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CHAPTER 70: Fungal Infections 643

• Kahn JO, Walker BD. Acute human immunodeficiency virus type
1 infection. N Engl J Med. 1998;339:33-39. • Removal of central venous catheters in patients with candidemia
leads to more rapid clearing of the organism from blood and
• Kaplan JE, Hanson D, Dworkin MS, et al. Epidemiology of human improved outcomes.
immunodeficiency virus-associated opportunistic infections in
the United States in the era of highly active antiretroviral therapy. • Prophylaxis against invasive candidiasis with fluconazole could be
Clin Infect Dis. 2000;30(suppl 1):S5-S14. considered in ICUs that have rates of candidemia that exceed 10%;
it should not be used in most ICUs.
• Panlilio AL, Cardo DM, Grohskopf LA, Heneine W, Ross CS.
Updated U.S. Public Health Service guidelines for the manage-
ment of occupational exposures to HIV and recommendations for
postexposure prophylaxis. MMWR Recomm Rep. 2005;54:1-17.
• Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of INTRODUCTION
adult HIV infection: 2012 recommendations of the International Invasive fungal infections are an increasingly prevalent problem in
Antiviral Society-USA panel. JAMA. 2012;308:387-402. hospitalized patients, especially those in intensive care units (ICU).
1-9
Candida species cause more than 90% of fungal infections in the ICU
setting. Candida species are the third most frequent cause of blood-
Acknowledgment: This work was supported in part by the National stream infections in ICUs in US hospitals and are responsible for 10%
1,4
Health and Research Development Programme, Health and Welfare, of nosocomial infections in some European ICUs. The reasons for
Ottawa, Canada, and the National Institutes of Health. the increase in invasive Candida infections in ICU patients include the
expanding numbers of immunocompromised patients, longer survival
REFERENCES in the ICU of patients who have multiple medical problems, increased
use of devices and invasive procedures that disrupt the host’s natural
Complete references available online at www.mhprofessional.com/hall barriers to infection, and the adverse effects of broad-spectrum antimi-
crobial agents on the normal human microbiota.
Far less frequent are infections due to Aspergillus species, but there

CHAPTER Fungal Infections are increasing reports of invasive aspergillosis in nonneutropenic
patients in the ICU.
10,11
Occasional patients who have endemic mycoses,
such as histoplasmosis and blastomycosis, cryptococcosis, or non-
Carol A. Kauffman
70 Aspergillus mold infections, such as mucormycosis, are cared for in the
ICU, but these infections will not be addressed in this chapter. The main
focus will be on invasive Candida infections.
EPIDEMIOLOGY OF FUNGAL INFECTIONS IN THE ICU
KEY POINTS
• Candida species are the third most frequent cause of bloodstream ■ SOURCES OF CANDIDA CAUSING INVASIVE INFECTION
infections in ICUs in US hospitals and are responsible for 10% of Candida species are part of the normal human microbiota. Most infec-
nosocomial infections in some European ICUs. tions are due to those strains of Candida that have colonized the gastro-
5,9
• Candida albicans is the most common cause of candidemia in ICU intestinal tract, genitourinary tract, or skin of the patient. Colonization
patients. In the last two decades in the United States, there has been with Candida is a prerequisite for subsequent infection except in those
a shift upward in the proportion of candidemias that are caused by rare circumstances in which exogenous introduction of Candida species
other Candida species, especially Candida glabrata. The prominent has occurred. 12,13 Disruption of the gastrointestinal mucosa, as occurs
Candida species in many neonatal ICUs is Candida parapsilosis. during surgery or with chemotherapy-induced ulcerations, in concert
• The risk factors for invasive candidiasis include extremes of age, with broad-spectrum antimicrobial agents, allows overgrowth of the
trauma, burns, high APACHE II score, recent abdominal surgery, patient’s own commensal Candida strains and subsequent egress to the
5,14
gastrointestinal tract perforation, pancreatitis, mechanical ventila- bloodstream. In addition, Candida that exists on the skin can enter
tion, central venous catheters, parenteral nutrition, dialysis, and the bloodstream directly by ingress along an indwelling intravenous
15
broad-spectrum antibiotic therapy. catheter. Less commonly, candidemia is due to Candida originating
• Candiduria is common in the ICU and is mostly related to the from the genitourinary tract, and then almost always in the setting of
obstruction. Rarely, if ever, are Candida species colonizing the oro-
16
presence of indwelling bladder catheters and broad-spectrum anti- pharynx responsible for invasive infection and candidemia. 17
microbial agents. The vast majority of patients who are candiduric Uncommonly, outbreaks of Candida infections have been linked to
are colonized, do not develop upper tract infection or candidemia, transmission from the hands of health care workers, especially those
and do not require treatment. who have onychomycosis or onycholysis or those who wear artificial
• All patients who have documented candidemia should have a nails. 12,18-20 Candida parapsilosis, the predominant species that colonizes
dilated eye examination by an ophthalmologist to determine hands, is the species most often associated with outbreaks, but other
whether metastatic infection is present in the eye. species have also been implicated. 21
• All patients with documented candidemia should be treated with
an antifungal agent. Prompt treatment of candidemia significantly ■ CANDIDA SPECIES CAUSING INVASIVE INFECTION
decreases the mortality rate, and delay for 24 hours or more after Candida albicans remains the most common cause of candidemia in
the blood culture is taken is associated with increased mortality. ICU patients 2,5,6,9,22 (Table 70-1). In the last two decades, increasing
• In an ICU in which C glabrata is a commonly isolated organism, numbers of ICUs in the United States have reported a shift upward in the
initial treatment should be with an echinocandin. If the ICU histor- proportion of candidemias that are caused by other Candida species. 22-28
ically has had few infections caused by C glabrata, initial treatment In some tertiary care centers, nearly 50% of candidemias now are caused
shoud be with fluconazole. After the organism has been identified, by non-albicans Candida species. The most prominent species to
28
therapy should be switched to the most appropriate agent. emerge in the United States is Candida glabrata. 5,22,29,30 Although many
hospitals in Europe report a picture similar to that seen in the United

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