Thread by @TxID_Edu, 1/18I bet you are wondering, what's all the fuss with #candidemia? Why [...]

1/18

I bet you are wondering, what& #39;s all the fuss with #candidemia? Why do we care? How to diagnose? How to treat?

Get ready for a thanksgiving treat!

Inspired by @DxRxEdu

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In the US, invasive candidiasis is the most common fungal infection in hospitalized patients (4th most common infection overall)

1. C. diff
2. Staph aureus
3. E. Coli
4. Candida

https://www-nejm-org.proxy1.library.jhu.edu/doi/pdf/10.1056/NEJMoa1801550?articleTools=true">https://www-nejm-org.proxy1.library.jhu.edu/doi/pdf/1...

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Which of the following is a risk factor for developing #candidemia?

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Here is a table summarizing the risk factors!

Some would include end-stage cirrhosis.

I feel that for some of these risk factors, you need more than one to be considered at increased risk, such as central lines, broad abx, colonization, etc

…https://link-springer-com.proxy1.library.jhu.edu/content/pdf/10.1007%2Fs12281-019-00367-1.pdf">https://link-springer-com.proxy1.library.jhu.edu/content/p...

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There are no specific signs/symptoms to point us in the right direction. We have to think about the RF above and realize when a patient is not improving.

Mortality

https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">2x with 12-24 hour delay in therapy

https://abs.twimg.com/emoji/v2/... draggable="false" alt="🤯" title="Explodierender Kopf" aria-label="Emoji: Explodierender Kopf">
(table w/ fluc, more to come on therapy)

https://www-jstor-org.proxy1.library.jhu.edu/stable/pdf/4484866.pdf?refreqid=excelsior%3A961adc4cceaa456aeead347c67e814eb">https://www-jstor-org.proxy1.library.jhu.edu/stable/pd...

5/There are no specific signs/symptoms to point us in the right direction. We have to think about the RF above and realize when a patient is not improving.Mortality https://abs.twimg.com/emoji/v2/... draggable=

2x with 12-24 hour delay in therapy https://abs.twimg.com/emoji/v2/... draggable="false" alt="🤯" title="Explodierender Kopf" aria-label="Emoji: Explodierender Kopf">(table w/ fluc, more to come on therapy) https://www-jstor-org.proxy1.library.jhu.edu/stable/pd..." title="5/There are no specific signs/symptoms to point us in the right direction. We have to think about the RF above and realize when a patient is not improving.Mortality https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">2x with 12-24 hour delay in therapy https://abs.twimg.com/emoji/v2/... draggable="false" alt="🤯" title="Explodierender Kopf" aria-label="Emoji: Explodierender Kopf">(table w/ fluc, more to come on therapy) https://www-jstor-org.proxy1.library.jhu.edu/stable/pd..." class="img-responsive" style="max-width:100%;"/>

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How to diagnose?

We should definitely be sending blood cultures (try for larger volumes if possible). Problem is that overall sensitivity is close to 50%

https://abs.twimg.com/emoji/v2/... draggable="false" alt="😰" title="Gesicht mit offenem Mund und Angstschweiß" aria-label="Emoji: Gesicht mit offenem Mund und Angstschweiß">

Median time to positivity is 2-3 days!! Even more

https://abs.twimg.com/emoji/v2/... draggable="false" alt="😰" title="Gesicht mit offenem Mund und Angstschweiß" aria-label="Emoji: Gesicht mit offenem Mund und Angstschweiß">

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Should we be using beta-d-glucan ( #BDG) to aid in the diagnosis of candidemia?
@GermHunterMD @ClancyNeil @DocWoc71 @ElliTheelPhD

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It can be a difficult question

Depending on the BDG assay, the patient population, and which studies you look at, sens/spec can range in 80s

In my mind, the problem is the false-positivity (table)

Some ICUs have been using it to discontinue antifungals if BDG is negative

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What about T2Candida?
- T2 magnetic resonance to detect 5 sp (albicans, glabrata, tropicalis, parapsilosis, krusei)-appealing due to

https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬇️" title="Pfeil nach unten" aria-label="Emoji: Pfeil nach unten">time to results, 3-5 hrs

Recent study, 68% candidemics +T2 test at day 0,

https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">94% with serial testing @martinhoenigl https://www.ncbi.nlm.nih.gov/pubmed/31613367 ">https://www.ncbi.nlm.nih.gov/pubmed/31...

T2Candida magnetic resonance in patients with invasive candidiasis: Strengths and limitations -...

T2Candida enables detection of five Candida species in whole blood within approximately 5 hours. Routinely drawn EDTA blood samples were prospectively stored and tested with T2Candida in patients...

https://www.ncbi.nlm.nih.gov/pubmed/31613367

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So, you get called in the morning because blood cultures sent from yesterday are now growing Candida sp, what do you start empirically?

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@DrPappasID and others in the IDSA 2016 guidelines recommend an #echinocandin as first line.

Could use fluconazole if the patient is not ill or unlikely to have resistant organism, but that is hard to tell initially

https://academic.oup.com/cid/article/62/4/e1/2462830">https://academic.oup.com/cid/artic...

12/

#IDDailyPearl for some of the Candida
- #albicans- most common
--can use fluc or echinocandin for bloodstream, may prefer one depending on clinical situation

- #glabrata- many are resistant to fluc
--seen more in elderly & cancer/SOT

images from http://www.clinicalfungi.org/ ">https://www.clinicalfungi.org/">...

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#IDDailyPearl
- #parapsilosis- biofilm on central lines
--can have higher MICs to echinocandins

- #tropicalis-

https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">freq in heme malig & stem cell tx

- #krusei-

https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">freq in immunodef & prolonged azole therapy --intrinsically resistant to fluc

images from http://www.clinicalfungi.org/ ">https://www.clinicalfungi.org/">...

13/ #IDDailyPearl - #parapsilosis- biofilm on central lines--can have higher MICs to echinocandins- #tropicalis-https://abs.twimg.com/emoji/v2/... draggable=

freq in heme malig & stem cell tx- #krusei-https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">freq in immunodef & prolonged azole therapy --intrinsically resistant to flucimages from https://www.clinicalfungi.org/">..." title="13/ #IDDailyPearl - #parapsilosis- biofilm on central lines--can have higher MICs to echinocandins- #tropicalis-https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">freq in heme malig & stem cell tx- #krusei-https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Pfeil nach oben" aria-label="Emoji: Pfeil nach oben">freq in immunodef & prolonged azole therapy --intrinsically resistant to flucimages from https://www.clinicalfungi.org/">...">

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I bet @andreaprinzi @Ahmed_HBabiker @richdavisphd @colleenkraftmd can provide more beautiful pictures and descriptions of the above!

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#IDDailyPearl
- #auris- lots of resistance...but does this confer increased mortality?

Several studies show NO increased mortality when compared to non-candida auris candidemia, including one published today!

https://abs.twimg.com/emoji/v2/... draggable="false" alt="💥" title="Symbol für eine Kollision" aria-label="Emoji: Symbol für eine Kollision">

@CDCgov released description below!

https://academic.oup.com/mmy/advance-article-abstract/doi/10.1093/mmy/myz112/5644126?redirectedFrom=PDF">https://academic.oup.com/mmy/advan...

15/ #IDDailyPearl - #auris- lots of resistance...but does this confer increased mortality? Several studies show NO increased mortality when compared to non-candida auris candidemia, including one published today!https://abs.twimg.com/emoji/v2/... draggable=

@CDCgov released description below! https://academic.oup.com/mmy/advan..." title="15/ #IDDailyPearl - #auris- lots of resistance...but does this confer increased mortality? Several studies show NO increased mortality when compared to non-candida auris candidemia, including one published today!https://abs.twimg.com/emoji/v2/... draggable="false" alt="💥" title="Symbol für eine Kollision" aria-label="Emoji: Symbol für eine Kollision"> @CDCgov released description below! https://academic.oup.com/mmy/advan...">

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So, you get that call in the morning for candidemia. You know that time is of the essence - you start an echinocandin based on the IDSA guidelines you just read! Now, what do you do next to improve mortality?

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@cmejiachew and @FungalDoc showed in @TheLancetInfDis that an ID consult improves mortality through the use of evidence-based practice:
- ophtho exams
- TTEs
- central line removals
- appropriate duration of therapy

https://www.ncbi.nlm.nih.gov/pubmed/31562024 ">https://www.ncbi.nlm.nih.gov/pubmed/31...

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To review:
- candidal infections are common in hospitalized patients
- there are RFs for candidemia (broad abx, ICU, central lines)
- high mortality & doubles quickly without therapy
- get blood cx
- start echinocandin
- get ID consult

Thank you, happy thanksgiving everyone

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