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Infectious Diseases


Answer 1
  1. Remove the triple lumen catheter and initiate treatment with fluconazole. The patient has candidemia associated with an indwelling intravenous catheter. Candida albicans is the most common species associated with candidemia. The absence of signs of infection at the catheter site does not exclude a line-related infection. Neutropenia, immunosuppressive and anticancer therapy, prolonged antibiotic use, upper gastrointestinal surgery, parenteral nutrition, and presence of implanted devices including intravenous cannulae are risk factors for development of candidemia. The most appropriate next step in management would be removal of the catheter and initiation of therapy with a systemic antifungal agent for treatment of acute infection and prevention of late sequelae of candidemia - particularly endophthalmitis, endocarditis, arthritis, and osteomyelitis. Removing the catheter alone is not adequate. A new catheter should not be inserted over a guidewire in the infected site of the old catheter. It is inappropriate to assume that a positive blood culture for Candida species represents contamination. Fluconazole therapy is less toxic and equal in efficacy to conventional amphotericin B for vascular catheter-related candidemia in patients who are clinically stable and not neutropenic. However, the Candida species involved should be considered when choosing between fluconazole and amphotericin B because Candida krusei is resistant to fluconazole, and Candida glabrata frequently exhibits an intermediate level of susceptibility to fluconazole.

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