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INVASIVE CANDIDIASIS

• Invasive fungal infection is mainly caused by candida species.

• Candidemia is the fourth most common cause of nosocomial blood stream infection.

• Main risk factors include use of broad spectrum antibacterial agents, use of central venous catheter, receipt of parenteral nutrition, receipt of renal replacement therapy, neutropenia, use of prosthetic valve and receipt of immunosuppresive agents.

• Invasive candidiasis comprises several conditions including candidemia, endocarditis, meningitis, endopthalmitis etc.

• Candida albicans remains the most common species isolated from patients for 44 - 71 % of disease.

• But recently epidemiological shift to non candida albican infection is increasing with common isolates being glabrata, paraspiliosis, tropicalis, krusei.

• Candida glabrata and krusei has intrinsic fluconazole resistance.

DIAGNOSIS

• Candida Score

• A candida score of >2.5 was assosciated with invasive fungal infection

Colonisation Index

• It is defined as the ratio of the number of distinct body sites colonized with genotypically identical strains of candida over the total number of sites tested.

• Average colonisation index is 0.4 for colonized patients & 0.7 for infected patients.

• 1,3 Beta glucan : They have a good negative predictive value. It may be false positive following colonisation, hemodialysis, albumin, plasma and Ig therapy, amoxiclav.

• Galtactomannan assay : It is negative in invasive candidiasis , positive in invasive aspergillosis.

• Germ tube test : Germ tube are present then the candida species is an C. albicans.

• FISH (Fluorescent in situ hybridisation) is new diagnostic method.

• Blood culture

MANAGEMENT

• Echinocandin is preferred in neutropenic & severe illness.

  • Caspofugin : Loading dose :70mg stat; then 50mg OD

  • Micafungin: 100mg OD

  • Anidulafungin Loading dose of 200mg , then 100mg daily

• Fluconazole are recommended in patients who are less critically ill or who has no recent exposure to azole.

  • Loading dose 6mg/kg for 2 doses, then 3-4 mg/kg 12 hr.

  • Voricanozole can be used as step down for selected case of candida krusei or voriconazole susceptible C. glabrata.

• Amphotericin B can be used as an alternative.

  • Amphotericin B deoxycholate : 0.5 -1.0mg/kg

  • Lipid formulation dose : 3-5mg/kg

• Recommended duration of therapy is for 2 weeks after documented clearance of candida from the blood stream.

• Intravenous catheter is strongly recommended to be removed.

Note

• In case of candida parapsilosis treatment with fluconazole is recommended.

• For infection with candida glabrata, an echinocandin is preferred.

Indication for Prophylaxsis

• Solid organ transplant

• High risk ICU patients

• Chemotherapy induced neutropenia

• Stem cell transplant recipients with neutropenia

Candida from respiratory secretions

• Candida pneumonia and candida lung abscess are very uncommon.

• Candida colonisation in critically ill patients on mechanical ventilation is common.

• Lungs have innate defense mechanism against candida species.

• Positive culture is usually a contamination and should not be treated.\

Candiduria

• Asymptomatic candiduria should not be treated, simple measures like removing the indwelling catheter is enough.

• Asymptomatic high risk (neutropenic patients, infants with low birth weight) candidiuria patients undergoing urologic intervention is treated with fluconazole 200 -400mg or AmBd at a dosage of 0.3 – 0.6mg/kg.

• Cystitis : Fluconazole 200mg OD for 2 weeks or AmBd : 0.3 – 0.6 mg/kg for 7 days.

• Pyelonephritis: Fluconazole 200- 400mg daily for 2 weeks or AmB d 0.5 -0.7mg/kg daily for 2 weeks in fluconazole resistance.

• For fungal ball surgical intervention is required.

• Bladder irrigation with amphotericin B resolves candiduria in >90% of patients but has a high relapse rate hence not recommended.

Vaginal Candidiasis

• Suspected clinically when a women complains of pruritus, irritation, vaginal soreness, external dysuria & dyspareunia. Signs include vulvar edema, erythema, excoriation, fissures and white thick curd like vaginal discharge. But these all non specific.

• A single dose of fluconazole 150mg is recommended for uncomplicated candida.

• Topical agents are also effective.

  • Clotrimazole 1% cream 5gm intravaginally for 7-14 days

Complicated VVC: Severe or recurrent disease, infection due to candida species other than C. albicans & or VVC in an abnormal host.

• Clotrimazole 100mg vaginal tablet for 7 days

• Fluconazole 150mg every 72h * 3 doses, then 1 per week for 6 months.

CNS Candidiasis

• Amphotericin B Lipid formulation : 3-5mg/kg with or without flucytosine 253g/kg * 4 times daily is recommended for initial several weeks.

• Fluconazole 400- 800mg daily as step down.

Oropharyngeal Candidiasis

• Clotrimazole troches 10mg 5 times daily

• For moderate to severe disease oral fluconazole 100-200mg for 7-14 days.

• If resistant consider other agents.

Candida endopthalmitis

• Candida endopthalmitis is definitively diagnosed by isolation of the organism from vitreous body by culture methods or histopathological identification of the organism.

• Amphotericin B 0.7-1mg/kg combined with flucytosine 25mg/kg 6thhrly for 4-6 weeks.

• Early surgical intervention with a partial vitrectomy is an important adjunct to antifungal therapy.

Updated on 27/3/2015

Reference :

• IDSA 2009 guidelines

• Diagnosis of invasive candidiasis in ICU ; Annals of intensive care springler journal

• The Washington Manual of Critical Care. Second Edition.