Clinical Scenario  A 42 year old white female was admitted to the hospital with hematemesis and melena. The patient had a history of cirrhosis with ascites. She was promptly transferred to the Intensive Care Unit for monitoring. Within 48 hours of her admission, her temperature rose to 39 0 C. Blood cultures were obtained and a diagnostic tap of the peritoneal fluid was preformed. The ascitic fluid demonstrated 0.5 X 10 9 neutrophils/L and grew E. coli. Her blood cultures also grew E. coli.

Clinical Scenario (continued)  Therapy was initiated with ceftazidime 2 gm q8h intravenously. However the patient developed respiratory distress and severe hypoxia necessitating intubation. Her chest x- ray was consisent with ARDS. A Swan Ganz catheter was placed for fluid status monitoring. She defervesced by the 4 th hospital day.

Clinical Scenario (continued)  On the 8 th day she once again became febrile. Blood cultures (2 sets) were obtained and grew Staphylococcus epidermidis. Thereafter, vancomycin was added to her antibiotic regimen and she became afebrile. Thereafter, vancomycin was added to her antibiotic regimen and she became afebrile.

Clinical Scenario (continued)  On the 14 th hospital day, she became febrile once more. Her urine culture grew ≥100 X 10 6 CFU’s of yeast /L (germ tube negative). Two sets of blood cultures grew yeast (germ tube negative) with a DTP of 160 minutes by the 15 th hospital day. Her central line was removed and grew <15 CFU’s of yeast within 24 hours. So on the 15 th day of hospitalization, fluconazole 800 mg IV followed by 800mg IV daily was initiated.

Clinical Scenario (continued)  The urine culture grew >100 X 10 6 CFU’s of C. glabrata and C. krusei. The blood cultures grew C. glabrata and C. krusei. Based on the identifications which were available on the 17 th hospital day, fluconazole was discontinued and AmB 1mg/kg/da was started. Within 3 days, her creatinine rose to 250  mol/L. AmB was discontinued and AmBisome was commenced. The patient defervesced and improved slowly.

Clinical Scenario – Questions 1. What are the risk factors for the development of candidemia? 2. By what mechanism did this patient develop candidemia? 3. How does one make the diagnosis of catheter- related candidemia?

Clinical Scenario – Questions (Continued) 4. Should the central venous catheter be removed to treat this patient’s candidemia? 5. What is the treatment of choice for this patient’s Candida bloodstream infection? 6. What is the duration of the treatment of central venous catheter-related candidemia?