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Critical Care Medicine

Answer 2
  1. Remove, culture, and replace all vascular catheters and begin IV amphotericin. The risk factors for Candida intravascular infection include use of broad-spectrum antibiotics, total parenteral nutrition, and immunosuppressive therapy. Because a single positive blood culture is highly predictive of systemic candida infection, it should never be considered a contaminant. The initial treatment of Candida infections includes removal of all possible foci of infection, including removal of intravascular lines. Candidemia may resolve spontaneously after removal of intravascular catheters. However, increasing evidence suggests that metastatic foci of infection may develop in some patients even after catheter removal and may manifest as endophthalmitis, endocarditis, arthritis, or meningitis. Therefore, all critically ill patients with candidemia should be regarded as having systemic infection and should be treated accordingly.4 Fluconazole and amphotericin demonstrate similar effectiveness in treating candidemia in patients without neutropenia and without major immunodeficiency.5,6 However, both in vitro and clinical data have demonstrated C. krusei to be intrinsically resistant to fluconazole. Prolonged bladder catheterization in the critically ill patient is often accompanied by the appearance of candiduria. Candiduria usually reflects catheter colonization; however, rarely, Candida species may cause cystitis and/or retrograde renal parenchymal infection. The management of asymptomatic candiduria in the catheterized patient, in whom no suspicion of renal candidiasis or renal obstruction exists, requires change of the indwelling catheter only, followed by observation. No data suggest that amphotericin B bladder irrigations prevent infections in colonized patients.

    4 Fisher JF, Newman CL, Sobel JD: Yeast in the urine: solutions for a budding problem. Clin Infect Dis 1995;20:183-189.

    5 Rex JH, Bennett JE, Sugar AM, et al: A randomized trial comparing fluconazole with amphotericin B for the treatment of candidemia in patients without neutropenia. N Engl J Med 1994;331:1325-1330.

    6 Rex JH, Pfaller MA, Barry AL, et al: Antifungal susceptibility testing of isolates from a randomized, multicenter trial of fluconazole versus amphotericin B as treatment of non-neutropenic patients with candidemia. Antimicrob Agents Chemother 1995;39:40-44.

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