A 34-year-old man comes to the emergency department due to 2 days of fever, chills, and drenching sweats. He has had no sore throat, cough, shortness of breath, chest pain, or dysuria. The patient has a history of Crohn disease and recently underwent abdominal surgery to remove a bowel stricture. The postoperative course was complicated by an enterocutaneous fistula, which has been treated over the past 6 weeks with antitumor necrosis factor therapy. This treatment has reduced the amount of drainage from the fistula. He has had no recent abdominal pain or diarrhea. The patient takes nothing by mouth and receives daily total parenteral nutrition. He has no other medical problems and does not use tobacco, alcohol, or illicit drugs.
Temperature is 38.3 C (101 F) , blood pressure is 110/60 mm Hg, pulse is 112/min, and respirations are 18/min. The patient is ill-appearing and diaphoretic. The lungs are clear to auscultation. Cardiac examination reveals tachycardia but is otherwise unremarkable. The abdomen is soft and nontender with clear discharge from the infraumbilical fistula site. The right upper arm peripherally inserted central catheter site has no erythema or tenderness.
Leukocyte count is 18,000/mm³, and serum creatinine is 0.9 mg/dL. Chest x-ray reveals no infiltrates. Urinalysis is normal. Blood cultures are obtained, and empiric broad-spectrum intravenous antibiotics are initiated.
Within the next 24 hours, both sets of blood cultures grow budding yeast.
Which of the following is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

This patient with budding yeasts on blood cultures likely has candidemia, a common hospital-acquired infection that is frequently linked to central venous catheters, total parenteral nutrition, and immunocompromised states (eg, neutropenia). Clinical manifestations are myriad and range from mild fever to full-blown sepsis with or without end-organ involvement (eg, chorioretinitis, endocarditis, meningitis). Blood cultures are the gold standard for diagnosis, but sensitivity is low (~50%) so serum markers (eg, beta-D-glucan) and/or biopsy with histology are sometimes required. budding yeasts The cornerstone of treatment for candidemia is: Central venous catheter removal - catheter removal speeds clearance of candidemia and reduces mortality rates; it should be performed when feasible (eg, alternate access is available)Empiric antifungal treatment - echinocandins such as caspofungin are first-line therapy due to excellent coverage against the most common infective species including Candida albicans, C glabrata, C tropicalis, C parapsilosis, and C krusei. Central venous catheter removal - catheter removal speeds clearance of candidemia and reduces mortality rates; it should be performed when feasible (eg, alternate access is available) Empiric antifungal treatment - echinocandins such as caspofungin are first-line therapy due to excellent coverage against the most common infective species including Candida albicans, C glabrata, C tropicalis, C parapsilosis, and C krusei. All patients with candidemia should also undergo ophthalmologic examination to evaluate for endophthalmitis. (Choice A) Although fluconazole has excellent efficacy against C albicans, it does not adequately cover many strains of C glabrata and C krusei. As such, azoles are not generally used as a first-line empiric therapy for candidemia. Changing the catheter via guidewire increases the risk of septic emboli and may result in inoculation of the new catheter. (Choice B) The catheter should be removed if possible. Liposomal amphotericin B is considered a second-line agent for candidemia due to a greater risk of side effects (when compared to echinocandins). (Choice C) Catheter removal without antifungal treatment is associated with high mortality rates. Treatment should not be delayed for species and susceptibility results; this patient requires the prompt initiation of antifungal therapy. (Choice E) Gram stain evidence of budding yeasts on blood cultures should never be considered a contaminant. There is no need to repeat blood cultures; antifungal treatment should be initiated. Educational objective: Candidemia is a common hospital-acquired infection and usually occurs in the setting of a central venous catheter, total parenteral nutrition, and/or an immunocompromised state (eg, neutropenia). The cornerstone of treatment is catheter removal and empiric antifungal therapy with an echinocandin (eg, caspofungin). Candida in blood cultures should never be considered a contaminant. __________ References: Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/19191635) Current treatment strategies for disseminated candidiasis. (http://www.ncbi.nlm.nih.gov/pubmed/16355336)

A 34-Year-Old Man Comes to the Emergency Department Due to 2