Page 913 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

644 PART 5: Infectious Disorders

TABLE 70-1 Candida Species Causing Infection in ICU Patients TABLE 70-2 Risk factors for Candidemia and Invasive Candidiasis
Species Comments Medical/surgical Interventions
Dialysis
Candida albicans Most common species; susceptible to fluconazole; can treat Central venous catheters
with fluconazole or echinocandins
Broad-spectrum antibiotics
Candida glabrata Increasingly found in ICUs, especially those with heavy fluconazole Parenteral nutrition
use; MICs high and many isolates resistant to fluconazole; more Prior surgery, especially GI tract
common in older adults; echinocandins preferred treatment Mechanical ventilation
Candida parapsilosis More common in neonatal ICUs; susceptible to fluconazole; Gastric acid suppression
most common central venous catheter–associated species; Immunosuppressive therapy
low mortality rates; higher MICs to echinocandins; fluconazole ICU stay >7 days
preferred treatment Host factors
Candida tropicalis More common in cancer patients; susceptible to fluconazole; Neonates, especially low birth weight
high mortality rates Older adults
Candida krusei More common in cancer patients; resistant to fluconazole; Neutropenia
echinocandin preferred; high mortality rates Renal failure
Bowel perforation
Candida lusitaniae Uncommon species; resistant to amphotericin B; fluconazole Pancreatitis
preferred treatment Burn wounds
Candida guilliermondii Uncommon species; higher MICs to echinocandins; fluconazole Trauma
preferred treatment High APACHE II score
Candida dubliniensis Uncommon species; similar to C albicans; susceptible to fluconazole Candida colonization
MIC, minimum inhibitory concentration. APACHE II, acute physiology and chronic health evaluation.

States, others have few candidemias due to C glabrata. Most hospi- CLINICAL DISEASE CAUSED BY CANDIDA SPECIES
2,31
tals in South and Central America report very few cases of C glabrata
infection and many more infections due to C parapsilosis and Candida A variety of different organ systems can be involved with invasive can-
32
tropicalis. Additionally, several studies have confirmed that C glabrata didiasis (Table 70-3). Forms of candidiasis other than candidemia are
is an uncommon cause of infection in children, but becomes an increas- less well defined. A common problem that arises in the ICU is how to
ingly important pathogen in older adults. 25,29 Medical centers that treat determine invasive disease in the abdomen, the urinary tract, and the
many patients with hematological malignancies report higher rates of respiratory tract. The presence of Candida in cultures from these sites
isolation of C glabrata and Candida krusei. This is due, in part, to may reflect colonization, which is extremely common in these sites, or
33
increased use of fluconazole in these centers. 34 may be an indicator of invasive infection. These sites have a rank order
The prominent Candida species in many neonatal ICUs is C parap- for the likelihood of invasive candidiasis, with intra-abdominal infec-
silosis, and this organism is especially likely to colonize central venous tions being the most common, urinary tract infections the next most
catheters. 21,22 Candida tropicalis is prominently noted in cancer common, and respiratory tract infections, rare. Uncommon sites of
patients. Other species, such as Candida lusitaniae, Candida guillier- Candida infection, such as endocarditis, meningitis, and osteoarticular
9,33
mondii, and Candida dubliniensis, are uncommon causes of candidemia infections, will not be discussed here.
and invasive candidiasis. 35 ■
■ RISKS FACTORS FOR INVASIVE CANDIDIASIS Candidemia is simply defined as the presence of Candida species in the
CANDIDEMIA
The risk factors for invasive candidiasis are many and include extremes blood. It is the most studied syndrome caused by Candida because it is
of age, trauma, burns, high APACHE II score, recent abdominal sur-
gery, gastrointestinal tract perforation, pancreatitis, mechanical ven-
tilation, central venous catheters, parenteral nutrition, dialysis, and TABLE 70-3 Types of Systemic Illnesses Caused by Candida Species in ICU Patients
broad-spectrum antibiotic therapy 2,4,7,9,22,29,36-38 (Table 70-2). A large
prospective multicenter study in the United States that evaluated risks Common
for candidemia in over 4000 patients admitted to surgical ICUs found Candidemia
that prior surgery, acute renal failure, parenteral nutrition, and central Intra-abdominal infections
venous catheters were independently associated with increased risk for peritonitis
developing candidemia. Another multicenter study in Spain noted abscesses
22
that the independent risk factors for development of candidemia were cholangitis
sepsis, prior surgery, parenteral nutrition, and Candida colonization at Less common
multiple sites. 2 Urinary tract infections
The risks of infection with non-albicans Candida species include cystitis
those noted above for Candida in general, but also include prior pyelonephritis
exposure to antifungal agents. 27,28 For C glabrata, risk factors include fungus balls
older age, recent abdominal surgery, use of multiple antibiotics, and Endophthalmitis
receipt of parenteral nutrition. 29,30,38 Among cancer patients who had C Uncommon
tropicalis fungemia, the independent risk factors included leukemia and Endocarditis
prolonged neutropenia. Patients with C krusei candidemia have been Meningitis
39
noted to be more likely to have had prior exposure to antifungal agents, Osteoarticular infections
have a hematologic malignancy or a stem cell transplant, have neutrope- Rare
nia, and have been treated with corticosteroids. 33 Pneumonia

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