Candidura, Candidemia and Candidal Endocarditis

1) Review Candiduria and Indications for treatment

Candiduria is extremely common and usually represents colonization, not true infection.
Main risk factor is presence of foley
Do not treat asymptomatic candiduria, unless 1) Neutropenic, or 2) Undergoing urological procedure (e.g. TURP).
However, if isolate candida from multiple sites (i.e. sputum and urine), in the appropriate clinical setting can be worrisome for disseminated candidiasis.
For symptomatic candiduria, best treatment is to remove foley. If that doesn't work, Fluconazole is drug of choice. Ampho B bladder washes are NOT recommended (high relapse rate, and associated with higher mortality vs fluconazole). Echinocandins do not reliably penetrate the urine.

2) Candidemia: Significance of blood cultures, Clinical Presentation and Workup, and Risk Factors

Blood cultures are insensitive for candidemia (as opposed to bacteremia - more sensitive). Classically, ~50% sensitive (but newer blood culture systems likely better than that).
NEVER DISREGARD CANDIDA IN THE BLOOD AS A CONTAMINANT. Believe it or not, a few times a year this happens. ALWAYS TREAT CANDIDEMIA AND WORK IT UP: i.e., find out why he is candidemic, look for complications (i.e. endophthalmitis, possibly endocarditis)
Clinical presentation can range from asymptomatic to septic shock - again, even if pt looks well, never disregard candida in the blood as contaminant!!
All pts with candidemia automatically warrant an ophtho consult for a dilated retinal exam to r/o endophthalmitis, which occurs in ~10-25% of cases. Significance of this is that if severe eye lesions are present, this warrants combination therapy (i.e. Amphoterecin + Flucytosine) and much longer course of therapy (> 6 weeks minimum).
Always dc and replace central lines in patients with candidemia

Risk Factors for Invasive Candidiasis - note that candida is part of the endogenous bowel flora, and also transmitted nosocomially on hands of health-care workers.

Central lines - Candida is the 4th most common cause of CVC infections
Broad spectrum antibiotics
TPN - fungi love the nutritious medium (esp C.parapsilosis)
Neutropenia, immunocompromised (often due to gut translocation)
IV drug abuse
Bowel surgery esp with anastomotic leaks

3) Review Antifungal Agents for Candidiasis.

Fluconazole - can be used for C.albicans, C.parapsilosis, and C. tropicalis. C.glabrata and C.krusei are resistant and increasingly common. Excellent PO bioavailability.
Echinocandins (Caspofungin, Micafungin, Anidulafungin) - work against virtually all strains, except potentially C.parapsilosis (higher MICs in vitro, but still usually responds clinically) --> drugs of choice for most pts (esp unstable pts) with candidemia
Amphoterecin B - works against most (not all) strains of Candida, but little advantage over echinocandins and much more toxic

4) Management of Candidal Endocarditis:

Medical: Per 2009 IDSA guidelines, warrants combination therapy with Amphoterecin B + Flucytosine, or Amphoterecin B + Echinocandin.
Surgical: Strong indication for valve replacement therapy, as very difficult to eradicate with antifungals alone.

** Other indications for surgery in endocarditis:
Class I: - New onset heart failure due to valvular dysfunction, or hemodynamic deterioration
            - Invasive complications: Perivalvular abscess, conduction abnormalities
            - Fungal endocarditis, or other highly resistant organisms
Class II:- Large (> 10 mm) vegetations
            - Recurrent systemic emboli while on appropriate antimicrobial therapy.

(Chanu Rhee MD, 7/23/10)