis

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  • No test has demonstrated reliable accuracy in clinical setting for diagnosis of disseminated Candida infection.
  • Fluorescence in situ hybridization has excellent sensitivity (99–100%) and specificity (100%) in identification of C. albicans from blood cultures.

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Laboratory Tests

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  • Blood cultures
    • Positive in only 25–45% of neutropenic patients with disseminated candidiasis at autopsy
    • Fluorescence in situ
  • Susceptibility testing if available
  • Complete blood count (CBC)

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Imaging

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  • Computed tomograpy (CT) and ultrasonography (US) have proved useful in confirming hepatosplenic candidiasis.
  • Imaging studies performed during neutropenic phase are often normal.

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Diagnostic Procedures

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  • Dilated fundoscopic examination to exclude candidal endophthalmitis

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Differential Diagnosis

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  • Resolution of signs and symptoms of infection
  • Cure infection.

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  • Early recognition and treatment of positive blood cultures critical for positive outcome.
    • Increased mortality if initiation of empiric antifungal treatment delayed >12 hours after obtaining positive blood sample.

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  • Consider removing all existing central venous catheters if patient has intact immune system.

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  • Treatment guided by:
    • Knowledge of infecting species
    • Clinical status of patient
    • Susceptibility of infecting isolate, when known
    • History of previous antifungal therapy
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