A 38-year-old hospitalized man is evaluated for persistent fever. He has a history of paraplegia after spinal injury and was admitted 2 weeks ago due to septic shock from an infected sacral pressure ulcer. His condition improved with broad-spectrum antibiotics, intravenous fluids, vasopressors, and wound debridement, but he has been having recurrent fevers for the past 4 days. The patient also has a history of asthma and takes an inhaled glucocorticoid and bronchodilator. Temperature is 38.3 C (101 F), blood pressure is 120/80 mm Hg, and pulse is 96/min. Several white patches are present on the oral mucosa. There is a peripherally inserted central venous catheter in the right arm with mild tenderness but no surrounding erythema. The sacral pressure ulcer has pink granulation tissue with a mild amount of serosanguinous fluid. A chronic indwelling urinary catheter is draining yellow-colored urine. Repeat blood cultures grow budding yeasts. Which of the following is the most likely source of the organism in this patient's blood culture?

Question

A 38-year-old hospitalized man is evaluated for persistent fever.  He has a history of paraplegia after spinal injury and was admitted 2 weeks ago due to septic shock from an infected sacral pressure ulcer.  His condition improved with broad-spectrum antibiotics, intravenous fluids, vasopressors, and wound debridement, but he has been having recurrent fevers for the past 4 days.  The patient also has a history of asthma and takes an inhaled glucocorticoid and bronchodilator.  Temperature is 38.3 C (101 F), blood pressure is 120/80 mm Hg, and pulse is 96/min.  Several white patches are present on the oral mucosa.  There is a peripherally inserted central venous catheter in the right arm with mild tenderness but no surrounding erythema.  The sacral pressure ulcer has pink granulation tissue with a mild amount of serosanguinous fluid.  A chronic indwelling urinary catheter is draining yellow-colored urine.  Repeat blood cultures grow budding yeasts.  Which of the following is the most likely source of the organism in this patient's blood culture?

Quizplus · Accepted Answer

Central venous catheters are the most common cause of nosocomial bloodstream infections as they create a direct pathway for colonized skin organisms to access the circulatory system. Coagulase-negative staphylococci and Staphylococcus aureus cause the majority of infections; however, Candida species are isolated in approximately 10% of cases. Candida is a budding yeast that frequently colonizes the skin, mucous membranes, and gastrointestinal tract of humans. Active infections are rare in healthy individuals and are usually limited to superficial structures (eg, vaginal candidiasis). However, patients with immunocompromise (eg, postchemotherapy) or intravascular catheter (especially in the intensive care unit setting) are at high risk for invasive disease. budding yeast Candida bloodstream infections may cause fever, sepsis, and/or multiorgan failure. Diagnosis is made primarily with blood cultures (or biopsy), but serum beta-D-glucan antigen can be used as a rapid indicator of possible infection. Treatment usually requires several weeks of intravenous antifungals. (Choice B) Candida in a blood culture should always prompt a search for a nidus of infection and should never be considered a contaminant. (Choice C) Indwelling urinary catheters, especially those obstructed by a fungus ball, may occasionally cause candidemia; however, this is a far less common source of infection than an intravascular catheter. (Choice D) This patient likely has oropharyngeal candidiasis (white mucosal plaques); however, mucous membrane infections are a rare cause of invasive disease. (Choice E) Pressure ulcers may cause bacteremia with a wide range of skin and fecal organisms; however, skin wounds are a rare cause of invasive candidal infections. Educational objective: Candidemia is common in patients hospitalized in the intensive care unit with intravascular catheters. Manifestations include fever, sepsis, and/or multiorgan failure. Blood cultures or biopsy are usually required for diagnosis. A positive blood culture for Candida should never be considered a contaminant. References: Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/26679628)

A 38-Year-Old Hospitalized Man Is Evaluated for Persistent Fever