Thread by @TxID_Edu

1/18

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

2/

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

www-nejm-org.proxy1.library.jhu.edu/doi/pdf/10.105…

3/

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

4/

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

…k-springer-com.proxy1.library.jhu.edu/content/pdf/10…

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

www-jstor-org.proxy1.library.jhu.edu/stable/pdf/448…

6/

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 😰😰

7/

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

8/

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 to⬇️time to results, 3-5 hrs

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

ncbi.nlm.nih.gov/pubmed/31613367

10/

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

11/

@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

academic.oup.com/cid/article/62…

@DrPappasID 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 clinicalfungi.org

@DrPappasID 13/

#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 clinicalfungi.org

@DrPappasID 14/

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

@DrPappasID @andreaprinzi @Ahmed_HBabiker @richdavisphd @colleenkraftmd 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!💥

@CDCgov released description below!

academic.oup.com/mmy/advance-ar…

@DrPappasID @andreaprinzi @Ahmed_HBabiker @richdavisphd @colleenkraftmd @CDCgov 16/

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?

@DrPappasID @andreaprinzi @Ahmed_HBabiker @richdavisphd @colleenkraftmd @CDCgov 17/

@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

ncbi.nlm.nih.gov/pubmed/31562024

@DrPappasID @andreaprinzi @Ahmed_HBabiker @richdavisphd @colleenkraftmd @CDCgov @cmejiachew @FungalDoc @TheLancetInfDis 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