What are the management options for fungemia associated with a central line (central venous catheter) in a pediatric patient?

From the Guidelines

For fungemia with a central line in a pediatric patient, immediate removal of the central line is strongly recommended along with prompt initiation of antifungal therapy. The most recent and highest quality study, although not directly provided, suggests that catheter removal and antifungal therapy are crucial for managing fungemia in pediatric patients with central lines 1.

Key Considerations

• Empiric treatment should begin with an echinocandin such as caspofungin or micafungin, due to their broad spectrum, fungicidal activity, and favorable safety profile in children.
• For Candida albicans, fluconazole may be used if the isolate is susceptible.
• Treatment duration should be at least 14 days after the first negative blood culture.
• Blood cultures should be obtained daily until clearance is documented.
• Ophthalmologic examination is necessary to rule out endophthalmitis.
• If the central line cannot be removed immediately, antifungal lock therapy should be considered alongside systemic treatment.
• The choice of antifungal may need adjustment based on identification and susceptibility testing of the fungal pathogen.

Rationale

Fungemia in pediatric patients with central lines is often caused by Candida species, with biofilm formation on catheters making eradication difficult without line removal. Echinocandins are preferred initially due to their broad spectrum, fungicidal activity, and favorable safety profile in children 1. The Infectious Diseases Society of America guidelines recommend antifungal therapy with fluconazole or an echinocandin for all CRBSI due to Candida species for 2 weeks after the last positive blood culture 1. Additionally, the 2016 guidelines for the use of antifungal agents in patients with invasive fungal diseases in Taiwan suggest that central venous catheters should be removed as early as possible in the course of candidemia for non-neutropenic patients when the source is presumed to be the CVC and the catheter can be removed safely 1.

From the FDA Drug Label

To decrease the risk of infusion reactions, concentrations above 1.5 mg/mL should be administered via central catheter [see Warnings and Precautions (5. 5)]. The answer to the question of fungemia with central line in a pediatric patient is that micafungin for injection should be administered via a central catheter if the concentration is above 1.5 mg/mL to decrease the risk of infusion reactions, as stated in the drug label 2.

From the Research

Fungemia with Central Line in a Pediatric Patient

• Fungemia is a serious infection that can occur in pediatric patients with central lines, and it is often caused by Candida species 3, 4, 5.
• The management of central line-associated fungemia can be challenging, and it often requires a combination of systemic antifungal therapy and removal of the central line 3, 4, 5.
• However, in some cases, removal of the central line may not be possible, and alternative treatments such as antifungal catheter lock therapy may be used 3.
• The choice of antifungal agent depends on the species of fungus causing the infection, as well as the patient's underlying medical condition and other factors 5, 6.
• Echinocandins, such as micafungin and caspofungin, are often recommended as first-line treatments for invasive candidiasis, including fungemia 6.
• In pediatric patients, the treatment of fungemia often involves a combination of antifungal therapy and removal of the central line, as well as supportive care to manage any underlying medical conditions 4, 7.

Treatment Options

• Antifungal catheter lock therapy with liposomal amphotericin B has been used to treat pediatric central line infections caused by Candida species 3.
• Systemic antifungal therapy with agents such as micafungin, caspofungin, and fluconazole may also be used to treat fungemia in pediatric patients 5, 6.
• Removal of the central line is often necessary to clear the infection, but in some cases, alternative treatments such as antifungal catheter lock therapy may be used 3, 4.

Risk Factors and Outcomes

• The presence of a central line is a major risk factor for the development of fungemia in pediatric patients 4, 7.
• Other risk factors for fungemia include underlying medical conditions such as cancer, neutropenia, and intestinal failure 4, 5, 7.
• The outcomes of fungemia in pediatric patients can be poor, with high mortality rates and prolonged hospital stays 4, 5, 6.
• However, with prompt and effective treatment, including removal of the central line and antifungal therapy, many pediatric patients with fungemia can be successfully treated 4, 7.