Organisms: Albicans, Topicalis, Krusie, Glabrate, Lusitanae, Parasilopsis

Candidiasis

2/9/10 PY Mindmaps

- contentious issue - difficult to diagnose - organisms: albicans, topicalis, krusie, glabrate, lusitanae, parasilopsis

- invasive if found in:

(1) blood (2) found in a sterile site (3) cultured from two non-continguous sites (4) identified species is a non-commensal (5) cultured from tissue or burn wound biopsy

HISTORY

- unexplained fever - sepsis syndrome - deterioration in the presence of the immunocompromised - candida cultured from: vascular catheterisation, colonisation of bladder, respiratory tract, wounds, intraperitoneal cavity

Risk Factors

- colonisation by a Candida species - broad spectrum antibiotic cover - Hickman lines - haemodialysis - recent abdominal surgery - GI tract perforation - CVL - TPN

EXAMINATION

- candida – oral, genital, retina - endoscopy

INVESTIGATIONS

- BAL - blood culture positive for candida (treat) - cultured from a sterile site (ie. aspiration of an abscess (hepatic)) -> treat - serological testing has a low specificity

Jeremy Fernando (2011) MANAGEMENT

Resuscitation Treat the cause – remove line, foreign bodies Drain abscesses Improve immunocompetence – reduce steroid, immunosuppressants, increase nutrition Reduce colonisation load – oral anti-fungal, bladder washout

Broad spectrum anti-fungal (IV):

- amphortericin B – 0.5-1mg/kg Q24 hrly – nephro and hepatotoxic, blood dyscrasias - caspafungin – 70mg LD -> 50mg Q24 hrly – GI upset, myalgias, increased LFT’s - voriconazole – 6mg/kg Q12hrly for 24 hrs (LD) -> 4mg/kg Q12hrly – transient visual disturbance, GI upset, fever, rash - itraconazole – 200mg Q12 hrly for 4 doses -> 200mg Q24 hrly - fluconazole – for proven albicans 10mg/kg IV daily

COMPLICATIONS

- liver abscess - splenic abscess - endocarditis - retinopathy

Prophylaxis with Fluconazole

Arguments For

- reduces invasive fungal infections - reduces total mortality across a broad range of clinical settings in non-neutropenic critically ill patients on systematic review

Arguments Against

- resistance formation - drug interaction with fluconazole - hepatotoxicity - certain species are resistant to fluconazole (glabrate, krusei, aspergillus)

Jeremy Fernando (2011)