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I bet you are wondering, what'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

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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

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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 2x with 12-24 hour delay in therapy
(table w/ fluc, more to come on therapy)

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

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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%

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

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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

9/
What about T2Candida?
- T2 magnetic resonance to detect 5 sp (albicans, glabrata, tropicalis, parapsilosis, krusei)-appealing due totime to results, 3-5 hrs

Recent study, 68% candidemics +T2 test at day 0, 94% with serial testing @martinhoenigl 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

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/ 

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

- #tropicalis-freq in heme malig & stem cell tx

- #krusei-freq in immunodef & prolonged azole therapy --intrinsically resistant to fluc

images from http://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!

@CDCgov released description below!

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

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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 

18/

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