PL. Invasive Fungal Infections. In: DiPiro, JT, Talbert RL, Yee
GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic
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- Yeasts that exist primarily as small, unicellular, thin-walled,
ovoid cells that reproduce by budding.
- 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.
- Generally acquired via the GI tract, although organisms
may also enter bloodstream via indwelling IV catheters.
- 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
- Antifungal prophylaxis with fluconazole in
patients with neutropenia unresponsive to antibiotics
- Patients undergoing hematopoietic stem cell transplantation
- Immunosuppressed patients
or hematologic malignancies
- Immunodeficiency diseases
- Immunosuppressive therapy with
- Antineoplastic agents
- Broad-spectrum antimicrobial agents
- Risk factors for ICU patients:
- Central venous
- Total parenteral nutrition
- Receipt of multiple antibiotics
- Extensive surgery and burns
- Renal failure and hemodialysis
- Mechanical ventilation
- Prior fungal colonization
- Dissemination of C. albicans results
in infection in kidney, brain, myocardium, skin, eye, bone, and
- 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
Means of Confirmation
- 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.
- 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)
- Computed tomograpy (CT) and ultrasonography (US) have
proved useful in confirming hepatosplenic candidiasis.
- Imaging studies performed during neutropenic phase are often
- Dilated fundoscopic examination to exclude candidal endophthalmitis
- Resolution of signs and symptoms of infection
- Cure infection.
- 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.
- Consider removing all existing central venous catheters
if patient has intact immune system.
- Treatment guided by:
- Knowledge of infecting
- Clinical status of patient
- Susceptibility of infecting isolate, when known
- History of previous antifungal therapy
- Continue ...