Description

Candida albicans and related species cause a variety of infections. Noninvasive candidal infections are common and can take many forms including esophagitis, vaginitis, onychomycosis, oral candidiasis (thrush).

• Invasive candidiasis occurs in the setting of an immunocompromised host and can be life-threatening.
• Candidemia is the most common form of invasive candidiasis.
• Other forms of invasive candidiasis include endocarditis, peritonitis, meningitis, osteomyelitis, arthritis, endophthalmitis.

Epidemiology

• All ages are susceptible to hematogenously disseminated candidiasis; premature neonates and immunocompromised patients are at highest risk.
• Predominant sex: male = female (hematogenously disseminated candidiasis)
• Fourth most common bloodstream infection
• Accounts for ~10% of nosocomial bloodstream infections

Incidence

• Incidence has increased in the past 2 decades.
• 6 to 13/100,000 cases per year in the United States

Prevalence
7 cases per 1,000 patients globally

Etiology and Pathophysiology

• Candida naturally grows on the skin and in the GI tract.
• Invasive fungal infection is caused by candidal species in the setting of decreased polymorphonuclear host defenses.
• C. albicans is the most frequent pathogen (45–49% of isolates).
• Five species cause >90% of candidal disease: C. albicans, Candida glabrata, Candida tropicalis, Candida parapsilosis, and Candida krusei.
• Human-to-human transmission is possible.

Risk Factors

• Indwelling intravascular access devices
• Parenteral nutrition
• Mechanical ventilation; ICU stay (>7 days)
• Broad-spectrum antibiotic therapy
• Recent chemotherapy or radiation
• Immunocompromised: HIV, neutropenia, chronic corticosteroid use, bone marrow or solid organ transplant
• Burns involving >30% of body surface
• Malignancy, diabetes mellitus, acute renal failure, end-stage renal disease, renal replacement therapy; cardiothoracic or abdominal surgery
• Premature birth
• Fungal colonization
• Infection ± sepsis; APACHE II score >20
• Pancreatitis

General Prevention

• Adult ICU: Consider treating patients at high risk for invasive candidiasis with fluconazole.
• Consider postoperative prophylaxis in solid organ transplant recipients at high risk for candidiasis using fluconazole or liposomal amphotericin B (L-AmB).
• Treat patients with chemotherapy-induced neutropenia or stem cell transplant at risk for neutropenia with echinocandins or azoles.

Commonly Associated Conditions

• Neutropenia (common)
• Hematologic malignancy or receiving immunosuppressive medications (common)
• Stem cell or organ transplant recipient (common)
• HIV (common)
• Trauma or burn patient receiving care in the ICU (less common)
• ICU patient with renal failure, TPN, or central venous catheter, or receiving broad-spectrum antibiotics (less common)