A 41-year-old previously healthy man is admitted to the hospital with 3 days of nausea, vomiting, and abdominal pain. He was found to have acute necrotizing pancreatitis due to alcohol use. His hospital course was complicated by hypotension requiring 8 L of intravenous fluids. He subsequently developed bilateral infiltrates and refractory hypoxemia requiring intubation and mechanical ventilation. While in the intensive care unit, he develops low-grade fevers and worsening hypoxemia requiring 100% FiO₂ and positive end-expiratory pressure of 12. Cultures are obtained and antibiotic coverage is broadened. His blood and urine cultures show no growth 48 hours later. However, sputum culture grows Candida species. Laboratory results are as follows: A repeat chest x-ray shows persistent bilateral infiltrates and new small bilateral pleural effusions. Which of the following is the most appropriate next step in managing this patient's positive sputum culture?

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Quizplus · Accepted Answer

Bronchial tree colonization with Candida species is common in critically ill patients receiving mechanical ventilation, but primary Candida pneumonia and invasive disease are rare. Candida pneumonia is usually not due to aspiration of oropharyngeal secretions but rather to hematogenous spread from disseminated candidiasis (eg, osteomyelitis, septic arthritis, or endocarditis). As a result, diagnosis of Candida pneumonia requires histopathological confirmation. Current guidelines do not recommend antifungal treatment or repeat cultures for immunocompetent patients with Candida from respiratory sputum or bronchoalveolar lavage unless they are immunocompromised (Choice D). Antifungal treatment is also reserved for immunocompetent patients with a primary Candida infection at another site who develop new pulmonary lesions suspicious for hematogenous spread (Choices A and B). Fluconazole is preferred for treating candidemia, but echinocandins (eg, micafungin) are recommended in patients with severe illness or recent azole exposure. (Choice E) Thoracentesis is not indicated in patients with small bilateral pleural effusions. Educational objective: Growth of Candida from respiratory secretions rarely indicates invasive candidiasis and should not be treated with antifungal therapy. __________ 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)

A 41-Year-Old Previously Healthy Man Is Admitted to the Hospital