Contentious issue difficult to diagnose



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Candidiasis

2/9/10


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- contentious issue

- difficult to diagnose

- organisms: albicans, topicalis, krusie, glabrate, lusitanae, parasilopsis


- invasive if found in:
(1) blood

  1. found in a sterile site

  2. cultured from two non-continguous sites

  3. identified species is a non-commensal

  4. 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

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)



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